立体定向毁损术治疗海洛因心理依赖(18个月随访分析)

目的探讨立体定向毁损治疗海洛因心理依赖手术疗效及安全性。方法应用立体定向手术治疗海洛因心理依赖58例,并于术后3个月、18个月进行随访,采用上门家访或电话随访。随访内容包括复吸与否、生活工作情况、有无神经精神功能障碍。上门家访时进行了渴求量表、欲望量表、记忆、智商、人格等精神心理测验。结果未复吸36例,复吸16例,失访6例,操守率为62.06%。记忆、智商、性欲比术前提高,无人格、行为等精神障碍。结论立体定向手术治疗海洛因心理依赖疗效明显优于常规药物戒毒治疗,是消除吸毒者心理依赖、摆脱毒瘾的有效方法,且对智力、欲望、思维、人格无明显负面影响。     

伏隔核毁损戒毒术不同毁损方法对疗效的影响(附74例报告)

目的 探讨立体定向伏隔核毁损术成除海洛因依赖不同毁损方法 与疗效的关系.方法 海洛因依赖患者74例,伏隔核毁损灶初始靶点坐标值:x:(±5.0)-(±6.5)mm,y:17-22 mm,z:(-6.0)-(-8.0)mm,随机采用A、B、C、D4种毁损方法 中的一种制作毁损灶.A、B、C 3组的毁损灶总体积相同,而位置不同,A组沿伏隔核内外方向扩大毁损灶,B组沿伏隔核前后方向扩大毁损灶,C组沿伏隔核内外及前后方向均扩大毁损灶;C、D两组的毁损灶位置相同,而体积不同,D组总体积大于c组.随访期4年,调查是否复吸,是否出现与毁损核团功能相关的特异性并发症.结果 总体未复吸率56.8%.经X~2检验4组未复吸率总体差异有统计学意义,C组未复吸率(78.9%)大于A组(31.3%)及B组(31.6%),经X~2检验均有统计学意义,而C、D组(80.0%)间未复吸率差异无统计学意义.总体特异并发症发生率24.3%(18/74).经X~2检验4组特异性并发症发生率总体差异无统计学意义,A组(12.5%,2/16)并发症发生率与B组(21.1%,4/19)、C组(26.3%,5/19)间差异无统计学意义.C、D(35.0%,7/20)组间差异亦无统计学意义.结论 立体定向伏隔核毁损术是戒除海洛因依赖的有效手段之一.毁损灶位于伏隔核中后1/3部,沿内外及前后方向均扩大毁损灶,疗效最佳,并发症发生率较低,C组毁损方法 最佳.     

立体定向手术治疗海洛因依赖的远期随访分析

目的评估立体定向毁损术治疗海洛因依赖的手术疗效,分析术后复吸原因。方法回顾性分析接受脑立体定向术的154例海洛因成瘾者的临床资料,采用症状自评量表对病人精神卫生状况进行调查随访。结果随访154例,时间5~6年,其中复吸52例(33.8%,复吸组),未复吸102例(66.2%,未复吸组)。复吸组术后躯体化、强迫症状、敌对、偏执、精神病性等因子明显高于未复吸组和国内常模(均P<0.05)。结论立体定向手术是海洛因依赖的安全有效的治疗方法。强迫症状和人格障碍的改善是消除心理依赖的基础及手术戒毒治疗成功的重要因素;精神病性和躯体化是复吸的主要原因。     

双侧伏隔核立体定向射频毁损或DBS治疗海洛因精神依赖

目的 探讨外科手术治疗戒除海洛因药物成瘾所致精神依赖的有效性。方法 通过立体定向手术，对27例药物成瘾患者的双侧伏隔核进行射频毁损，1例患者双侧伏隔核行脑深部电刺激仪（DBS）植入术。结果 所有患者平均随访8个月，失随访2例，总随访数26例，其中优效者18例（69.2％），良好者4例（15.3％），一般者2例（7．7％），差效者2例（7．7％）。结论 立体定向引导下行双侧扣带回和（或）伏隔核射频热凝毁损或高频电刺激，戒除海洛因药物成瘾所致精神依赖是一种有效、可行的方法。     

