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definitions - Psychosurgery

psychosurgery (n.)

1.brain surgery on human patients intended to relieve severe and otherwise intractable mental or behavioral problems

Psychosurgery (n.)

1.(MeSH)Treatment of chronic, severe and intractable psychiatric disorders by surgical removal or interruption of certain areas or pathways in the brain, especially in the prefrontal lobes.

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synonyms - Psychosurgery

Psychosurgery (n.) (MeSH)

Gyrectomy  (MeSH), Leucotomy  (MeSH), Leukotomy  (MeSH), Lobotomy  (MeSH), Topectomy  (MeSH)

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Psychosurgery

                   
Psychosurgery
Intervention
MeSH D011612

Psychosurgery, also called neurosurgery for mental disorder (NMD), is the neurosurgical treatment of mental disorder.[1] Psychosurgery has always been a controversial medical field.[1] The modern history of psychosurgery begins in the 1880s under the Swiss psychiatrist Gottlieb Burckhardt.[2][3] The first significant foray into psychosurgery in the twentieth century was conducted by the Portuguese neurologist Egas Moniz. During the mid-1930s he developed the operation known as leucotomy. The practice was enthusiastically taken up in America by the neuropsychiatrist Walter Freeman and the neurosurgeon James W. Watts who devised what became the standard prefrontal procedure and named their operative technique lobotomy.[4] After World War II, Freeman broke with Watts and introduced a modification of the procedure which he termed transorbital lobotomy. This simplified procedure where an ice-pick or similar instrument entered the brain through the eye socket dispensed with the need for a neurosurgeon and became subject to widespread use in America.[1] In spite of the award of the Nobel prize to Moniz in 1949 the lobotomy was largely discredited and replaced by chlorpromazine in the 1950s. Other forms of psychosurgery, although used on a much smaller scale, survived. Some countries have abandoned psychosurgery altogether; in others, for example the US and the UK, it is regulated and only used in a few centres on small numbers of people with depression or obsessive-compulsive disorder (OCD) who have already undergone years of treatment.[5] In some other countries it is used in the treatment of schizophrenia and addiction.[6]

Psychosurgery is a collaboration between psychiatrists and neurosurgeons. During the operation, which is carried out under a general anaesthetic and using stereotactic methods, a small piece of brain is destroyed or removed. The most common types of psychosurgery in current or recent use are capsulotomy, cingulotomy, subcaudate tractotomy and limbic leucotomy. Lesions are made by radiation, thermo-coagulation, freezing or cutting.[1] About a third of patients show significant improvement in their symptoms after operation.[1] Advances in surgical technique have greatly reduced the incidence of death and serious damage from psychosurgery; the remaining risks include seizures, incontinence, decreased drive and initiative, weight gain, and cognitive and affective problems.[1]

Currently, interest in the neurosurgical treatment of mental illness is shifting from ablative psychosurgery (where the aim is to destroy brain tissue) to deep brain stimulation (DBS) where the aim is to stimulate areas of the brain with implanted electrodes.[7]

Contents

  History

  Early psychosurgery

There is evidence that trepanning (or trephining) — the practice of drilling holes in the skull — has been in widespread, if infrequent, use since 5000 BC.[1][8] This may have been done in an attempt to allow the brain to expand in the case of increased brain fluid pressure, for example, after head injuries. However, psychosurgery as understood today was not commonly practiced until the 1930s.[2]

  Gottlieb Burkhardt

The first systematic attempt at human psychosurgery is commonly attributed to the Swiss psychiatrist Gottlieb Burckhardt.[9] In December 1888 Burckhardt operated on the brains of six patients (one of whom died a few days after the operation) at the Préfargier Asylum, cutting out a piece of cerebral cortex. He presented the results at the Berlin Medical Congress and published a report, but the response was hostile and he did no further operations.[10] Early in the 20th century Russian neurologist Vladimir Bekhterev and Estonian neurosurgeon Ludvig Puusepp operated on three patients with mental illness, with discouraging results.[10]

