Psychosurgery

History

Contemporary psychosurgery

Patient selection

Postoperative care

Current status

Resources

Psychosurgery is the alteration or destruction of brain matter in order to alleviate severe, long-lasting, and harmful psychiatric symptoms that do not respond to psychotherapy, behavioral, physical, or drug treatments. Psychosurgery involves opening up the skull or entering the brain through natural fissures such as the eye sockets, and injecting various tissue-altering solutions, removing or destroying brain tissue using various tools, or severing certain connections between different parts of the brain. Techniques used in this controversial and now rarely performed surgical procedure have changed greatly since its beginning in the 1930s.

History

The use of psychosurgery has been traced back to approximately 2000 BC using archaeological evidence of skulls with relatively precise holes that seem to have been bored intentionally. It is unclear whether brain matter was directly manipulated in this process called trepanation. Its intended purpose may have been to relieve what was thought to be excess pressure in the skull. Some cultures seem to have performed trepanation in order to allow what they thought were bad spirits to escape.

The first report of surgery on the brain to relieve psychiatric symptoms has been traced to the director of a mental asylum in Switzerland, Gottlieb Burckhardt, who in 1890 removed parts of the cerebral cortex. He performed this procedure on six patients described as highly excitable. The procedure, however, did not seem to lessen the patients’ degree of excitability, and in fact seemed to lead to seizures. Burckhardt’s procedure met with great opposition and he was forced to stop performing the surgery.

Modern psychosurgery can be traced to the Portuguese physician Egas Moniz (1875-1955) who performed the first prefrontal leukotomy in 1935. Apparently, Moniz had been influenced by a case involving the unintentional damage of a patient’s prefrontal areas of the brain in which the patient, although suffering some personality change, continued to function. Moniz also seemed to be influenced by research at Yale reporting that an agitated chimpanzee was greatly calmed after its frontal lobes had been severely damaged.

Moniz’s first operation involved drilling two holes in the upper forehead area and injecting absolute alcohol directly into the frontal lobes of the brain. The absolute alcohol acted to destroy the brain tissue it came into contact with. In following operations, Moniz used an instrument called a leukotome, which consists of a narrow rod with a retractable wire loop at one end. Moniz would insert the instrument through the drilled holes, extend the wire loop, and rotate it to destroy brain tissue located in the frontal lobes of the brain. Moniz reported some success in removing some of the patients’ more striking psychotic symptoms such as hallucinations and delusions. The accuracy of Moniz’s findings and the degree of his success, however, are now questioned. It seems that while it lessened a patient’s anxiety and aggression, it often produced marked personality changes and impaired intellectual performance.

The practice of psychosurgery began to receive more attention after Moniz’s reports of success, and its study was taken up by a number of researchers, most notably the American physician Walter J. Freeman and neurosurgeon James W. Watts in the late 1930s. These two prominent physicians greatly publicized the prefrontal leukotomy, revised Moniz’s initial procedures, and changed the procedure’s name to lobotomy.

Around this time, American neurosurgeon J.G. Lyerly developed a procedure that allowed visualization of the brain during surgery. This enabled more precise surgical intervention and seemed to lead to increased use of psychosurgery. Meanwhile, Freeman and Watts continued their research, and the publication of their widely acclaimed book Psychosurgery in 1942 led to increases in psychosurgical procedures worldwide. During the mid-1940s, surgeons developed a number of different psychosurgical techniques intended to improve patient outcome following lobotomy, and the use of psychosurgery increased dramatically.

In the 1950s chlorpromazine and a number of antipsychotic medications were introduced and the number of lobotomies declined rapidly. These drugs not only provided relief from some patients’ severe and harmful symptoms, but they were also simple and inexpensive compared to psychosurgery. Moreover, unlike psychosurgery, their effects were apparently reversible. It had become evident over time that lobotomies were not as effective as previously thought, and that, in fact, they often resulted in brain damage.

In order to understand the ease with which psychosurgical procedures were taken up by so many physicians it must be understood that most psychiatrists believed psychotic symptoms would not respond to psychotherapy, and up until the 1950s there were no effective drug treatments for serious mental disorders. Thus, psychosurgery was viewed as having the potential to treat disorders that had been seen as untreatable. Moreover, the treatment of the mentally ill at this time was largely custodial, and the number of severely disturbed individuals in mental health treatment centers was too great to be treated with psychotherapy, which was just beginning to gain acceptance in the 1940s and 1950s. In sum, psychosurgery appealed to many mental health professionals as a potentially effective and economical treatment for patients for whom there seemed to be no effective treatment.

