I would like to thank the Scientific
Committee of the Congress for the opportunity to present this
paper.
Some Autists may present violent
and aggressive behaviour, as breaking goods and things, physical
aggression of people and self-injury actions : bumps on the head
and face, pinches, scratches, beats, etc. This behaviour may
become so severe that they require the use of pharmacological
and physical restraints, and seriously disturbs the already precarious
relation of the Autist with the environment, hinders the education
process and may endanger his health .
Encouraged by the results obtained
with the stereotactic surgery in the treatment of aggressive disorder
in schizophrenic patients, we decided to apply similar therapeutical
criteria on some Autist patients presenting severe aggressive
disorders.
Surgical treatment of mental symptoms
is known as Psychosurgery. Over the past lustrums, an important
controversy took place about the ethic, scientific and, even,
legal aspects of surgery for the treatment of mental disease.
It is, therefore, convenient to define our concept of Psychosurgery.
Psychosurgery is : "Any surgical
procedure on brain tissue - normal or pathological - with the
fundamental purpose of modifying, for the benefit of the patient,
certain emotional and/or ideational disorders, of pathological
nature, affecting harmfully that patient's existence".
I would like to emphasize that any
surgical operation that does not respect the concepts of "pathological
nature", and "for the benefit of the patient" should
be considered a non therapeutical action, but some kind of mutilation.
Material
Between 1991 and 1994, we operated
10 young Autists: 6 f emales and 4 males, aged between 17 and
27 (average = 19). All of them had already been studied and diagnosed
by the experts in the field of Autism.
All of them met the criteria requested for the operation :
- Diagnosis of Autism, (according to the criteria of Coleman and Gillberg, and DSM.IIII).
- The main objective of the operation was clearly defined : to control a chronic pathological, aggressive behaviour of more than 5 years of evolution.
- The aggressive behaviour had been treated, from the begining, by specialists with all the therapeutical tools available. Neither high dose of sedative drugs, nor behaviour therapy, nor physical restraint : hands tied up in the back, protection helmets, etc., could achieve the control of their violent actions. One of the patients (case no 8) was blind because of selfbeating, despite the fact that her hands used to be tied up in the back. Another patient (case no 10) has been hospitalized in a psychiatric institution for more than 4 years, with her hands tied up in the back all the time and with special care, to prevent her from beating her head and face against furniture, walls or her own knees. Despite of all this, her face was full of bruises.
- As a consequence of these severe behaviour disorders, family's life was deeply disturbed and the Institutions had great difficulties to carry on with the daily routines.
- Some of these Autists had to be hospitalizad in psychiatric hospitals for chronic mental disorders.
- Their families were greatly motivated to cooperate in the difficult task we all had to face.
- Before taking a definite decision, each case was analysed by two independent specialists, taking into consideration this new therapeutical approach. They had to evaluate whether there was another alternative or any contraindication, to the surgical treatment.
- The operation, its risks and therapeutical possibilities were explained to the patient's family. At the begining, we used as a reference other patients, operated because of deep violent disorders, but with schizophrenia and mentally different diagnosis retarded patients.
- After the decision had been taken, the operation was delayed for some weeks so that the the family had the opportunity to think it over and to listen to other opinions.
- Routine preoperatory studies were
done : blood test, chest X-Ray, EKG, EEG, neurological and psycological
tests. It is convenient to have detailed TAC or MR studies as
complementary diagnostic material. Six out of ten patients were
found to have morphological brain abnormalities. It is also very
useful to have video studies; it was done on 8 out of the 10 patients.
Method
We used the Leksell's stereotactic
technic. The electrodes are introduced through two burr-holes
located in the frontal area. Our purpose, the functional modification
of the symptom, is achieved by destroying the selected brain structures,
by thermocoagulation with radiofrecuency current, at a temperature
of 68-700ºC. The size of the thermocoagulations vary between
4x4 mm. and 18x6 mm.
Surgical targets
:
In the first operation, the same two surgical targets were used in every patient, with some variations in size and locations :
In the second operation, I added
a new surgical target in 4 patients : the anterior part of the
Cingulum bundle. Size : 8x8 mm..
Results
:
No surgical unwanted neurological
nor psychological side-effects were detected.
As soon as the effects of anesthesia
clears up, the patients showed a change of their attitude and
behaviour : more relaxed and quiet, better emotional communication,
more obedient, less restless and compulsive, more cheerful and
none of the usual agressive actions showed during so many years.
Some of them expressed new and unespected ways of affection.
Long term evolution
:
After 4-8 weeks had elapsed, 7 patients
showed a progressive recurrence of the aggressive behaviour, although
never reached the preoperatory level. We kept them under observation
during some months, before deciding to carry out a second surgical
intervention.
In the second operation the capsulotomy
was enlarged in all 7 patients. The effects of the second operation
were less spectacular than those of the first one; but in all
the 7 patients the aggressive behaviour was controled. They were
discharged from hospital 3-5 days afterwards.
The long term evolution has been followed up very closely, keeping in contact with the parents and with the Institutions. The results up to date, can be summarized as follows :
- Eight patients do not have any pathological aggressive behaviour.
- Two patients (case no 3 and no 10) show occasional moderate violent actions when they are disturbed or become excited. They do not require specific pharmacological nor physical restraint and their behaviour does not interfere in the normal daily activities at home nor at the Institutions.
- Five patients have showed a progressive improvement in autist symptoms since the operation.
- Some symptoms, such as : stereotypic movements, screams, the compulsion to keep the hands in the back tied (rolled with some cloth), bulimia, potomany, restless and hyperactivity, etc., have also improved or disappeared.
- Our experience on long term evolution
in patients treated with psychosurgery for other mental disorders,
have showed that after one year has elapsed, recurrences very
seldom occur. In some patients, if the operation has been successful,
the improvement in cognitive and emotional capacitas may continue
during several years.
Conclusions:
Surgical treatment can abolish pathological
self aggressive and heteroaggressive behaviour in autist patients,
without any unwanted side-effects.
- Some patients, have improved in some specific autist symptoms and behaviour.
- This improvement may progress for years after the operation as corresponding to a learning process.
- We hope that the benefits of stereotactic surgery will further improve in future, as result of progress in the knowledge of the biological basis of the Autism and in the technics of funcional diagnosis: MR and PET.
- Surgical treatment must not be considered as a therapeutical solution for Autism. Surgery's main goal is to improve certain specific symptoms, as is the case of aggressiveness and, if succesful, may facilitate the development of potencial skills.