Frontal view of a normal human brain.
Psychosurgery can also be referred to as neurosurgery. Eskandar MD, Cosgrove, and Rauch of the Departments of Neurosurgery and Psychiatry, Massachusetts General Hospital, Harvard Medical School, describe psychiatric neurosurgery as "the surgical ablation or disconnection of brain tissue with the intent of altering abnormal affective and behavioral states caused by mental illness." The neurosurgeon group further states that the "surgical target may be cerebral cortex, nuclei, or pathways that display either normal or abnormal physiologic activity."
Psychosurgery History and Early Prefrontal Lobotomy
Burkhardt reported the first use of psychosurgery modern times in 1891 (Cosgrove, Rauch, 2005). The most well-known example of dramatic psychosurgery is that of a prefrontal lobotomy. Mashoura, Walker, and Martuza in an article entitled “Psychosurgery: Past, Present, and Future” as published in Stanford Medical, stated that psychosurgery has a "complex and controversial history," and that "its abuse was due in part to the early 20th century schism of psychoanalysis and biological psychiatry."
The widespread disuse of the lobotomy in the 1950s gave way to the widespread use of psychopharmacology, along with its own issues and controversies. The surgical lobotomy gave way to a "chemical lobotomy" in psychiatric hospitals, with the advent of strong typical antipsychotic drugs that left patients largely immobilized.
Thorazine (chlorpromazine hydrochloride) was the first to be developed, but was among typical antipsychotic drugs such as Haldol (Haloperidol), Prolixin (fluphenazine), and others. Typical antipsychotics are also referred to as dopamine antagonists, neuroleptics, classic antipsychotics, and first generation antipsychotics. They were and are used for similar reasons as lobotomies, to produce psychomotor slowing, emotional quieting, and affective indifference. They are still in use, although atypical antipsychotics developed around 1994 that have fewer and less intense side effects are used more frequently today.
First developed in Portugal, the prefrontal lobotomy, particularly for violent patients in mental hospitals, was administered upon tens of thousands of patients between 1935 and 1955, including widespread use in U.S. mental institutions. NPR reports that 50,000 lobotomies were performed in the United States during this time period. The two types of lobotomies were prefrontal and transorbital.
With a prefrontal lobotomy, the surgeon drills holes through the patient’s skull to access the frontal lobes. An "improved" version of the lobotomy was the transorbital lobotomy developed by Dr. Walter Freeman. In this surgery, the surgeon goes through the eye sockets (without permanently damaging the eyes), with completion in less than 10 minutes. In the movie One Flew Over the Cuckoo's Nest, Jack Nicholson received a transorbital lobotomy.
As is often the case with newly developed therapeutic techniques, initial reports of results tended to be enthusiastic, downplaying complications (including a one-in-four death rate) and undesirable side effects. At times, the desired effect of calming the patient was achieved, but there were also times the patient became a "vegetable."
Side Effects of Psychosurgery, Lobotomy, and Modern Law
Some of the disturbing side effects of prefrontal lobotomy are the permanent inability to inhibit impulses, and an unnatural "tranquility" with undesirable shallowness or absence of feeling. In 1951, the Soviet Union banned all such operations.
Elliot Valnestein, in the book Great and Desperate Cures explained how psychosurgery in the form of the lobotomy came to be accepted. Valenstein concluded that psychiatrists needed to gain acceptance for the practice of psychiatry as a medical science, and that the use of the surgery fitted well into that need during the 1930s and 1940s. Also, the lobotomy proved to be a cost-effective treatment, and was an effective way to maintain control over mental patients who were often violent and difficult to deal with.
While the lobotomy fell out of use with the advent of psychotropic drugs, psychosurgery has been gaining support in modified and less-invasive forms (than the lobotomy) in the treatment of some difficult-to-manage disorders, as discussed in the remainder of this article.
Ice picks such as these were often used in performing lobotomies.
Why and When Psychosurgery Was and Is Utilized
Psychosurgery in general is not commonly used, but suggested or resorted to in enough cases that it should not be considered rare. It is suggested or used as a last resort for the intractable psychotic, severe and chronic cases of OCD (Obsessive-Compulsive Disorder), at times for depression and chronic anxiety, and occasionally in treating severe pain in the case of terminal illness.