Contemporary psychosurgery

Over time, psychosurgical procedures have been created that are more precise and restricted in terms of the amount of brain tissue affected. During the 1950s, a stereotaxic instrument was developed that held the patient’s head in a stable position and allowed the more precise manipulation of brain tissue by providing a set of three-dimensional coordinates. Stereotaxic instruments generally consist of a rigid frame with an adjustable probe holder. The instrument is secured on the patient’s skull, and in modern psychosurgery is used in conjunction with images of the patient’s brain created with brain-imaging techniques. Brain-imaging techniques such as computed tomography and magnetic resonance imaging allow accurate visualization of the brain and precise location of a targeted brain area or lesion. Coordinates of the targeted visual area are then matched with points on the stereotaxic instrument’s frame, which has been included in the image. Using these measurements, the attached probe holder’s position is adjusted so that the probe will reach the intended area in the brain. Because of individual anatomical differences, surgeons will often electrically stimulate the targeted area observing the effect on a conscious patient in order to verify accurate placement of the probe.

Over the years, neurosurgeons have begun to use electrodes to deliver electric currents and radio frequency waves to specific sites in the brain rather than using various sharp instruments. Compared with the earlier lobotomies, relatively small areas of brain tissue are destroyed with these techniques. Other methods of affecting brain tissue include using cryoprobes that freeze tissue at sites surrounding the probe, radioactive elements, and ultrasonic beams. The most commonly used method today is radio frequency waves.

The more modern restricted psychosurgical procedures usually target various parts of the brain’s limbic system. The limbic system is made up of a number of different brain structures that form an arc located in the forebrain. The limbic system seems highly involved in emotional and motivational behaviors. These techniques include destruction of small areas of the frontothalamus, orbital undercutting, cingulectomy, subcaudate tractotomy, limbic leucotomy, anterior capsulotomy, and amygdalotomy. Cingulectomy involves severing fibers in the cingulum, a prominent brain structure that is part of the limbic system. Subcaudate tractotomy was developed in 1964 in Great Britain and uses radioactive yttrium-90 implants to interrupt the signals transmitted in the white matter of the brain. This type of psychosurgery involves a smaller lesion and decreased side effects.

The limbic leucotomy was developed in 1973 and combines the subcaudate tractotomy and the cingulectomy. In this surgery, two lesions are created and brain material is destroyed using a cryoprobe or electrode. An anterior capsulotomy interrupts connections in the frontothalamus with electrodes. There seems to be marked side effects associated with this procedure. Amygdalotomy is a type of psychosurgery in which fibers of the amygdala are severed. The amygdala is a small brain structure that is part of the temporal lobe and is classified as being a part of the limbic system. Cingulectomies are now the most common type of psychosurgery procedure used.

Psychosurgery was initially widely accepted without much evidence as to its efficacy and side effects and it has generated a great deal of controversy for many reasons. These include the fact that it involves the destruction of seemingly healthy brain tissue, it is irreversible, and, at least in its earliest procedures, frequently seemed to cause some very harmful side effects. The National Commission for the Protection of Human Subjects of

KEY TERMS

Antipsychotic drugs— These drugs, also called neuroleptics, seem to block the uptake of dopamine in the brain. They help to reduce psychotic symptoms across a number of mental illnesses.

Computed tomography— A technique for visualizing a plane of the body using a number of x rays that are converted into one image by computer.

Cortex— The outer layer of the brain.

Delusions— Fixed, false beliefs that are resistant to reason or factual disproof.

Dopamine— A neurotransmitter that acts to decrease the activity of certain nerve cells in the brain, it seems to be involved in schizophrenia.

Hallucinations— A sensory experience of something that does not exist outside the mind. A person can experience a hallucination in any of the five senses.

Leukotomy— A rarely used psychosurgical procedure in which tissue in the frontal lobes of the brain is destroyed.

Limbic system— A part of the brain made up of a number of different structures, it forms an arc and is located in the forebrain. The limbic system seems highly involved in emotional and motivational behaviors.