  Egas Moniz

But it was the Portuguese neurologist Egas Moniz who, in 1935, was responsible for introducing psychosurgery into mainstream psychiatric practice, and coined the term "psychosurgery".[10] Moniz developed a theory that people with mental illnesses, particularly "obsessive and melancholic cases" had a disorder of the synapses which allowed unhealthy thoughts to circulate continuously in their brains. Moniz hoped that by surgically interrupting pathways in their brain he could encourage new healthier synaptic connections.[11] In November 1935, under Moniz's direction, surgeon Pedro Almeida Lima drilled a series of holes on either side of a woman's skull and injected ethanol to destroy small areas of subcortical white matter in the frontal lobes. After a few operations using ethanol, Moniz and Almeida Lima changed their technique and cut out small cores of brain tissue. They designed an instrument which they called a leucotome, and called the operation a leucotomy (cutting of the white matter).[11] After twenty operations they published an account of their work. The reception was generally not friendly but a few psychiatrists, notably in Italy and the US, were inspired to experiment for themselves.[11]

  Walter Freeman and James Watts

In the US, psychosurgery was taken up and zealously promoted by neurologist Walter Freeman and neurosurgeon James Watts.[12] They started a psychosurgery program at George Washington University in 1936, first using Moniz's method but then devised a method of their own in which the connections between the prefrontal lobes and deeper structures in the brain were severed by making a sweeping cut through a burr hole on either side of the skull.[12] They called their new operation a lobotomy.[11]

  Orbitoclasts, used in frontal lobotomies

Freeman went on to develop a new form of lobotomy which dispensed with the need for a neurosurgeon. He hammered an ice pick-like instrument, an orbitoclast, through the eye socket and swept through the frontal lobes. The transorbital or "ice pick" lobotomy was done under local anesthesia or using electroconvulsive therapy to render the patient unconscious and could be performed in mental hospitals lacking surgical facilities.[13] Such was Freeman's zeal that he began to travel around the nation in his own personal van, which he called his "lobotomobile", demonstrating the procedure in psychiatic hospitals.[14] Freeman's patients included 19 children, one of whom was 4 years old.[15]

  Popularization and decline

The 1940s saw a rapid expansion of psychosurgery, in spite of the fact that it involved a significant risk of death[16] and severe personality changes.[17] By the end of the decade, up to 5000 psychosurgical operations were being carried out annually in the US.[17] In 1949, Moniz was awarded the Nobel Prize for Physiology or Medicine. But psychosurgery went into rapid decline in the 1950s, due to the introduction of new drugs and a growing awareness of the long-term damage caused by the operations,[12] as well as doubts about its efficacy.[1]

  Procedural innovations

Beginning in the 1940s various new techniques were designed in the hope of reducing the adverse effects of the operation; William Beecher Scoville's orbital undercutting, Jean Talairach's anterior capsulotomy, and Hugh Cairn's bilateral cingulotomy.[12] Stereotactic techniques made it possible to place lesions more accurately, and experiments were done with alternatives to cutting instruments such as radiation.[12] By the 1970s the standard or transorbital lobotomy had been replaced with other forms of psychosurgical operations.

  1970s to the present

During the 1960s and 1970s psychosurgery became the subject of increasing public concern and debate, culminating in the US with congressional hearings.[1] Surprisingly, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in 1977 endorsed the continued limited use of psychosurgical procedures.[1] In this new, regulated era, a few facilities in some countries, such as the US, continue to use psychosurgery on small numbers of patients, with the number of operations declining further over the 30 years, a period during which there have been no major advances in ablative psychosurgery.[7]

  Neurological effects

The frontal lobe of the brain controls a number of advanced cognitive functions, as well as motor control. Motor control is located at the rear of the frontal lobe, and is usually unaffected by psychosurgery. The anterior or prefrontal area is involved in impulse control, judgement with everyday life and situations, language, memory, motor function, problem solving, sexual behaviour, socialization and spontaneity. Frontal lobes assist in planning, coordinating, controlling and executing behaviour.

The efficacy is not high: one study of cingulotomy (which usually involves a 2–3 cm lesion in the cingulum near the corpus callosum) found improvement in 5 out of 18 patients.[18]

  Present day

All the forms of psychosurgery in use today (or used in recent years) target the limbic system, which involves structures such as the amygdala, hippocampus, certain thalamic and hypothalamic nuclei, prefrontal and orbitofrontal cortex, and cingulate gyrus — all connected by fibre pathways and thought to play a part in the regulation of emotion.[19] There is no international consensus on the best target site.[19]

Anterior cingulotomy was first used by Hugh Cairns in the UK, and developed in the US by H.T. Ballantine jnr.[12] In recent decades it has been the most commonly used psychosurgical procedure in the US.[19] The target site is the anterior cingulate cortex; the operation disconnects the thalamic and posterior frontal regions and damages the anterior cingulate region.[19]