伏隔核毁损术治疗药物依赖性脑病术后疗效随访分析

目的 评价伏隔核定向毁损术戒毒的安全性和有效性。方法 伏隔核定向毁损戒毒术后随访期达1年以上者42例，通过家庭访问、门诊、书信、电话，精神心理测评量表和随访调查问卷进行长期追踪随访，分析手术对一般生理学指标、本能行为、人格特征的影响及手术疗效、复吸率、并发症。对未复吸患者，不定期随机抽查尿检和纳络酮催瘾试验。结果 除术后短期内出现中枢性高热外，手术对其他生理学指标无明显影响；对本能行为的影响主要表现为术后1个月性相关暗示刺激诱发动机降低，术后3个月恢复至正常水平。术后患者人格特征总体趋势无明显变化；短期内可出现注意力、近期记忆和睡眠障碍，于1周-1个月内自行恢复；对工作能力和远期记忆无影响；未复吸19例，复吸21例，失随访2例，术后1年期以上平均操守率45．2％，复吸率54．8％；影响手术疗效的因素：术前生理脱毒是否彻底，毁损灶大小，患者吸毒史长短、吸食毒品种类和所处社会环境；本组无死亡及感染病例。近期并发症：癫痫样发作1例（2.4％）；远期并发症：动机形成障碍、对特征性刺激注意力下降、社会活动退避反应6例（14．3％），经康复训练3-6个月后症状减轻。结论 伏隔核定向毁损术戒毒是安全、有效、可行的。手术的副反应和并发症发生率低，程度轻，是短暂的，可恢复的，与患者不能摆脱毒品折磨的痛苦相比，是在可接受范围内的。手术戒毒效果明显好于常规药物戒毒效果，是在常规药物戒毒无效的基础上，用于克服心理依赖，防止复吸的一种重要手段。     

立体定向治疗海洛因心理依赖临床报道

目的探讨立体定向手术治疗药物依赖并评估手术安全性及疗效。方法采用CT引导下立体定向双侧杏仁核、伏膈核及扣带回射频毁损，术后147～253d内随访。结果70例病人中55例药物依赖心理完全消失，9例术后复吸，并发症少。结论立体定向手术是一种有效和可行的治疗药物依赖方法。     

P300和脑功能成像在定向术治疗海洛因依赖中的应用

目的探讨定向毁损术治疗海洛因依赖者手术前后P300和脑功能成像的变化及其关系。方法对77例海洛因依赖者定向术术前和术后6~12个月随访期内进行P300和正电子发射断层摄影术(PET)、功能磁共振成像(fMR I)检查,评估P300和脑功能成像的变化及其与手术疗效的关系,并与30名正常人比较,进行相关统计学分析。结果海洛因依赖者术前及术后随访复吸者P300中的P3波潜伏期延长和波幅降低,与术后未复吸者和正常对照组比较均存在显著性差异(P<0.01)。P300、PET、fMR I异常术前分别为63例、69例和54例,而随访时分别为32例、18例和13例,其中,疗效优者异常分别有9例、3例和2例,疗效差者有23例、15例和11例;而且,fMR I异常病例PET和P300均异常,PET异常病例P300均异常。各检查项目术前和随访时比较,及手术疗效优与手术疗效差组间比较均具有统计意义(P<0.05)。结论海洛因依赖者存在一定认知障碍和脑功能异常区,定向手术可以改善患者认知功能。手术前后事件相关电位P300和PET、fMR I的改变具有一定相关性并可以作为评估海洛因依赖者手术治疗效果的客观指标。     

立体定向术治疗海洛因成瘾临床随访观察

目的:了解立体定向术治疗海洛因成瘾者后3年的复吸率和不良反应。方法:对接受脑立体定向术治疗的海洛因成瘾者215例,运用门诊随访、信访、电话随访和登门拜访的方式,采取统一随访表、家属问卷和心理卫生调查表进行随访,了解患者出院后的病情信息。结果:术后3年有75例患者复吸,未复吸者107例,失随访32例,1例在手术3年后车祸去世。未复吸者中64例参加工作,出院后结婚20例,生子女24例,不吸烟者7例,目前存在睡眠障碍16例,情绪不稳、行为幼稚者4例,记忆力下降12例,自感性功能下降1例。结论:立体定向手术治疗海洛因成瘾是有效的,不良反应较小,有进一步研究的价值。     

多靶点亚核团毁损治疗难治性精神分裂症1232例

目的探讨双侧多靶点亚核团毁损手术治疗难治性精神分裂症的疗效和安全性。方法采用螺旋CT定位，对1232例难治性精神分裂症患者，实施立体定向同期双侧多靶点亚核团射频热凝毁损手术。结果1232例患者术后2周随访：显著进步428例，进步722例，无效81例，无加重病例，死亡1例（术后3d死于急性肺动脉栓塞），有效率93.34％；1134例术后远期（6-54个月）随访：恢复204例，显著进步424例，进步410例，无效96例，无加重病例，有效率91.53％；术后除早期一过性并发症外，远期并发症发生率小于1％。结论多靶点亚核团毁损手术治疗难治性精神分裂症疗效显著，安全性高；对阳性、阴性症状均有效果，亚核团毁损既保留了正常的脑功能,又控制了精神症状。     