Magnetic resonance imaging— A technique using radio frequency pulses that creates images which show various size, density and spatial qualities of the targeted body area, e.g. the brain. Neuroimaging techniques—High technology methods that enable visualization of the brain without surgery such as computed tomography and magnetic resonance imaging.

Psychotherapy— A broad term that usually refers to interpersonal verbal treatment of disease or disorder that addresses psychological and social factors.

Stereotaxic instrument— Generally, a rigid frame with an adjustable probe holder that is secured on patient’s skull for psychosurgery, it enables more accurate brain tissue manipulation.

Biomedical and Behavioral Research was created in the mid-1970s to examine research procedures that appeared questionable in the United States. The commission sponsored a number of studies looking at the risks and benefits of psychosurgery. Basically, the Commission concluded that psychosurgery can be highly beneficial for certain types of disorders, but that every procedure should be screened by an institutional review board before it is allowed.

In a review of psychosurgery procedures performed between 1976 and 1977, Elliot Valenstein, in a report for the Commission, concluded that approximately 60-90% of the patients showed a marked reduction in their more severe symptoms, and a very low risk of some of the permanent negative side effects seen in earlier lobotomy procedures. Valenstein primarily looked at more restricted frontal lobe operations and cingulectomy.

Currently, psychosurgery is only performed as a last resort. Most of the psychiatric disorders that were originally treated with psychosurgery, such as schizophrenia and severe depression with psychotic symptoms, are now treated in a more satisfactory manner by drugs. Even current psychosurgical procedures appear beneficial for only a very limited number of patients. It seems that patients suffering severe major depression with physiological symptoms and obsessive tendencies along with agitation and marked tension are most likely to benefit, providing there has been a reasonably stable personality before the onset of symptoms. In rare cases, psychosurgery is performed in patients that show severe violent outbursts and who may cause harm to themselves or others. Used cautiously, these procedures can reduce some of a patient’s more disturbing symptoms without producing irreversible negative effects on personality and intellectual functioning.

Patient selection

Because the positive effects of psychosurgery are limited to only a few types of psychiatric conditions, diagnosis and thorough evaluation of the patient is crucial. The mental health professional must first establish that the patient’s condition is chronic or long-lasting, having been present continuously for a minimum of three years. In addition, the patient’s symptoms must be observed to not respond to psychotherapy, behavioral, physical, or drug treatments.

Postoperative care

Most current psychosurgeries require the patient to spend only a few days in the hospital. Physical complications following the more limited psychosurgeries are relatively rare but hemorrhage may occur following surgery and epilepsy sometimes develops even a number of months following the surgical procedure. In general, the effects of the surgery on the patient usually take some time before they can be observed and it is essential that the patient receive thorough postoperative care and return for follow-up assessment.

In order to increase the benefit of psychosurgery, most professionals involved in psychosurgery strongly recommend intense postoperative psychiatric care. It seems that some patients benefit more from various drug, behavioral, and psychotherapy treatments following a procedure than they did prior to it.

Current status

Psychosurgery has gone through periods of widespread, relatively uncritical acceptance, and periods of great disfavor in the medical community. In the early years of its use there were no well-conducted, detailed, rigorous studies of outcome or differences in procedure. The development of various diagnostic and psychological assessment measures has enabled more rigorous follow-up studies of patients assessing the relationship between different procedures, a patient’s characteristics, and their long-term outcome.

As stated previously, psychosurgical procedures have changed dramatically since their beginning. Psychosurgery is still rarely used today, despite a recent resurgence in the procedure. It is most likely to benefit patients with particular symptom patterns seen in some patients with chronic major depression or obsessive-compulsive disorder. These include compulsions, obsessions, and long-lasting, high levels of anxiety (often seen as agitation). These patients often respond well to psychosurgery. Moreover, because they are usually coherent and rational, consent can be obtained from the patient and their family. Psychosurgery has benefited greatly from improvements in technology such as magnetic resonance imaging, probe techniques, and stereotaxic instruments. Future technological developments and increased understanding of the brain, particularly the limbic system, show potential for increasing the safety efficacy of psychosurgical techniques.

Resources

BOOKS

Kaye, Andrew H. Essential Neurosurgery, 3rd ed. Malden, MA: Blackwell Publishing Professional, 2005.