Anterior capsulotomy was developed in Sweden, where it became the most frequently used procedure. It is also used in Scotland. The aim of the operation is to disconnect the orbitofrontal cortex and thalamic nuclei.[19]

Subcaudate tractotomy was the most commonly used form of psychosurgery in the UK from the 1960s to the 1990s. It targets the lower medial quadrant of the frontal lobes, severing connections between the limbic system and supra-orbital part of the frontal lobe.[19]

Limbic leucotomy is a combination of subcaudate tractotomy and anterior cingulotomy. It was used at Atkinson Morley Hospital London in the 1990s[19] and also at Massachusetts General Hospital.[20]

Amygdalotomy, which targets the amygdala, was developed as a treatment for aggression by Hideki Narabayashi in 1961 and is still used occasionally, for example at the Medical College of Georgia.[21]

There is debate about whether or not deep brain stimulation (DBS) should be classed as a form of psychosurgery.[22]

Endoscopic sympathetic block (a form of endoscopic thoracic sympathectomy) for patients with anxiety disorder is sometimes considered to be a psychiatric treatment, despite it not being surgery of the brain. There is also renewed interest in using it to treat schizophrenia.[23] ESB disrupts brain regulation of many organs normally affected by emotion, such as the heart and blood vessels. A large study demonstrated significant reduction in "alertness" and "fear" in patients with social phobia as well as improvement in their quality of life.[24]

  Psychosurgery by country

  Asia

In China psychosurgical operations which make a lesion in the nucleus accumbens are used in the treatment of drug and alcohol dependence.[25][26] Psychosurgery is also used in the treatment of schizophrenia, depression, and other mental disorders.[6] Psychosurgery is not regulated in China, and its use has been criticised in the West.[6]

India had an extensive psychosurgery programme until the 1980s, using it to treat addiction, and aggressive behaviour in adults and children, as well as for depression and OCD.[27] Cingulotomy and capsulotomy for depression and OCD continue to be used, for example at the BSES MG Hospital in Mumbai.[28]

In Japan the first lobotomy was performed in 1939 and the operation was used extensively in mental hospitals.[29] However, psychosurgery fell into disrepute in the 1970s, partly due to its use on children with behavioural problems.[30]

  Australia and New Zealand

In the 1980s there were 10-20 operations a year in Australia and New Zealand.[7] The number had decreased to one or two a year by the 1990s.[7] According to one report, no operations have been carried out since 2000,[7] although the Victorian Psychosurgery Review Board dealt with 3 applications between 2006 and 2008.[31]

  Europe

In the twenty year period 1971-1991 the Committee on Psychosurgery in the Netherlands and Belgium oversaw 79 operations.[5] Since 2000 there has been only one centre in Belgium performing psychosurgery, carrying out about 8 or 9 operations a year (some capsulotomies and some DBS), mostly for OCD.[7]

In France about five people a year were undergoing psychosurgery in the early 1980s.[32] In 2005 the Health Authority recommended the use of ablative psychosurgery and DBS for OCD.[33]

In the early 2000s in Spain about 24 psychosurgical operations (capsulotomy, cingulotomy, subcaudate tractotomy, and hypothalamotomy) a year were being performed. OCD was the most common diagnosis, but psychosurgery was also being used in the treatment of anxiety and schizophrenia, and other disorders.[34]

In the UK between the late 1990s and 2010 there were just two centres using psychosurgery: a few stereotactic anterior capsulotomies are performed every year at the University Hospital of Wales, Cardiff, while anterior cingulotomies are carried out by the Advanced Interventions Service at Ninewells Hospital, Dundee. The patients have diagnoses of depression, obsessive-compulsive disorder, and anxiety. Ablative psychosurgery was not performed in England between the late 1990s and 2010,[5] although a couple of hospitals have been experimenting with DBS.[35] In 2010 Frenchay Hospital, Bristol, performed an anterior cingulotomy on a woman who had previously undergone DBS.[36]

In Russia in 1998 the Institute of the Human Brain (Russian Academy of Sciences) started a programme of stereotactic cingulotomy for the treatment of drug addiction. About 85 people, all under the age of 35, were operated on annually.[37] In the former USSR, leucotomies were used for the treatment of schizophrenia in the 1940s, but the practice was prohibited by the Ministry of Health in 1950.[38]

