Brain Stimulation Therapies for Clinicians,

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nial, is left unchallenged. McHugh is confident that he can tell   Brain Stimulation Therapies for Clinicians, by Edmund
these apart, while certain that others cannot.                     S. Higgins, M.D., and Mark S. George, M.D. Washington, D.C.,
   What bothers McHugh about psychoanalysis? First, the            American Psychiatric Publishing, Inc., 2009, 203 pp., $70.00.
psychoanalysis he rails against would not be familiar to the
vast majority of contemporary psychoanalysts. He states that          Brain stimulation in psychiatry used to be synonymous
“psychoanalysts are sure that patients’ problems rest upon         with ECT. The recent publication of Brain Stimulation Thera-
                                                                   pies for Clinicians reflects the exciting development that clini-
some hidden sexual conflict” (p. 27)—perhaps 100 years ago,
                                                                   cians now have more than one brain stimulation technique
but hardly today. McHugh terms his enemies as “manneristic
                                                                   with which to treat patients who are resistant to pharma-
Freudians”—a straw man he creates for his argument—who
                                                                   cotherapy. While ECT is still a mainstay in the treatment of
copy the master Freud but lack his genius. One can always
                                                                   severe and medication-resistant psychiatric disorders,
find disciples who miss the point, whether the master is Freud
                                                                   clinicians now have a growing list of Food and Drug Adminis-
or Kraepelin or even McHugh. But he is disturbingly comfort-
                                                                   tration (FDA) approved or investigational interventions that
able in generalizing the problem to all Freudian disciples,
                                                                   alter brain function via electrical or magnetic fields. These in-
even those who are in strong agreement with him on recov-
                                                                   terventions include new modifications of ECT, vagus nerve
ered memories and PTSD, and even to Freud himself. Fur-
                                                                   stimulation, transcranial magnetic stimulation (TMS), mag-
thermore, he casually dismisses psychoanalytic views that
                                                                   netic seizure therapy, deep brain stimulation, transcranial di-
have been widely accepted in mainstream psychotherapy              rect current stimulation, implanted cortical stimulation, and
without alerting the reader that his position is idiosyncratic,    others on the horizon. Two of these tools, TMS and transcra-
rejecting a broad professional consensus, and without dis-         nial direct current stimulation, are noninvasive, which opens
cussing counterarguments. Thus when he states (p. 173), “No        the additional possibility of probing brain function in both
one any longer believes that the hysterical patient’s physical     health and disease and in ways not possible previously. As in-
display represents symbolically his or her unconscious con-        terventions, noninvasive neuromodulation tools can be used
flicts over sexual gratification,” he is simply wrong. Further-    to examine relationships between brain and behavior, mov-
more, if the thought is brought up to date, e.g., “hysterical      ing us from correlation to causation and testing hypotheses
physical symptoms are symbolically linked to unconscious           generated by functional imaging. They also hold out the pos-
conflicts, often involving sexual, aggressive, or dependent        sibility of leveraging knowledge about pathophysiology to de-
fantasies, and frequently reinforced by the secondary gain         velop targeted therapeutic interventions.
that accompanies them,” it represents the dominant view of            The face of clinical brain stimulation is changing rapidly.
American psychiatrists, both psychoanalytic and otherwise.         Take, for example, our oldest intervention—ECT. With ECT, we
McHugh has every right to challenge this view and advocate         have moved from the original goal of inducing a generalized
his alternative theory, one that emphasizes secondary gain,        seizure to the recognition that not all seizures are equally ef-
ignores the role of childhood and unconscious factors, and         fective. Innovations in electrode placement and parameters of
offers no explanation at all for the specific content of the       stimulation have dramatically improved the risk-benefit ratio
symptoms. However, if he neither mentions nor deals with           of ECT. It is important to recognize, however, that some of
the dominant view, the book is far less suitable for readers       these seemingly new innovations actually have historical
who are not well versed in the field.                              roots. For example, ultrabrief pulse ECT, recently reported to
  In sum, this is a brilliant but deeply flawed book. McHugh       improve cognitive outcome (1), was published by Cronholm
invites us to join him in an adventure of exposing a foolish fad   and Ottosson as early as the 1960s (2, 3). Indeed, the 1959 book
that has injured patients and families and in speculating about    Treatment of Mental Disorder chronicles many since forgotten
the underlying vulnerabilities in psychiatry that predisposed it   variations in electrical parameters that likewise await redis-
to these errors. With great enthusiasm and biting language,        covery (4). Similarly, one of the latest developments, the use of
but no data, he links these underlying errors to Freud and psy-    deep brain stimulation in the treatment of depression, had its
choanalysts. He is consistent in his metanarrative, a common-      roots in the classic work of J. Lawrence Pool, who in 1948 used
sense empiricist who won’t be taken in by false theories, but is   deep brain stimulation in the caudate of a Parkinson’s patient
inconsistent in his selection of evidence, presenting only that    for the treatment of his depressive symptoms.