Pressman, Jack D. Last Resort: Psychosurgery and the Limits of Medicine. Cambridge, U.K.: Cambridge University Press, 2002.

Valenstein, E.S. Great and Desperate Cures: The Rise and Fall of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books, 1986.

Marie Doorey

Psychosurgery

Psychosurgery is the alteration or destruction of brain matter in order to alleviate severe, long-lasting, and harmful psychiatric symptoms that do not respond to psychotherapy, behavioral, physical, or drug treatments. Psychosurgery involves opening up the skull or entering the brain through natural fissures such as the eye sockets, and injecting various tissue-altering solutions, removing or destroying brain tissue using various tools, or severing certain connections between different parts of the brain. Techniques used in this controversial and now rarely performed surgical procedure have changed greatly since its beginning in the 1930s.

History

The use of psychosurgery has been traced back to approximately 2000 b.c. using archaeological evidence of skulls with relatively precise holes that seem to have been bored intentionally. It is unclear whether brain matter was directly manipulated in this process called trepanation. Its intended purpose may have been to relieve what was thought to be excess pressure in the skull. Some cultures seem to have performed trepanation in order to allow what they thought were bad spirits to escape.

The first report of surgery on the brain to relieve psychiatric symptoms has been traced to the director of a mental asylum in Switzerland, Gottlieb Burckhardt, who in 1890 removed parts of the cerebral cortex. He performed this procedure on six patients described as highly excitable. The procedure, however, did not seem to lessen the patients' degree of excitability, and in fact seemed to lead to seizures. Burckhardt's procedure met with great opposition and he was forced to stop performing the surgery.

Modern psychosurgery can be traced to the Portuguese physician Egas Moniz (1875-1955) who performed the first prefrontal leukotomy in 1935. Apparently, Moniz had been influenced by a case involving the unintentional damage of a patient's prefrontal areas of the brain in which the patient, although suffering some personality change, continued to function. Moniz also seemed to be influenced by research at Yale reporting that an agitated chimpanzee was greatly calmed after its frontal lobes had been severely damaged.

Moniz's first operation involved drilling two holes in the upper forehead area and injecting absolute alcohol directly into the frontal lobes of the brain. The absolute alcohol acted to destroy the brain tissue it came into contact with. In following operations, Moniz used an instrument called a leukotome, which consists of a narrow rod with a retractable wire loop at one end. Moniz would insert the instrument through the drilled holes, extend the wire loop, and rotate it to destroy brain tissue located in the frontal lobes of the brain. Moniz reported some success in removing some of the patients' more striking psychotic symptoms such as hallucinations and delusions. The accuracy of Moniz's findings and the degree of his success, however, are now questioned. It seems that while it lessened a patient's anxiety and aggression, it often produced marked personality changes and impaired intellectual performance.

The practice of psychosurgery began to receive more attention after Moniz's reports of success, and its study was taken up by a number of researchers, most notably the American physician Walter J. Freeman and neurosurgeon James W. Watts in the late 1930s. These two prominent physicians greatly publicized the prefrontal leukotomy, revised Moniz's initial procedures, and changed the procedure's name to lobotomy.

Around this time, American neurosurgeon J.G. Lyerly developed a procedure that allowed visualization of the brain during surgery. This enabled more precise surgical intervention and seemed to lead to increased use of psychosurgery. Meanwhile, Freeman and Watts continued their research, and the publication of their widely acclaimed book Psychosurgery in 1942 led to increases in psychosurgical procedures worldwide. During the mid-1940s, surgeons developed a number of different psychosurgical techniques intended to improve patient outcome following lobotomy, and the use of psychosurgery increased dramatically.

In the 1950s chlorpromazine and a number of antipsychotic medications were introduced and the number of lobotomies declined rapidly. These drugs not only provided relief from some patients' severe and harmful symptoms, but they were also simple and inexpensive compared to psychosurgery. Moreover, unlike psychosurgery, their effects were apparently reversible. It had become evident over time that lobotomies were not as effective as previously thought, and that, in fact, they often resulted in brain damage.

