Psychosurgery: Prefrontal lobotomy, cingulotomy, capsulotomy. Brief history and modern use
16th October 2023
Psychosurgery Psychosurgery is also referred to as neurosurgery. Psychosurgery's first use in modern times was reported by Burkhardt in 1891. (Cosgrove, Rauch, 2005).The most well known example of dramatic psychosurgery is that of the prefrontal lobotomy. First used in Portugal, the prefrontal lobotomy, particularly for violent patients in mental hospitals, was rendered upon tens of thousands of patients between 1935 and 1955. As is often the case with newly developed therapeutic techniques, initial reports of results tended to be enthusiastic, downplaying complications, (including a 1 in 4 death rate) and undesirable side effects. Permanent inability to inhibit impulses, an unnatural "tranquility" with undesirable shallowness of absence of felling, were some of the disturbing side effects of the prefrontal lobotomy. In 1951, the Soviet Union banned all such operations. The operation is rare today, however, law still permits it in the U.S. and many other countries, so that there has been something of a comeback in a modified form of the treatment for some difficult to treat disorders. Psychosurgery in general is still relatively rare, and used as a last resort for the intractable psychotic, severely and chronic cases of OCD (Obsessive Compulsive Disorder), and occasionally in treating severe pain in the case of terminal illness. Cosgover and Rauch (Harvard) state, Surgical intervention remains an important therapeutic option for disabling psychiatric disease and is probably underutilized." Despite this, they also state concerning psychosurgery, "However, despite these modern treatment methods, many patients fail to respond adequately and remain severely disabled." (Cosgrove, Rauch, 2005). See the book: Great and Deperate Curse by Elliot Valnestein, where he explains how the treatment came to be accepted. He concluded that psychiatrists needed to gain accepting as a medical science, and that the use of surgery fitted well into that need in the 1930s and 1940s. Also, it proved to be a cost-effective treatment, and a way to maintain control over mental patients. Modern psychosurgery techniques Today, the permanent damage to the brain has been substantially minimized and there are fewer detrimental side effects. Cingulotomy A small bundle of nerve fibers that connect the frontal lobes with the limbic system is interrupted, with a precise operation. Consgrove and Rauch (Harvard) report concerning cingulotomy, that "although the patient may experience an immediate reduction in anxiety, there is generally a delay to the onset of 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 MGH since 1962. Cingulotomy is the treatment of choice in this country whereas in Europe, capsulotomy and limbic leucotomy are more prevalent. They all appear roughly equivalent therapeuticly but in terms of unwanted side effects, cingulotomy appears to be the safest of all procedures currently performed. (Cosgrove, Rauch, 2005). Capsulotomy Originally developed in Sweden, it is a surgery which 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 reported as 20%.(Cosgrove, Rauch, 2005). Neurosurgery without the need to drill has been develop using a gamma knife or proton beam. Statistical effectiveness: Cingulotomy The results of bilateral cingulotomy in 198 patients suffering from a variety of psychiatric disorders were reported retrospectively by Ballantine et al 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 nonobsessive 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 successful outcome, at least 25 to 30% of patients benefited substantially from the procedure. [Jenike and Baer, 1991].(Cosgrove, Rauch, 2005). Anterior capsulotomy In the first 116 patients operated on by Leksell, 50% of patients with obsessional neurosis and 48% of depressed patients had a satisfactory response. Only 20% of patients with anxiety neurosis and 14% of patients with schizophrenia were improved. 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, 9 were schizophrenics, 4 depressives and 3 obsessives. In another series of 35 patients with OCD who underwent capsulotomy and were followed prospectively by independent psychiatrists, 16 were rated as free of symptoms and 9 were much improved for an overall satisfactory result of 70%.(Cosgrove, Rauch, 2005). Deep Brain Stimulation Deep brain stimulation is a highly experimental neurosurgical treatment for chronic depression in which the brain is stimulated with electrical impulses. Although it's been approved for several other conditions, deep brain stimulation hasn't been approved by the Food and Drug Administration (FDA) for depression treatment and is in the early stages of research. Requiring 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. Risks Any surgical procedure carries risks. Because deep brain stimulation involves brain surgery, the procedure may be especially risky, posing some serious health risks. Also, the brain stimulation itself may cause side effects. Possible surgical complications Complications of surgery may include:Bleeding in the brain Stroke Infection Breathing problems Nausea Heart problems Incision scarring Possible side effects after surgery Side effects and adverse health problems associated with deep brain stimulation include, but may not be limited to:Bleeding in the brain Seizure Infection Delirium Unwanted mood changes, such as mania and depression Movement disorders Lightheadedness Insomnia Dizziness Device malfunction Temporary tingling in your face or limbs Also, people who have undergone deep brain stimulation to treat Parkinson's disease have reported a variety of problems, including:Panic attacks Mania Speech difficulty Movement problems Increased suicidal thoughts and behavior Standard treatment for people with Parkinson's disease, essential tremor and dystonia. The long-term risks and side effects of deep brain stimulation for depression aren't known. (Deep Brain Stimulation. MayoClinic.com. http://www.mayoclinic.com/health/deep-brain-stimulation/MY00184) There have not been enough studies on psychosurgery to make firm conclusions. In ones studied orf about 253 sever OCD patients, about one-half experienced a 35% reduction in intensity of symptoms after surgery. ( Mindus, eta all, 1993, 1994). No deaths occurred and increased risk of suicide was not reported in this study). References: 1. Carson, Robert. C., Butcher, James, N., Mineka, Susan, (2000). Abnormal Psychology and Modern Life. 11th Edition. Boston: Allyn & Bacon 2. 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 3. Deep Brain Stimulation. (July 31, 2008). Mayo Clinic. http://www.mayoclinic.com/health/deep-brain-stimulation/MY00184 |