Alan A. Stone, MD, in Psychiatric Times states about psychosurgery, "Despite its wretched history, psychosurgery is back with a new name—neurosurgery for mental disorders."
Neurosurgeons Cosgrove and Rauch (Harvard Medical and Massachusetts General Hospital), proponents of psychosurgery, acknowledge, "Surgical intervention remains an important therapeutic option for disabling psychiatric disease," which they feel is "probably underutilized." But they also agree concerning psychosurgery that "Despite these modern treatment methods, many patients fail to respond adequately and remain severely disabled" after psychosurgery. (Cosgrove, Rauch, 2005).
Modern Use of Psychosurgery and Types of Disorders for Which Psychosurgery is Utilized
Various forms of psychosurgery are performed today in neurosurgical centers in general hospitals in the United States and elsewhere.
Some of the conditions for which various types of neurosurgery is performed are:
· Parkinson's Disease
· Obsessive-Compulsive Disorder (OCD)
· Obsessive neurosis
· Intractable depression
Additionally, psychosurgery has been performed though not as commonly for:
· Anxiety Neurosis
Modern Psychosurgery Techniques
Today, the rate of permanent damage to the brain has been substantially improved in comparison to the historical use of psychosurgery procedures, and there are fewer severely detrimental side effects. However, serious aftereffects can still be experienced by a significant percentage of those who undertake psychosurgery today, and extreme caution is in order with any of these procedures.
Modern psychosurgery techniques include:
· Stereotactic limbic leukotomyin in the form of:
· Subcaudate tractotomy and
Two other forms of psychosurgery are:
· Deep Brain Stimulation
Subcaudate tractotomy was first developed in 1965, and involves interrupting the nerve fibers that connect the orbitofrontal cortex to the thalamus. It has frequently been used for non-treatable depression and OCD. Radioactive seeds are planted in the frontal lobes, or radio waves are used to destroy brain tissue.
Approximately 1,300 subcaudate tractotomies were performed in one institution in Britain Brook Hospital during the 1980s, with its widespread use ending in 1994, although the procedure is still performed today. Subcaudate tractotomy is performed more commonly in Britain than in the U.S. (where the anterior cingulotomy is preferred).
This is a procedure wherein a small bundle of nerve fibers that connect the frontal lobes with the limbic system is severed with a precise operation.
Cosgrove and Rauch (Harvard) note concerning cingulotomy that "although the patient may experience an immediate reduction in anxiety, there is generally a delay on the onset of a beneficial effect on depression and obsessive-compulsive disorder. This latency may be as long as six to twelve weeks and must be clearly explained to the patient and referring psychiatrist.”
If there has been no response to the initial cingulotomy after three to six months, then reoperation and enlargement of the cingulotomy lesion is considered. "There have been over 800 cingulotomies performed at the Massachusetts General Hospital (MGH) since 1962 (2005).
Cingulotomy is the treatment of choice in this country, whereas in Europe, capsulotomy and limbic leucotomy are more prevalent. They all appear roughly equivalent therapeutically, but in terms of unwanted side effects, cingulotomy appears to be the safest of all procedures currently performed (Cosgrove, Rauch, 2005).
Statistical Effectiveness of Cingulotomy
Ballantine, et al, retrospectively reported the results of bilateral cingulotomy in 198 patients suffering from a variety of psychiatric disorders in 1987. With a mean follow-up of 8.6 years, 62% of patients with severe affective disorder were found to have had worthwhile improvement.
Similarly, in patients with obsessive-compulsive disorder, approximately 56% were found to have undergone worthwhile improvement. In 14 patients suffering from non-obsessive anxiety disorders, 50% were found to be functionally well, and 29% were found to have shown marked improvement. A recent retrospective study evaluating cingulotomy in 33 patients with refractory obsessive-compulsive disorder demonstrated that using very strict criteria for a successful outcome, at least 25 to 30% of patients benefited substantially from the procedure [Jenike and Baer, 1991] (Cosgrove, Rauch, 2005).
Capsulotomy - Psychosurgery Involving the Drilling of Small Holes in Skull
Originally developed in Sweden, capsulotomy is a surgery that involves drilling very small holes in the skull, and inserting tiny electrodes in the brain. The electrodes are heated up, which destroys the adjacent cellular structures.