In order to understand the ease with which psychosurgical procedures were taken up by so many physicians it must be understood that most psychiatrists believed psychotic symptoms would not respond to psychotherapy, and up until the 1950s there were no effective drug treatments for serious mental disorders. Thus, psychosurgery was viewed as having the potential to treat disorders that had been seen as untreatable. Moreover, the treatment of the mentally ill at this time was largely custodial, and the number of severely disturbed individuals in mental health treatment centers was too great to be treated with psychotherapy, which was just beginning to gain acceptance in the 1940s and 1950s. In sum, psychosurgery appealed to many mental health professionals as a potentially effective and economical treatment for patients for whom there seemed to be no effective treatment.

Contemporary psychosurgery

Over time, psychosurgical procedures have been created that are more precise and restricted in terms of the amount of brain tissue affected. During the 1950s, a stereotaxic instrument was developed that held the patient's head in a stable position and allowed the more precise manipulation of brain tissue by providing a set of three-dimensional coordinates. Stereotaxic instruments generally consist of a rigid frame with an adjustable probe holder. The instrument is secured on the patient's skull, and in modern psychosurgery is used in conjunction with images of the patient's brain created with brain-imaging techniques. Brain-imaging techniques such as computed tomography and magnetic resonance imaging allow accurate visualization of the brain and precise location of a targeted brain area or lesion. Coordinates of the targeted visual area are then matched with points on the stereotaxic instrument's frame, which has been included in the image. Using these measurements, the attached probe holder's position is adjusted so that the probe will reach the intended area in the brain. Because of individual anatomical differences, surgeons will often electrically stimulate the targeted area observing the effect on a conscious patient in order to verify accurate placement of the probe.

Over the years, neurosurgeons have begun to use electrodes to deliver electric currents and radio frequency waves to specific sites in the brain rather than using various sharp instruments. Compared with the earlier lobotomies, relatively small areas of brain tissue are destroyed with these techniques. Other methods of affecting brain tissue include using cryoprobes that freeze tissue at sites surrounding the probe, radioactive elements, and ultrasonic beams. The most commonly used method today is radio frequency waves.

The more modern restricted psychosurgical procedures usually target various parts of the brain's limbic system. The limbic system is made up of a number of different brain structures that form an arc located in the forebrain. The limbic system seems highly involved in emotional and motivational behaviors. These techniques include destruction of small areas of the frontothalamus, orbital undercutting, cingulectomy, subcaudate tractotomy, limbic leucotomy, anterior capsulotomy, and amygdalotomy. Cingulectomy involves severing fibers in the cingulum, a prominent brain structure that is part of the limbic system. Subcaudate tractotomy was developed in 1964 in Great Britain and uses radioactive yttrium-90 implants to interrupt the signals transmitted in the white matter of the brain. This type of psychosurgery involves a smaller lesion and decreased side effects. The limbic leucotomy was developed in 1973 and combines the subcaudate tractotomy and the cingulectomy. In this surgery, two lesions are created and brain material is destroyed using a cryoprobe or electrode. An anterior capsulotomy interrupts connections in the frontothalamus with electrodes. There seems to be marked side effects associated with this procedure. Amygdalotomy is a type of psychosurgery in which fibers of the amygdala are severed. The amygdala is a small brain structure that is part of the temporal lobe and is classified as being a part of the limbic system. Cingulectomies are now the most common type of psychosurgery procedure used.

Psychosurgery was initially widely accepted without much evidence as to its efficacy and side effects and it has generated a great deal of controversy for many reasons. These include the fact that it involves the destruction of seemingly healthy brain tissue, it is irreversible, and, at least in its earliest procedures, frequently seemed to cause some very harmful side effects. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research was created in the mid-1970s to examine research procedures that appeared questionable in the United States. The commission sponsored a number of studies looking at the risks and benefits of psychosurgery. Basically, the Commission concluded that psychosurgery can be highly beneficial for certain types of disorders, but that every procedure should be screened by an institutional review board before it is allowed.

In a review of psychosurgery procedures performed between 1976 and 1977, Elliot Valenstein, in a report for the Commission, concluded that approximately 60-90% of the patients showed a marked reduction in their more severe symptoms, and a very low risk of some of the permanent negative side effects seen in earlier lobotomy procedures. Valenstein primarily looked at more restricted frontal lobe operations and cingulectomy.