which supports his views. Oddly, this is the very error for           These tools may have historical roots, but with today’s ad-
which he rightly indicts the recovered memory movement.            vanced technology we can achieve forms of brain stimulation
                                                                   not dreamt possible decades ago. For example, new delivery
   Let the reader beware: There is much to learn here about
                                                                   systems for deep brain stimulation include light-emitting di-
recovered memory and PTSD enthusiasts, about popular fads
                                                                   odes that can deliver precisely timed light-driven stimulation
in psychiatry, and, unfortunately, about the dangers of blind
                                                                   to trigger synaptic transmission in cells containing light-sen-
skepticism—applied selectively to ideas with which one dif-
                                                                   sitive ion channels (5). These developments open the possi-
fers, regardless of the evidence.
                                                                   bility of selectively targeting specific neuronal populations
                                       ROBERT MICHELS, M.D.        that overlap in space, thereby improving the functional selec-
                                              New York, N.Y.       tivity of our as yet most focal intervention. In another ex-
                                                                   ample, the original TMS devices induced pulses that were
The author reports no competing interests.                         shaped like sine waves because these were easier to generate
                                                                   using the electrical components available at the time. How-
Book review accepted for publication January 2009 (doi:            ever, it has been known for decades that sine wave ECT is less
10.1176/appi.ajp.2009.09010101).                                   efficient and induced more side effects than brief-pulse

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                                                                                                                       BOOK FORUM


square waves. Fortunately, engineering advances have now             duction for physicians and non-medical professionals, to
made it possible to perform TMS with a controllable pulse            whom the book will be most useful, as a guide to the brain
shape (cTMS) (6). Developments such as this will enable us to        stimulating modalities available to consider in referring for
empirically determine the relations between pulse character-         new or adjunctive treatment. It offers an essential, crisp, and
istics and physiological outcome and should aid in the refine-       very accessible and easily read review of the different thera-
ment of brain stimulation interventions.                             peutic modalities and their applications. Highly practical and
   Conceptualizations of how brain stimulation works are             comprehensive in content, this book nonetheless deserves a
likewise evolving apace with neuroscience developments. For          complete reading, as it tersely orients the reader to the entire
example, the original conceptualization that deep brain stim-        field. This book serves as a useful introduction to the field that
ulation “shuts down” the stimulated brain region depicted in         will leave the reader wanting more, and it nicely showcases
chapter 7 has recently given way to new theories of altered          the significant contributions of the authors to the field. After
neural dynamics. This shift in thinking from a static lesion to      this introductory level text, the reader will be well prepared to
a dynamic alteration in the functioning of a distributed net-        consult one of the more comprehensive texts that are now
work reflects an evolution of thought regarding the functional       available. All sections of this book are well referenced and give
role of neural oscillations. For decades, the field has passively    the reader enough papers to follow up with for each specific
recorded the electrical signals generated by the electrical          topic. However, for the specialist seeking to know more about
activity of the brain, but only recently are we beginning to         this rapidly expanding field, the papers cited represent a frac-
understand whether these rhythms are epiphenomena of                 tion of the literature currently available.
neuronal activity or its very substance (7). Now that we can            The authors achieve their stated goal of inviting the reader
noninvasively and exogenously evoke oscillations with TMS            into the world of brain stimulation and offering a starter kit for
(8), we are equipped for the first time to experimentally deter-     further exploration. However, the field is rapidly changing,
mine their function and therapeutic potential.                       and, in the words of Elbert Hubbard, “The world is moving so
   These tools have much to teach us about how the brain             fast these days that the man who says it can’t be done is gener-
works and about the brain basis of psychiatric illness. For ex-      ally interrupted by someone doing it.” Echoing this sentiment,
ample, the distributed network of brain regions hypothesized         Trimble comments in his foreword to the book, “I predict that
to be involved in depression can be accessed at a variety of         a succession of revised versions will follow from this first edi-
nodes. Lateral cortical regions can be targeted with TMS and         tion of the book, and that even the authors will look back with
implanted cortical stimulation, while deep nodes can be tar-         surprise that they had not more accurately predicted the fu-
geted via deep brain stimulation. The clinical impact of inter-      ture.” Indeed, there are already major new developments since
vening in the circuit at these different access points can teach     the book’s publication. The most notable of these is the recent
us about the functional role of the circuit and inform treat-        FDA approval of TMS for the treatment of depression (October
ment development. These tools may also offer new insights            2008). Furthermore, topics that were dismissed as having little
into how ECT works. In ECT, the seizure and the electricity          data now have substantial literatures. For example, magnetic
that induced it are coupled. With TMS, implanted cortical            seizure therapy has shown evidence of safety and preliminary
stimulation, and deep brain stimulation, we can deliver elec-        evidence of antidepressant efficacy, and a large two-center
tricity in a regionally specific fashion without inducing a sei-     randomized trial is under way. Additionally, follow-up studies
zure, while with magnetic seizure therapy we can trigger cor-        of larger samples of depressed patients receiving deep brain
tically focused seizures without exposing deeper brain               stimulation have been published and large-scale sham-con-
structures to electricity. This enables us to examine the rela-      trolled multicenter trials are under way.