When there is little response from the first surgery, a repeat, deeper surgery is performed. The rate of resurgery is reportedly 20% (Cosgrove, Rauch, 2005). Neurosurgery without the need to drill has been developed using a gamma knife or proton beam.
Anterior Capsulotomy - Facts and Statistics
In the first 116 patients operated on by Leksell, 50% of patients with obsessive neurosis and 48% of depressed patients had a "satisfactory" response. Only 20% of patients with anxiety neurosis and 14% of patients with schizophrenia showed any improvement. In this classification system, only patients who were free of symptoms or markedly improved were judged as having a satisfactory response.
Of the patients who were rated as worse after capsulotomy, nine were schizophrenic, four were depressive, and three obsessive.
Percentages of Success and Failure with Capsulotomy Psychosurgery
Satisfactory response to capsulotomy:
· Obsessive Neurosis - 48%
· Anxiety Neurosis - 20%
· Schizophrenia - 14%
Rated Worse After Capsulotomy Psychosurgery - 14%
Deep Brain Stimulation
-------Highly Experimental Neurosurgery for Chronic Depression
Deep brain stimulation is a highly experimental neurosurgical treatment for chronic depression in which the brain is stimulated with electrical impulses.
Although the technique has been approved for several other conditions as well, deep brain stimulation has not been approved by the Food and Drug Administration (FDA) for depression treatment, and is in the early stages of research.
Since it requires brain surgery, deep brain stimulation is the most invasive form of brain stimulation treatment for depression. Deep brain stimulation works much like a pacemaker for your brain.
Deep Brain Stimulation Risks
Any surgical procedure carries risks, including all types of brain surgery. Deep brain stimulation involves brain surgery, and is an especially risky procedure posing risks within the brain from the surgery, as well as on general health. The brain stimulation itself may cause severe side effects.
Possible surgical complications may include:
· Bleeding in the brain
· Breathing problems
· Heart problems
· Incision scarring
Possible side effects of deep brain surgery after surgery include:
· Bleeding in the brain
· Unwanted mood changes such as mania and depression
· Movement disorders
· Device malfunction
· Temporary tingling in the face or limbs
Those who have undergone deep brain stimulation to treat Parkinson's disease have reported a variety of problems, including:
· Panic attacks
· Speech difficulty
· Movement problems
· Increased suicidal thoughts and behavior
The long-term risks and side effects of deep brain stimulation for depression are not fully known.
(Deep Brain Stimulation. MayoClinic.com). http://www.mayoclinic.com/health/deep-brain-stimulation/MY00184)
Effectiveness of Psychosurgery on OCD Patients
There have not been enough studies on psychosurgery to make firm conclusions. In one small study of 35 patients with OCD who underwent capsulotomy and were followed by independent psychiatrists, 16 were rated as free of symptoms, and nine were much improved for an overall satisfactory result of 70% (Cosgrove, Rauch, 2005). Side effects, however, were not considered in this report.
In another study of about 253 severe OCD patients, about one-half experienced a 35% reduction in intensity of symptoms after surgery (Mindus, et al. 1993, 1994).
· Another summary of studies was not as optimistic, with only 30% experiencing a 35% reduction in the intensity of OCD symptoms (Mashoura, Walker, Martuza, 2005).
· Unlike the more primitive lobotomy, deaths or increased risk of suicide does not seem to commonly result from current psychosurgery techniques.
Bipolar Disorder: While psychosurgery has been performed for intractable bipolar disorder, it has not been effective on treating mania, notes Cho, Lee, and Chen in the published study, "Limbic leukotomy for intractable major affective disorders: a 7-year follow-up study using nine comprehensive psychiatric test evaluations."
Conclusion on Psychosurgery and Today's Ethical Considerations
Despite the fact that modern psychosurgery is a far cry from past days of widespread abuse of the practice in psychiatric hospitals, the use of psychosurgery for mental disorders is still far from mainstream or without controversy. Massachusetts General Hospital (MGH) in Boston has led the way in the U.S., with a pilot program and the leading center for psychosurgery in the country.
Author Andrew Solomon states that MGH only performs 15 to 20 procedures per year (2011), with a vigorous pre-screening process before surgery that lasts a full year.