Currently, psychosurgery is only performed as a last resort. Most of the psychiatric disorders that were originally treated with psychosurgery, such as schizophrenia and severe depression with psychotic symptoms, are now treated in a more satisfactory manner by drugs. Even current psychosurgical procedures appear beneficial for only a very limited number of patients. It seems that patients suffering severe major depression with physiological symptoms and obsessive tendencies along with agitation and marked tension are most likely to benefit, providing there has been a reasonably stable personality before the onset of symptoms. In rare cases, psychosurgery is performed in patients that show severe violent outbursts and who may cause harm to themselves or others. Used cautiously, these procedures can reduce some of a patient's more disturbing symptoms without producing irreversible negative effects on personality and intellectual functioning.

Patient selection

Because the positive effects of psychosurgery are limited to only a few types of psychiatric conditions, diagnosis and thorough evaluation of the patient is crucial. The mental health professional must first establish that the patient's condition is chronic or long-lasting, having been present continuously for a minimum of three years. In addition, the patient's symptoms must be observed to not respond to psychotherapy, behavioral, physical, or drug treatments.

Postoperative care

Most current psychosurgeries require the patient to spend only a few days in the hospital. Physical complications following the more limited psychosurgeries are relatively rare but hemorrhage may occur following surgery and epilepsy sometimes develops even a number of months following the surgical procedure. In general, the effects of the surgery on the patient usually take some time before they can be observed and it is essential that the patient receive thorough postoperative care and return for follow-up assessment.

In order to increase the benefit of psychosurgery, most professionals involved in psychosurgery strongly recommend intense postoperative psychiatric care. It seems that some patients benefit more from various drug, behavioral, and psychotherapy treatments following a procedure than they did prior to it.

Current status

Psychosurgery has gone through periods of widespread, relatively uncritical acceptance, and periods of great disfavor in the medical community. In the early years of its use there were no well-conducted, detailed, rigorous studies of outcome or differences in procedure. The development of various diagnostic and psychological assessment measures has enabled more rigorous follow-up studies of patients assessing the relationship between different procedures, a patient's characteristics, and their long-term outcome.

As stated previously, psychosurgical procedures have changed dramatically since their beginning. Psychosurgery is still rarely used today, despite a recent resurgence in the procedure. It is most likely to benefit patients with particular symptom patterns seen in some patients with chronic major depression or obsessive-compulsive disorder. These include compulsions, obsessions, and long-lasting, high levels of anxiety (often seen as agitation). These patients often respond well to psychosurgery. Moreover, because they are usually coherent and rational, consent can be obtained from the patient and their family. Psychosurgery has benefited greatly from improvements in technology such as magnetic resonance imaging, probe techniques, and stereotaxic instruments. Future technological developments and increased understanding of the brain, particularly the limbic system, show potential for increasing the safety efficacy of psychosurgical techniques.

Resources

books

Jennett, B., and K.W. Lindsay. An Introduction to Neuro-Surgery. 5th ed. Oxford: Butterworth-Heinemann, 1994.

Valenstein, E.S. Great and Desperate Cures: The Rise and Fall of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books, 1986.

Marie Doorey

KEY TERMS

Antipsychotic drugs

—These drugs, also called neuroleptics, seem to block the uptake of dopamine in the brain. They help to reduce psychotic symptoms across a number of mental illnesses.

Computed tomography

—A technique for visualizing a plane of the body using a number of x rays that are converted into one image by computer.

Cortex

—The outer layer of the brain.

Delusions

—Fixed, false beliefs that are resistant to reason or factual disproof.

Dopamine

—A neurotransmitter that acts to decrease the activity of certain nerve cells in the brain, it seems to be involved in schizophrenia.

Hallucinations

—A sensory experience of something that does not exist outside the mind. A person can experience a hallucination in any of the five senses.

Leukotomy

—A rarely used psychosurgical procedure in which tissue in the frontal lobes of the brain is destroyed.

Limbic system

—A part of the brain made up of a number of different structures, it forms an arc and is located in the forebrain. The limbic system seems highly involved in emotional and motivational behaviors.

Magnetic Resonance Imaging

—A technique using radio frequency pulses that creates images which show various size, density and spatial qualities of the targeted body area, e.g. the brain.

Neuroimaging techniques

—High technology methods that enable visualization of the brain without surgery such as computed tomography and magnetic resonance imaging.