颅内靶点立体定向毁损术治疗帕金森病围手术期的配合与护理

目的探讨颅内靶点立体定向毁损术治疗帕金森病围手术期的配合与护理。方法局麻下用对10例帕金森病病人进行颅内靶点立体定向毁损术治疗。护士积极配合配合医生做好对病人的术前、术中及术后的护理。结果10例帕金森病病人中，显效8例，有效2例。病人肢体震颤、肌强直等运动障碍术后明显改善，仅有2例发生并发症（1例术后轻偏瘫，l例顽固性呃逆）无死亡病例。结论颅内靶点立体定向毁损术治疗帕金森病，不仅定位精确，毁损灶小，而且对肌肉震颤和肌强直等运动障碍症状的控制效果好。在护理上应注意术中配合和并发症的预防护理。     

Treatment Considerations in Anticonvulsant Monotherapy

Summary: The long-standing practice of polypharmacy in treating epilepsy is giving way to use of monotherapy. Monotherapy can improve seizure control as well as reduce the risk of serious idiosyncratic reactions, dose-related side effects, and complex drug interactions. Monotherapy also offers improved compliance and cost-effectiveness. The basis of monotherapy is accurate diagnosis and assessment of the patient's seizure type(s), followed by selection of a single appropriate anticonvulsant drug. Many patients currently treated with multiple anticonvulsants can be successfully converted to monotherapy with a carefully monitored program in which troublesome and redundant drugs are gradually withdrawn from the therapeutic regimen.     

Dextromethorphan: Cellular Effects Reducing Neuronal Hyperactivity

Summary: Dextromethorphan is a dextrorotary morphinan without affinity for opioid receptors, commonly used as an antitussive medication. During the past 5 years, interest in the compound and its demethylated derivative, dextrorphan, has been revived because additional neuroprotective and an-tiepileptic properties were found in in vitro studies, animal experiments, and a few clinical cases. Both morphinans are able to inhibit N -methyl-D-aspartate (NMDA) receptor channels and voltage-operated calcium and sodium channels with different potencies. The inhibition of the NMDA receptor is believed to be the predominant mechanism of action responsible for the anticonvulsant and neuroprotective properties of the compounds.     

Pediatric Epilepsy Surgery

Summary: The use of implantable arrays of epidural electrodes has made it possible to carry out extraoperative electrocorticography (ECoG) and functional localization in the awake child. This has permitted cortical excisions that are determined by criteria similar to those obtained during surgical procedures performed under local anesthesia in adults. In addition, the method also permits simultaneous ECoG and video monitoring during the child's symptomatic seizures, providing additional important localizing information that is impractical to obtain in operations under local anesthesia. We report our experience with 75 children, ages 5 months to 15 years, whom we have managed with epidural electrode arrays. The method of extraoperative ECoG is described and illustrative cases are presented to demonstrate its feasibility and utility in children. In addition, we call attention to gliomas as a common cause of chronic focal seizures in children. Of 49 children undergoing resection and followed for from 1 to 14 years (mean of 5.8 years), 32 (65%) are either seizure free or have had a significant reduction in seizure frequency that has unambiguously improved their quality of life. The results are analyzed further by relating the surgical outcome to each of the pathologic entities that caused the seizures. This analysis reveals the variety of neurological conditions that commonly cause intractable focal seizure disorder in children and distinguishes those pathologic entities in which the seizure disorder is apt to respond to surgical intervention from those that will not.     

Un nouveau cadre conceptuel de travail pour une psychiatrie revisitée ? Introduction à deux articles de E. Kandel

In two articles which appeared in the American Journal of Psychiatry and that were subsequently translated for Évolution Psychiatrique, E. Kandel examines the bases for a reinterpreted psychiatry that is prepared to confront the major challenge of the 3rd millenium: that of insight into the mind and brain. This requires a major reorganization of the discipline, which involves a reinvestment of the scientific approach and a critical  assessment of the data provided by psychoanalytical psychiatry and cognitive neurosciences. Seven concepts have therefore been proposed for interactive re-examination: consciousness, the unconscious, memory, emotion, development, desire, impulse. The dynamic relations existing between genetics and the environment allow one to see how evolutions are possible from actions at different levels, both psychotherapeutic and pharmacological. Imaging and other techniques provide additional objective information to the process of human interaction which remains the basis of psychiatry. A common framework for psychiatry and the neurosciences, a reconsideration and renewal of the psychoanalytical approach are both possible and necessary.     