  North America

In the US the Massachusetts General Hospital has a psychosurgery program.[39] Operations are also performed at a few other centres. In Mexico psychosurgery is used in the treatment of anorexia,[40] and in the treatment of aggression.[41]

  South America

Venezuela has three centres performing psychosurgery. Capsulotomies, cingulotomies and amygdalotomies are used to treat OCD and aggression.[42]

  Individuals who underwent lobotomy

  Fictional examples

  • In Unruhe, Ep. 4 Season 4, of the TV show The X-Files, serial killer Gerry Schnauz performs lobotomies on women he intends to save from mental 'unrest.'
  • Frances Farmer: Though Farmer is the person perhaps best associated in the public mind with lobotomy due to its depiction in the fictionalized biographical film Frances, archival medical and other records have conclusively proven Farmer never underwent the procedure. The author who initially alleged the lobotomy later admitted in court he had made it up.[1] (Footnoted site contains court transcripts which are also available through LexisNexis.)
  • Ken Kesey's famed fictional character, Randle Patrick McMurphy, in One Flew Over the Cuckoo's Nest who was, in the movie, played by Jack Nicholson.
  • J. Frank Parnell, erratic driver of the radioactive Chevy Malibu in the movie Repo Man.
  • A Hole in One, a 2004 movie about a young lady who wants an ice pick lobotomy during the height of its popularity.
  • Rat Korga, major character in Samuel R. Delany's science fiction novel Stars in My Pocket Like Grains of Sand, voluntarily opts for psychosurgery to make him content to be a slave.
  • Session 9, a 2001 horror movie about a group of men hired to remove the asbestos from a defunct mental hospital.
  • Hannibal, in which Hannibal Lecter lobotomizes Paul Krendler, played by Ray Liotta.
  • In the book The Bell Jar by Sylvia Plath, the character Esther Greenwood meets a girl named Valerie in the asylum who has had a lobotomy.
  • Iron Maiden's famous fictional mascot, Eddie, was lobotomised on-stage during one of Maiden's live shows; this concert was filmed for German TV but that particular segment was cut out due to being deemed "Too violent". The cover of their fourth album Piece of Mind (and many of the following releases) shows Eddie after being lobotomised.
  • In Episode 6 of Mortal Kombat Legacy, Raiden is captured at a psychiatric hospital and given a crude lobotomy to "cure" him of his "violent outbursts and delusions" of being a god.
  • In the book Cyteen by C. J. Cherryh, psychosurgery involves the use of drugs that bring the mind into a state where it is very receptive to audio and/or visual cues, which help the psychosurgeon to reprogram the individual. This procedure is non-invasive, and involves administering drugs versus actual surgery.
  • In the television miniseries Kingdom Hospital, the character Mary was killed by a botched lobotomy. In the companion book, The Journals of Eleanor Druse, Eleanor had a transorbital lobotomy in her childhood.
  • In the novel Project 17 the Denver State Hospital is rumored to have been the founding of lobotomy.
  • In science fiction, psychosurgery is typically presented as far more advanced than its modern day counterparts, often including such things as selective memory erasure, direct alteration of thoughts, and generally having a higher effectiveness than in reality. Examples of it can be found in books by Alastair Reynolds, Richard Morgan, and others.
  • In Suddenly Last Summer (1959 adaptation of the Tennessee Williams play), a wealthy woman named Violet Venable (Katharine Hepburn) wants her niece Catherine Holly (Elizabeth Taylor) lobotomized to silence her talk about Violet's son Sebastian's homosexuality.
  • In From Hell (film), set in Victorian London, Queen Victoria herself (Liz Moscrop) is implicated in ordering lobotomies for several characters in order to "silence" them if they knew too much information. Characters who underwent these crude lobotomies (including Sir William Gull played by Ian Holm), were depicted with shaved heads and in vegetative states. However, in 1888 (the year the story takes place), the lobotomy procedure had not been invented yet.
  • In the fourth season of Melrose Place, Kimberly - under the influence of one of her multiple personalities - has Peter committed to a mental institution under false pretenses. She begins to perform a lobotomy on Peter, but is interrupted by Amanda and Michael's rescue attempt.
  • In the science fiction series Firefly, child prodigy, River Tam, is assumed to have undergone some form of lobotomy against her will, leaving her in a mentally unstable state.[citation needed]
  • In the novel Shutter Island and its film adaptation it is indicated that the main character, Teddy Daniels, will undergo a transorbital lobotomy.
  • In the movie Sucker Punch, the main character of Babydoll undergoes a frontal lobotomy at the end of the film.