Psychotherapy

—A broad term that usually refers to interpersonal verbal treatment of disease or disorder that addresses psychological and social factors.

Stereotaxic instrument

—Generally, a rigid frame with an adjustable probe holder that is secured on patient's skull for psychosurgery, it enables more accurate brain tissue manipulation.

Psychosurgery

Definition

Psychosurgery is the treatment of a psychiatric disorder using surgical techniques to destroy brain tissue and is now rarely used.

Purpose

It is a last-resort treatment for extreme, debilitating, psychiatric disorders.

Description

Early psychosurgery—historical perspective

Ironically, brain surgery, a medical practice requiring extraordinary levels of skill and care, may be one of the oldest of all medical procedures. This surprising observation is supported by physical evidence dating back 40,000 years ago to Neolithic times. Archeologists have found numerous human skulls showing signs of a procedure called trepanation or trepanning—an operation in which a hole is cut through the bone that covers the brain (skull) in order to access the brain. A key feature of the wounds found in these ancient skulls is the smoothness and shininess around the edges of the holes. This is a clear sign of new bone growth and evidence that the person whose skull was opened not only survived the operation but lived months or even years afterwards while the bone regrew.

Having one's skull opened in a modern surgical setting is not taken lightly, even with the most modern surgical techniques. The prospect of undergoing the operation in the late Stone Age may appear to us to imply certain death. However, the survival rate of the operation was quite high. Close examination of archeological findings suggests that 75% of those who underwent the procedure lived long enough for new bone to grow around the opening. That number is actually higher than the survival rate for brain surgery during the nineteenth century, when Stone Age trepanned skulls were first identified. Brain surgery during the mid-1860s frequently resulted in infections that killed up to 75% of patients.

Trepanned skulls have been found all over the world, including sites in Peru, China, India, and France, and parts of the Middle East and Africa. While trepanning is an effective surgical technique for relieving pressure on the brain caused by bleeding, most archeologists suspect the operation was carried out in the Stone Age to achieve a different goal. Trepanning, they suspect, was performed to release evil spirits or demons, which the shamans or witch doctors of the time believed produced symptoms of what we know as mental disorders and, perhaps, diseases of the brain. The instruments used in trepanning were likely to have been made of obsidian, a very hard, glasslike, volcanic rock that can hold a very sharp cutting edge. There is also evidence that the end of a wooden stick, hardened by fire and turned back-and-forth rapidly while pressed against the skull may have served as a primitive, but effective, surgical drill.

Neuroscientist and author Elliot Valenstein believes that trepanning did not amount to intentional brain surgery. He quotes from the Latin text by the twelfth-century surgeon Roger of Salerno, who wrote: "For mania and melancholy, the skin of the top of the head should be incised in a cruciate fashion and the skull perforated to allow matter to escape."

A curious example of what might be called pseudopsychosurgery occurred during the Middle Ages. Some unscrupulous individuals wandered across Europe convincing gullible people that mental disorders were caused by a "stone of madness." To fool others, these quacks faked operating on the brains of mentally ill individuals and, using sleight-of-hand, appeared to produce a real stone from the victim's head, thus "proving" their claim and effecting a "cure." No doubt, these frauds quickly moved on to other towns before their patients showed signs of continuing psychiatric symptoms.

The impetus for developing a radical treatment

Unfortunately, effective treatments for mental illnesses remained unavailable until the second half of the twentieth century. Before then, psychiatric "care" consisted mostly of imprisonment, neglect , restraint, and/or punishment. During the eighteenth century, more humane conditions of confinement were introduced, but effective treatments remained unavailable. Physicians were desperate for treatments that might make it easier to control violent and deranged patients.

By the end of the nineteenth century, researchers became aware of the role played by the frontal cortex—a part of the brain located behind the forehead—in behavior control. They discovered from the results of animal experiments and observing humans who suffered damage to this part of the brain that the frontal lobes affect emotions and behavior. This bit of knowledge, combined with the development of effective anesthesia, led to the first modern instances of psychosurgery during the 1890s. A Swiss surgeon named Gottlieb Burkhardt deliberately damaged the frontal lobes of six psychiatric patients in hopes of relieving psychiatric symptoms; at least one of his subjects died and the experimental surgery was discontinued amid criticism from other physicians.

