Successful Treatment of Intractable Aggressive Behavior, Psychotic Features and Substance Dependence Using Bilateral Stereotactic Anterior Cingulotomy in a Patient with Paranoid Schizophrenia

Background: Psychosurgery is the mainstay treatment for refractory psychiatric illness. Anterior cingulotomy can be used for treating various mental and chronic pain disorders. Objective: To report success of this procedure in the treatment of severe aggressive behavior in a patient with paranoid schizophrenia. Case Report: A 44-year-old male developed psychotic features, substance dependence and aggressive behavior since he was at the age of 25. The patient was admitted several times in a forensic psychiatric hospital. His psychiatric symptoms were refractory to medical therapy and electroconvulsive therapy. Bilateral anterior cingulotomy was performed by using modern technique of stereotactic brain surgery to suppress his violence. Results: There was no aggressive behavior after the operation. Auditory hallucination, paranoid delusion and substance abuse behavior also disappeared. The patient could return to live in his community and started working as a seller in a primary school. There was no cognitive disturbance and recurrent symptom at one year postoperatively. However, antipsychotics were continuously prescribed as a maintenance therapy. Conclusion: Psychosurgery is an appropriate option in refractory cases of psychiatric illness. Anterior cingulotomy renders favorable result in the treatment of aggression behavior, psychotic manifestation and substance dependence. To date, this article is the first case report of schizophrenia treated by modern techniques of psychosurgery in the 21^st century of Thailand.