  See also

  References

  1. ^ a b c d e f g h i j Mashour, G.A.; Walker, E.E.; Martuza, R.L. (2005). "Psychosurgery: past, present and future". Brain Research Review 48 (3): 409–18. DOI:10.1016/j.brainresrev.2004.09.002. PMID 15914249. 
  2. ^ a b Berrios, G.E. (1997). "The origins of psychosurgery". History of Psychiatry 8: 61–82. DOI:10.1177/0957154X9700802905. 
  3. ^ Shorter, Edward (1997). A history of psychiatry: from the era of the asylum to the age of prozac. New York: John Wiley & Sons. p. 225. ISBN 978-0-471-15749-6. http://books.google.ie/books?id=-Oybg_APowMC&pg=PA389. 
  4. ^ Freeman, Walter; James W. Watts (1942). Psychosurgery. Baltimore. 
  5. ^ a b c Neurosurgery working group 2000 Neurosurgery for mental disorder. London: Royal College of Psychiatrists
  6. ^ a b c N. Zamiska 2007 In China, brain surgery is pushed on the mentally ill. Wall Street Journal, 2 November
  7. ^ a b c d e f Sachdev, P.; Chen, X. (2009). "Neurosurgical treatment of mood disorders: traditional psychosurgery and the advent of deep brain stimulation". Current Opinion in Psychiatry 22 (1): 25–31. DOI:10.1097/YCO.0b013e32831c8475. PMID 19122531. 
  8. ^ Feldman, RP; Goodrich JT. (March 2001). "Psychosurgery: a historical overview.". Psychosurgery: a historical overview 48 (3): 647–57. PMID 11270556. 
  9. ^ For example, Whitaker, H.A.; Stemmer, B.; Joanette, Y. (1996). "A psychosurgical chapter in the history of cerebral localization: the six cases of Gottlieb Burkhardt". In Code, Christopher; Wallesch, C.-W.; Joanette, Y.; Roch, A.. Classic Cases in Neuropsychology. Hove: Psychology Press. pp. 276. ISBN 978-0-86377-395-2. http://books.google.ie/books?id=59pMz9m83yQC&pg=PA276.  Stone, James L. (2001-01). "Dr. Gottlieb Burckhardt the Pioneer of Psychosurgery". Journal of the History of the Neurosciences 10 (1): 79–92. DOI:10.1076/jhin.10.1.79.5634. ISSN 0964-704X. PMID 11446267. http://www.informaworld.com/openurl?genre=article&doi=10.1076/jhin.10.1.79.5634&magic=crossref. Retrieved 2011-08-12.  Manjila, S.; S. Rengachary, A. R Xavier, B. Parker, M. Guthikonda (2008). "Modern psychosurgery before Egas Moniz: a tribute to Gottlieb Burckhardt". Journal of Neurosurgery: Pediatrics 25 (1): 1.  However, Kotowicz notes a difference, irregularly observed, among medical historians and medical practitioners in their location of the origin of psychosurgery. The latter group, he contends, tend to favour beginning the narrative with Burckhardt whilst the former group favour starting with Moniz. Kotowicz, Zbigniew (2005). "Gottlieb Burckhardt and Egas Moniz–Two Beginnings of Psychosurgery". Gesnerus 62 (1-2): 78–9.  In the context of early psychosurgery, Berrios unusually also refers to the operations performed in 1889 by a surgeon (Harrison Cripps) at the behest of the British psychiatrist Thomas Claye Shaw in which fluid was drawn from the brain of a patient diagnosed with General Paralysis of the Insane. While the purpose of the operation was aimed towards the alleviation of mental symptoms attendant on the condition the procedure did not aim to interfere directly with brain tissue and therefore it has been excluded from most conventional accounts of psychosurgery. Berrios, German E. (1991). "Psychosurgery in Britain and elsewhere: a conceptual history". In Berrios, German E.; Freeman, Hugh. 150 Years of British psychiatry, 1841-1991. Gaskell. pp. 181–5. ISBN 978-0-902241-36-7. 
  10. ^ a b c Kotowicz, Z. (2005). "Gottlieb Burckhardt and Egas Moniz - two beginnings of psychosurgery". Gesnerus 62 (1-2): 77–101. PMID 16201322. 
  11. ^ a b c d E. Moniz 1956 How I succeeded in performing the prefrontal leukotomy. In A.M. Sackler et al. (eds.) The great physiodynamic therapies in psychiatry; an historical reappraisal. New York: Hoeber, 131-37