Serious questions remain, though, about the program, methodologies, and ethics. While MGH has been touted as a model program, some experts question that label. In Psychiatric Times, Alan A. Stone, M.D. writes, "in my opinion, even if one accepts the practices in place at MGH, this should not be considered a model program for centers around the world." In one case of patterning after the model of MGH, widespread serious abuse of neurosurgery has been documented in China, and important ethical considerations are still unresolved.
1. As of 2008 there has been no system of institutional review from those outside of the MGH program. The only opinions were from members of the hospital's own staff.
2. Another serious issue, and one that comes up frequently in psychiatric treatment is that of informed consent. Can a person with intractable OCD be in a position to provide his or her own informed consent? Should the family decide for him/her?
3. While doctors who refer patients to the MGH neurosurgery program testify that their patients have not responded to medication treatment or to cognitive-behavioral therapy (CBT), it can be very difficult to determine if patients have actually adhered to their treatment.
4. MGH offers neurosurgery to patients as young as 18 years of age. The brain does not stop developing, however, until the mid-20s. Is it appropriate to promote such a drastic, last-resort method on brains that are still in physical and emotional flux?
As to the efficacy of psychosurgery, perhaps the most carefully studied patients are those who have been treated for intractable OCD with stereotactic cingulotomy. While there have been some studies indicated significant improvements in from 28% to 50% of cases, "the nature of these studies [supporting the practice of psychosurgery] and the ongoing treatment [medications and CBT post surgery] ... limit interpretation of these results."
Psychiatry Times points to the overriding ethical question: Do we know enough neuroscience to know that we are not doing more harm than good in the long run? It and recommends "utmost scientific caution."
1. Carson, Robert. C., Butcher, James, N., Mineka, Susan, (2000). Abnormal Psychology and Modern Life. 11th Edition. Boston: Allyn & Bacon
2. Cho, D., Lee W. Y., Chen C. C. (2008, February). Limbic leukotomy for intractable major affective disorders: a 7-year follow-up study using nine comprehensive psychiatric test evaluations. Journal of Clinical Neuroscience. Feb;15(2):138-42. Epub 2007 Dec 18.
3. Cosgrove, G. R., MD., FRCS(C), Rauch, S.L., MD, (May 31, 2005). Psychosurgery. Departments of Neurosurgery and Psychiatry, Massachusetts General Hospital and, Harvard Medical School, Boston, Massachusetts
4. Deep Brain Stimulation. (July 31, 2008). Mayo Clinic. http://www.mayoclinic.com/health/deep-brain-stimulation/MY00184
5. Eskandar, E. N., Cosgrove, G. R., Rauch, S. L. (2001). Psychiatric Neurosurgery. Departments of Neurosurgery and Psychiatry, Massachusetts General Hospital. Boston, Massachusetts. http://neurosurgery.mgh.harvard.edu/functional/Psychosurgery2001.htm
6. Frequently Asked Questions About Lobotomies. (2005, November 16). National Public Radio (NPR). http://www.npr.org/templates/story/story.php?storyId=5014565
7. Kartsounis, L.D. Poynton, A., Bridges. P.K., Bartlett. J.R. (1991). Brain. 1991 Dec; 114 (Pt 6):2657-73. http://www.ncbi.nlm.nih.gov/pubmed/1782537
8. Mashoura, G. A., Walker, E. E., Martuza, R. L. (2005). Psychosurgery: past, present, and future. Brain Research Reviews. Retrieved April 19, 2015 from Stanford Medicine. http://med.stanford.edu/dura/Articles/Psychosurgery.pdf
9. MGH Psychiatric Neurosurgery Committee, (May 11, 2005). Massachusetts General Hospital.
10. Neurosurgery Service, Functional and Stereotactic Surgery Center. Massachusetts General Hospital.
11. Solomon, A. (2001). The Noonday Demon. New York: Simon & Schuster.
12. Stone, A. A. (2008, June 1). Psychosurgery—Old and New. Psychiatric Times. http://www.psychiatrictimes.com/articles/psychosurgery%E2%80%94old-and-new
13. Subcaudate Tractotomy. OCD-UK. Retrieved April 19, 2015. http://www.ocduk.org/subcaudate-tractotomy