Opioids and the developing organism: A comprehensive bibliography, 1984–1988

A comprehensive bibliography of the literature concerned with opioids and the developing organism for 1984-1988 is presented. Utilized with companion papers (Neurosci. Biobehav. Rev. 6:439-479; 1982; 8:387-403; 1984), these articles cover the clinical and laboratory references beginning in 1875. For the years 1984, 1985, 1986, 1987, and 1988, a total of 877 citations were recorded. A series of indexes accompanies the citations in order to make the literature more accessible. These indexes are divided into clinical and laboratory topics, and subdivided into such topics as the type of opioid explored and the general area of biological interest (e.g., physiology).     

La biologie et le futur de la psychanalyse : un nouveau cadre conceptuel de travail pour une psychiatrie revisitée

The American Journal of Psychiatry has received a number of letters in response to my earlier “Framework” article (1). Some of these are reprinted elsewhere in this issue, and I have answered them briefly there. However, one issue raised by some letters deserves a more detailed answer, and that relates to whether biology is at all relevant to psychoanalysis. To my mind, this issue is so central to the future of psychoanalysis that it cannot be addressed with a brief comment. I therefore have written this article in an attempt to outline the importance of biology for the future of psychoanalysis.     

Facteurs de risque environnementaux à la schizophrénie

Schizophrenia is currently a major concern, its prevalence being estimated at around 1% and its social consequences being severe. The elucidation of the pathophysiology of the disease is difficult due to the great variability of clinical expressions, the instability of the clinical symptoms during the evolution and the absence of reliable biological markers. The existence of a familial aggregation in schizophrenia is well known, the risk of presenting the disease for first-degree relatives of patients being 5 to 10 times higher than the risk observed in the general population. The genetic component was further confirmed by twin and adoption studies. Although the concordance for the disease is higher (40 to 70%) among monozygotic twins as compared with dizygotic twins (15%) it does not reach 100%, which implies that environmental factors modulate the effects of the genotype. However, the role of these factors and especially their interaction with genetic factors remain unclear but the implications of some specific environmental factors are well documented by recent research data. The current literature on sex differences in schizophrenia is consistent. Several studies have suggested that male and female patients may differ in age at the onset and expression of clinical symptoms. Complications during pregnancy or birth-giving may increase the risk of developing schizophrenia later in life. The major complications are oxygen deprivation during pregnancy, bleeding, maternal malnutrition or infection (exposure to influenza, for example). A low birth weight is associated with an increased risk of schizophrenia. Psychoses are more common among people living in an urban environment and among those born during winter months. Schizophrenia is probably more prevalent in people who are living promiscuously, are subject to toxic abuse, poor nutrition and stress but here more precise data are needed. Moreover, immigrants have a higher risk of developing psychotic disorders. In addition, head traumas are associated with an increased risk of schizophrenia. Though they are contentious, some studies suggest that substance abuse (cannabis use in European countries) is related to the development of schizophrenia, especially in people with genetic vulnerability. Moreover, substance misuse may worsen the symptoms. If the environment is sufficiently stressful, people with a high genetic vulnerability will develop some degree of mental illness, including schizophrenia. Conversely, a less stressful or a protective environment may decrease the risk of its onset in persons with a predisposition to schizophrenia.     

Introduction: Goals

Summary: Epilepsy is characterized by recurrent seizures. Many epilepsies with focal seizures as well as convulsive generalized seizures respond satisfactorily to antiepileptic drugs (AEDs) that reduce repetitive firing (e.g., phenytoin, carbamazepine, and valproate) or that augment GABA_A-mediated inhibition (e.g., phenobarbital and benzodiazepines). A number of drugs presently under development, such as NMDA receptor antagonists, loreclezole, losigamone, meth-ysticine, and dextromethorphan, are promising in acute animal models of otherwise drug-resistant convulsant activity. As a result of recent studies in both experimental models and surgically resected human epileptic brain, the prospects for development of AEDs have significantly improved. Several new AEDs recently have reached the commercial market or are in experimental or clinical trials. A comparative presentation of the standing of the new AEDs with respect to their efficacy and side effects is necessary, but still very difficult. Because initial experience with new AEDs is restricted to populations with severe drug-resistant epilepsy, the crucial question whether potential new AEDs can alter prognosis is not yet definitively answered. There is a clear need to compare the effects of standard AEDs and new AEDs in naive patients and over longer follow-up periods. Moreover, because of the strong desire to develop antiepileptic therapy that directly treats the primary etiology of a given epileptic syndrome , or modifies the neurobiological processes that cause recurrent seizures, better experimental epilepsy models for chronic epilepsy and further clinical studies are necessary to increase the knowledge on the pathophysiology of distinct epileptic syndromes. In this respect, studies on the differences between responders and nonresponders to a given AED treatment are extremely valuable.