  12. ^ a b c d e f Heller, A.C.; Amar, Arun P.; Liu, Charles Y.; Apuzzo, Michael L.J. (2006). "Surgery of the mind and mood: a mosaic of issues in time and evolution". Neurosurgery 59 (4): 720–40. DOI:10.1227/01.NEU.0000240227.72514.27. PMID 18695579. 
  13. ^ El-Hai, Jack (2005). The Lobotomist. Wiley. ISBN 0-471-23292-0. 
  14. ^ V. Mark Durand & David H. Barlow (2006). "Essentials of Abnormal Psychology, 4th edition". Thomson Wadsworth. http://www.wadsworth.com/cgi-wadsworth/course_products_wp.pl?fid=M20b&product_isbn_issn=0534605753&discipline_number=24. 
  15. ^ Stewart, D.G.; Davis, K.L. (2008). "Images in psychiatry: the lobotomist". American Journal of Psychiatry 165 (4): 457–8. DOI:10.1176/appi.ajp.2008.08020174. PMID 18381916. http://ajp.psychiatryonline.org/cgi/content/full/165/4/457. 
  16. ^ G.C. Tooth and M.P. Newton 1961 Leucotomy in England and Wales, 1942-54. London: HMSO
  17. ^ a b Swayze II (1995). "Frontal leucotomy and related psychosurgical procedures in the era before antipsychotics (1935-54) an historical overview". American Journal of Psychiatry 152 (4): 505–15. PMID 7900928. 
  18. ^ Baer, L.; Rauch, SL; Ballantine Jr, HT; Martuza, R; Cosgrove, R; Cassem, E; Giriunas, I; Manzo, PA et al. (1995). "Cingulotomy for intractable obsessive-compulsive disorder". Archives of General Psychiatry 52 (5): 384–392. PMID 7726719. 
  19. ^ a b c d e f g Clinical resource and audit group 1996 Neurosurgery for mental disorder. Edinburgh: Scottish Office
  20. ^ Price, B.H.; Baral, I; Cosgrove, GR; Rauch, SL; Nierenberg, AA; Jenike, MA; Cassem, EH (2001). "Improvement in severe self-mutilation following limbic leucotomy: a series of five consecutive cases". Journal of Clinical Psychiatry 62 (12): 925–32. DOI:10.4088/JCP.v62n1202. PMID 11780871. 
  21. ^ Fountas, K.N.; Smith, J.R.; Lee, G.P. (2007). "Bilateral stereotactic amygdalotomy for self-mutilation disorder: a case report and review of the literature". Stereotactic and Functional Neurosurgery 85 (2-3): 121–8. DOI:10.1159/000098527. PMID 17228178. 
  22. ^ Johnson, J. (2009). "A dark history: memories of lobotomy in the new era of psychosurgery". Medicine Studies 1: 367–78. DOI:10.1007/s12376-009-0031-7. 
  23. ^ Teleranta T. Psychoneurological applications of endoscopic sympathetic blocks (ESB)
  24. ^ Pohjavaara P. Social phobia: aetiology, course and treatment with endoscopic sympathetic block (ESB)
  25. ^ Wu HM, Wang XL, Chang CW, Li N, Gao L, Geng N, Ma JH, Zhao W et al. (2010). "Preliminary findings in ablating the nucleus accumbens using stereotactic surgery for alleviating psychological dependence on alcohol". Neurosci Lett. 473 (2): 77–81. DOI:10.1016/j.neulet.2010.02.019. PMID 20156524. 
  26. ^ Gao, G.D.; Wang, X; He, S; Li, W; Wang, Q; Liang, Q; Zhao, Y; Hou, F et al. (2003). "Clinical study for alleviating opiate drug psychological dependence by a method of ablating the nucleus accumbens with stereotactic surgery". Stereotactic and Functional Neurosurgery 81 (1-4): 96–104. DOI:10.1159/000075111. PMID 14742971. 
  27. ^ P.K. Doshi 2009 History of stereotactic surgery in India. In A.M. Lozano, P.L. Gildenberg and R.R. Tasker (eds.) Textbook of stereotactic and functional neurosurgery. Berlin: Springer, 155-68
  28. ^ Neurosurgery at the BSES MG Hospital
  29. ^ Fujikura, I. (1993). "History of psychosurgery". Nippon Ishigaku Zasshi 39 (2): 217–22. PMID 11639762. 
  30. ^ Ramamurthi, B. (2000). "Stereotactic surgery in India: the past, present and the future". Neurology India 48 (1): 1–7. PMID 10751807. http://www.neurologyindia.com/text.asp?2000/48/1/1/1482. 