tive contributions of the electricity and the seizure to the effi-      The authors make their case that the future of brain stimu-
cacy and side effects of ECT.                                        lation as a treatment is very bright. As scientific advances
   Collectively, brain stimulation tools represent a new family      continue at a rapid pace, brain stimulation treatments seem
of therapeutic interventions that utilize various forms of elec-     likely to play an enormous role not just in advancing psychi-
trical fields, either directly applied or indirectly induced via     atric research but also for a growing range of clinical indica-
magnetic fields, to treat and study neuropsychiatric disor-          tions. The authors boldly suggest that the array of emerging
ders. These tools, and the science behind them, define the           brain stimulation modalities have the potential to revolution-
emerging field of therapeutic neuromodulation. Excitement            ize the practice of psychiatry during the current century. At
about therapeutic neuromodulation is great and has rekin-            the very least, brain stimulation—from early devices such as
dled interest in the fundamental principles of how electrical        ECT to the newest ones such as deep brain stimulation—of-
fields change brain function. The authors point out that the         fers a new and diverse class of therapeutics that the reader
brain is an electrical organ. Like the heart, there is a role for    will come to believe can be an alternative to current psycho-
both chemical and electrical interventions in the treatment of       therapeutic and pharmacological interventions. But to realize
brain-based disorders. This recognition calls for a greater em-      this promise, we have much work to do as a field. Whereas
phasis on the electrical aspects of brain function in medical        biochemistry and molecular biology are the basic sciences of
education to prepare the next generation of clinicians and re-       pharmacotherapy, the emerging field of brain stimulation will
searchers to optimally apply these brain stimulation tools.          require a basic-science understanding of how electrical mod-
   This book addresses the need for a basic familiarity with         ulation of neuronal populations alters the functioning of dis-
the electrical aspects of brain function (i.e., neurophysiology)     tributed networks. Only through a nuanced understanding of
and the physics and engineering of brain stimulation (i.e., in-      this process may we hope to rationally design device-based
terventional neurophysiology) to help prepare clinicians to          therapies than can treat the currently untreatable and dis-
understand and use these tools. It provides an excellent intro-      cover the otherwise unknowable.

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References                                                                 First, I learned what to do about the uncertainty that is al-
  1. Sackeim HA, Prudic J, Nobler MS, Fitzsimons L, Lisanby SH,         ways present in managing violence. The authors take that
     Payne N, Berman RM, Brakemeier EL, Perera T, Devanand D:           uncertainty seriously. Even the best structured interviewing
     Effects of pulse width and electrode placement on the efficacy     techniques fall short in the prediction of violence. The man-
     and cognitive effects of electroconvulsive therapy. Brain Stimu-   agement of complex disorders—and especially comorbidi-
     lat 2008; 1:71–83                                                  ties—is imperfect and the systems within which we work
  2. Cronholm B, Ottosson JO: Ultrabrief stimulus technique in elec-
                                                                        are fallible. Yet we can make the most of structure, commu-
     troconvulsive therapy, II: comparative studies of therapeutic
                                                                        nication, and respect, those basic actions and values that
     effects and memory disturbances in treatment of endogenous
     depression with the Elther Es electroshock apparatus and Sie-      are instilled in every young psychiatrist and that must be
     mens Konvulsator III. J Nerv Ment Dis 1963; 137:268–276            used to their maximum effectiveness in the presence of the
