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The hypothalamus at the crossroads of psychopathology and neurosurgery

机译：下丘脑在心理病理学和神经外科的十字路口

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The neurosurgical endeavor to treat psychiatric patients may have been part of human history since its beginning. The modern era of psychosurgery can be traced to the heroic attempts of Gottlieb Burckhardt and Egas Moniz to alleviate mental symptoms through the ablation of restricted areas of the frontal lobes in patients with disabling psychiatric illnesses. Thanks to the adaptation of the stereotactic frame to human patients, the ablation of large volumes of brain tissue has been practically abandoned in favor of controlled interventions with discrete targets. Consonant with the role of the hypothalamus in the mediation of the most fundamental approach-avoidance behaviors, some hypothalamic nuclei and regions, in particular, have been selected as targets for the treatment of aggressiveness (posterior hypothalamus), pathological obesity (lateral or ventromedial nuclei), sexual deviations (ventromedial nucleus), and drug dependence (ventromedial nucleus). Some recent improvements in outcomes may have been due to the use of stereotactically guided deep brain stimulation and the change of therapeutic focus from categorical diagnoses (such as schizophrenia) to dimensional symptoms (such as aggressiveness), which are nonspecific in terms of formal diagnosis. However, agreement has never been reached on 2 related issues: 1) the choice of target, based on individual diagnoses; and 2) reliable prediction of outcomes related to individual targets. Despite the lingering controversies on such critical aspects, the experience of the past decades should pave the way for advances in the field. The current failure of pharmacological treatments in a considerable proportion of patients with chronic disabling mental disorders is reminiscent of the state of affairs that prevailed in the years before the early psychosurgical attempts. This article reviews the functional organization of the hypothalamus, the effects of ablation and stimulation of discrete hypothalamic regions, and the stereotactic targets that have most often been used in the treatment of psychopathological and behavioral symptoms; finally, the implications of current and past experience are presented from the perspective of how this fund of knowledge may usefully contribute to the future of hypothalamic psychosurgery.
机译：自开始以来，治疗精神病患者的神经外科手术就可能已成为人类历史的一部分。心理外科手术的现代时代可以追溯到Gottlieb Burckhardt和Egas Moniz进行的英勇尝试，目的是通过消融残疾精神病患者的额叶有限区域来减轻精神症状。由于立体定向框架适应人类患者，实际上已经放弃了大量脑组织的消融，而采用了针对离散目标的受控干预措施。与下丘脑在最基本的避免进近行为的介导中的作用相辅相成，特别是选择了一些下丘脑核和区域作为攻击性（后下丘脑），病理性肥胖症（外侧或腹侧核）的治疗靶标。 ），性行为偏向（脑室顶核）和药物依赖性（脑室顶核）。最近的一些结果改善可能是由于使用了立体定向引导的深部脑刺激，以及治疗重点从分类诊断（例如精神分裂症）到尺寸症状（例如侵略性）的改变，而这些症状在形式诊断上是非特异性的。但是，在两个相关问题上尚未达成共识：1）根据个体诊断选择目标; 2）可靠地预测与单个目标相关的结果。尽管在这些关键方面一直存在争议，但过去几十年的经验应该为该领域的进步铺平道路。当前，在相当一部分患有慢性致残性精神障碍的患者中，药物治疗的失败使人想起了在早期心理外科尝试之前的几年中所处的状况。本文综述了下丘脑的功能组织，下丘脑离散区域的消融和刺激作用，以及最常用于治疗心理病理和行为症状的立体定向靶标;最后，从知识的积累如何为下丘脑心理手术的未来做出有益的贡献的角度，介绍了当前和过去的经验。

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