  31. ^ Victorian Psychosurgery Review Board www.prb.vic.gov.au
  32. ^ "La neurochirurgie fonctionnelle d'affections psychiatriques sévères" (in French) (PDF). Comité Consultatif National d'Ethique. 2002-04-25. http://www.ccne-ethique.fr/docs/fr/avis071.pdf.  (French national consultative committee on ethics, opinion #71: Functional neurosurgery of severe psychatric conditions)
  33. ^ S. Wainrib 2006 Psychiatrie; vers le nouveau 'sujet toc'. Le Monde, 6 December 2006
  34. ^ Barcia, J.A. et al. (2007). "Present status of psychosurgery in Spain". Neurocirugía 18: 301–11. 
  35. ^ Brain pacemaker lifts depression (BBC article)
  36. ^ Care Quality Commission 2010 Monitoring the use of the Mental Health Act in 2009/10: 93
  37. ^ Medvedev, S.V.; Anichkov, A.D.; Polykov, Y.I. (2003). "Physiological mechanisms of the effectiveness of bilateral stereotactic cingulotomy against strong psychological dependence in drug addicts". Human Physiology 29 (4): 492–7. DOI:10.1023/A:1024945927301. 
  38. ^ Lichterman, B.L. (1993). "On the history of psychosurgery in Russia". Acta Neurochirugie 125: 104. 
  39. ^ Massachusetts General Hospital Functional and Stereotactic Neurosurgery Center
  40. ^ El ISSSTE es pionero en psicocirugía contra anorexia. La Cronica, 17 September 2004
  41. ^ F. Jiménez-Ponce et al. 2011 Evaluation of bilateral cingulotomy and anterior capsulotomy for the treatment of aggressive behavior.Cirugia y Cirujanos 79(2): 107-13
  42. ^ G. Chiappe 2010 Las Obsesiones se peuden operar. El Universal, 30 March 2010
  43. ^ Prior, Alex (6 February 2008). "Music's boy wonder: Composer, conductor, singer... and he's only fifteen". The Independent. http://www.independent.co.uk/arts-entertainment/music/features/musics-boy-wonder-composer-conductor-singer-and-hes-only-fifteen-778670.html. Retrieved 11 July 2010. 
  44. ^ "Frequently Asked Questions About Lobotomies". NPR.org. 16 November 2005. http://www.npr.org/templates/story/story.php?storyId=5014565. Retrieved 11 July 2010. 
  45. ^ Gussow, Mel (7 September 1996). "Rose Williams, 86, Sister And the Muse of Playwright". New York Times. http://www.nytimes.com/1996/09/07/arts/rose-williams-86-sister-and-the-muse-of-playwright.html. Retrieved 11 July 2010. 
  46. ^ Dully, Howard; Charles Fleming (2008). My Lobotomy. London: Vermilion. ISBN 978-0-09-192219-1. 

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WordGame

The English word games are:
○   Anagrams
○   Wildcard, crossword
○   Lettris
○   Boggle.

Lettris

Lettris is a curious tetris-clone game where all the bricks have the same square shape but different content. Each square carries a letter. To make squares disappear and save space for other squares you have to assemble English words (left, right, up, down) from the falling squares.

boggle

Boggle gives you 3 minutes to find as many words (3 letters or more) as you can in a grid of 16 letters. You can also try the grid of 16 letters. Letters must be adjacent and longer words score better. See if you can get into the grid Hall of Fame !

English dictionary
Main references

Most English definitions are provided by WordNet .
English thesaurus is mainly derived from The Integral Dictionary (TID).
English Encyclopedia is licensed by Wikipedia (GNU).

Copyrights

The wordgames anagrams, crossword, Lettris and Boggle are provided by Memodata.
The web service Alexandria is granted from Memodata for the Ebay search.
The SensagentBox are offered by sensAgent.

Translation

Change the target language to find translations.
Tips: browse the semantic fields (see From ideas to words) in two languages to learn more.

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