  3. Cronholm B, Ottosson JO: Ultrabrief stimulus technique in elec-    violent patient.
     troconvulsive therapy, I: influence on retrograde amnesia of          This message is threaded through the chapters. Lim and
     treatments with the Elther Es electroschock apparatus, Sie-        Bell, in their chapter on cultural competence in the assess-
     mens Konvulsator III, and of lidocaine-modified treatment. J       ment of risk for violence, stress ways in which to communi-
     Nerv Ment Dis 1963; 137:117–123                                    cate respect. “It is important,” they assert, “not to micro-in-
  4. Alexander L: Treatment of Mental Disorder. Philadelphia, WB
                                                                        sult or micro-aggress against the patient in the process of the
     Saunders, 1959
                                                                        evaluation” (p. 46). They give an excellent list of examples,
  5. Aravanis AM, Wang LP, Zhang F, Meltzer LA, Mogri MZ,
     Schneider MB, Deisseroth K: An optical neural interface: in vivo
                                                                        ranging from the disrespect implied in a young white doctor
     control of rodent motor cortex with integrated fiberoptic and      calling an older black person by his first name to that con-
     optogenetic technology. J Neural Eng 2007; 4:S143–S156             tained in denying the existence of racism and its effects. Lim
  6. Peterchev AV, Jalinous R, Lisanby SH: A transcranial magnetic      and Bell provide a strong rationale for the ways in which the
     stimulator inducing near-rectangular pulses with controllable      communication of respect creates the appropriate basis for a
     pulse width (cTMS). IEEE Trans Biomed Eng 2008; 55:257–266         trusting conversation. It is in that context that the sensitive
  7. Lakatos P, Karmos G, Mehta AD, Ulbert I, Schroeder CE: Entrain-    and essential information will be exchanged.
     ment of neuronal oscillations as a mechanism of attentional           Second, I was given much food for thought in the crisply
     selection. Science 2008; 320:110–113
                                                                        written case vignettes that enliven every chapter. The com-
  8. Massimini M, Ferrarelli F, Esser SK, Riedner BA, Huber R, Mur-
                                                                        plexities and limitations are thus given living, breathing form
     phy M, Peterson MJ, Tononi G: Triggering sleep slow waves by
     transcranial magnetic stimulation. Proc Natl Acad Sci USA          in the lives of people. I appreciated this. Much of the manage-
     2007; 104:8496–8501                                                ment of violence lies outside the limits of our effectiveness. I
                                                                        appreciated the clinician-authors sharing stories of life at the
                                        SARAH H. LISANBY, M.D.
                                      VLADAN NOVAKOVIC, M.D.            edge of practice.
                                                 New York, N.Y.            Lindemayer and Khan, in their chapter on emergency ser-
                                                                        vices, walk the reader through common situations in the as-
Drs. Lisanby and Novakovic have received grant/research sup-            sessment and management of the violent patient presenting
port from NIH, DARPA, AFAR, NARSAD, Stanley Medical Re-                 to an emergency service. They offer a detailed explanation of
search Institute, NYSTAR, Tourette Syndrome Association,                the organization of clinical services they utilize. In their case
Neuronetics, Cyberonics, ANS, and Magstim and have served               vignettes, they use four subsections: initial symptoms, past
on a Data Safety and Monitoring Board for Northstar Neuro-              history, initial examination, and treatment and course of ill-
science. Columbia University has filed patent applications for          ness. This window into their practice allows us to see their
TMS technology developed in Dr. Lisanby’s Division.                     decision making when time is of the essence, and the patient
                                                                        is at risk for being violent at the moment the assessment is
Book review accepted for publication January 2009 (doi:                 being made. Like Lim and Bell, they argue for and demon-
10.1176/appi.ajp.2009.08121837).                                        strate how respect and communication are fundamental to
                                                                        good practice.
Textbook of Violence Assessment and Management,                            Third, I got an excellent picture of what needs to be done to
by Robert I. Simon, M.D., and Kenneth Tardiff, M.D., M.P.H.             move the field forward, both in clinical and research domains.
Washington, D.C., American Psychiatric Publishing, Inc., 2008,          The authors are sharp in their critique of existing knowledge;
683 pp., $99.00.                                                        they are in accord that more research must be done if we are to
                                                                        improve the effectiveness of clinical practice. As a researcher,
   I know a fair amount about violence. Having done research            these are not simply good marching orders: the collective as-
on substance abuse and violence and youth violence, I was               sessment is motivational. In order to expand the knowledge
somewhat skeptical about having much to learn from this                 base, we will need to convince the larger mental health collec-
textbook. Furthermore, it is rare for me to approach a text-            tive that this is needed, and this book does a wonderful job of
book with bated breath. Much to my surprise, the chapters               presenting the case.
gripped me. The authors’ and editors’ seriousness of purpose               Violence is a serious problem, and our methods of predic-
made me read closely, but I was also rewarded for paying at-            tion and treatment are imperfect. One problem that is high-
tention. Each chapter highlighted important ideas in tables,            lighted in the volume is the problem of adoption of new prac-
as well as in a list of key points at the end. These well-written       tices. Monahan’s chapter on structured risk assessment
lists helped me to focus on what I had just read, reinforcing           demonstrates that this method is better than unstructured
the complex ideas. OK, so it was a good read—but what did I             clinical interviews, which lack sensitivity and specificity. Yet
get from this book?                                                     few clinicians have changed their mode of practice. This is a

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