Psychosurgery in the twentieth century

PREFRONTAL LEUCOTOMY. In 1900, an Estonian surgeon, Lodivicus Pussepp, picked up where Burkhardt left off. He cut nerve tracks leading from the frontal lobes to other parts of the brain in psychiatric patients, with unimpressive results. A decade later, he injected tissue-destroying chemicals into the frontal lobes of mentally ill patients through holes drilled over the frontal lobes. Although the procedure accomplished little or nothing in the way of therapy, Pussepp remained optimistic about the ability of this procedure to improve the condition of psychiatric patients. Interest in the frontal lobes as a target for treating mental disorders continued on a small scale until the heyday of psychosurgery began in the 1930s.

In 1935, researchers in the United States reported that damaging the frontal lobes and a nearby region of the brain called the prefrontal cortex could pacify a previously aggressive chimpanzee. A Portuguese psychiatrist , Antonio Egas Moniz, learned of these results and recruited neurosurgeon Almeida Lima to operate on some humans suffering from severe psychoses. Moniz's aim was to disconnect nerve pathways running from the frontal lobes to a part of the brain called the thalamus, which is located closer to the center of the brain. By cutting these connections, Moniz hypothesized that he could disconnect a neural circuit that ran from the frontal cortex to the thalamus and then to other parts of the brain's surface. He hoped that interrupting this pathway would disrupt the repetitive thoughts that Moniz believed were responsible for psychotic symptoms.

But as Elliot Valenstein writes in his book Great and Desperate Cures, The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness, "Although Moniz' rationale for prefrontal leucotomy was so vague as to constitute no theory at all, his explanation was repeated so often that it—like the emperor's new clothes in Hans Christian Andersen's famous story— acquired a veneer of truth and was accepted (or at least repeated) by many other people." Psychiatrists were so desperate for a treatment for severe cases of mental illness that they allowed themselves to support the use of a procedure that was unproven and increasingly subject to abuse.

Moniz and Lima called their procedure leucotomy. It involved trepanning the skull, one hole on each side of the head, inserting a wire knife and cutting the targeted nerve fibers. Results were mixed enough for Moniz to recommend that the procedure be reserved only for the most seriously mentally ill patients for whom no other course of care or treatment worked. Nevertheless, after 1936, use of the technique spread rapidly, with equally unimpressive results overall. With little evidence of effectiveness and facing opposition from many psychiatrists, particularly psychotherapists, the technique would probably have been abandoned were it not for a pair of American physicians who revived the questionable procedure.

THE PREFRONTAL LOBOTOMY. American neurologist Walter Freeman and neurosurgeon James Watts began operating on patients in 1936 and soon began aggressively promoting its effectiveness. Eventually, they overcame doubts expressed by their colleagues who somewhat reluctantly accepted the procedure now referred to as prefrontal lobotomy. In 1946, Freeman simplified Moniz's leucotomy procedure, reducing it to a less complicated, less messy, and less time-consuming operation known as the "ice-pick lobotomy." This allowed Freeman to line up patients and, under local anesthesia, tap an ice pick through the thin bone on the roof of their eye sockets. With the ice pick in the brain, Freeman would sweep it back and forth to cut the frontal lobe's connections to the rest of the brain. This in-and-out procedure required no hospitalization but many physicians viewed it with alarm. Watts himself refused to cooperate with Freeman after this technique was developed.

Still, in the 1940s, U.S. physicians performed an estimated 18,000 lobotomies. It was equally popular in other countries where more than 50,000 operations were conducted during the same period. Sadly, Moniz's warning was forgotten. The procedure was not reserved for the most hopeless cases but instead applied to "difficult" patients and became a way to control behavior rather than to relieve symptoms of mental disorder. The abuse often bordered on the criminal. Yet, Moniz received the 1949 Nobel Prize for Medicine and Physiology for pioneering the procedure.

Fortunately, but still too late, critics of the operation began to convince others that there was no scientific proof that lobotomies helped mentally ill patients. It could certainly calm violent patients but it did so at a terrible cost. As one nurse who recently treated an aged patient who had been lobotomized years before said, "You look in her eyes and you see there is no one there." Victims of the procedure lack emotions, ambition, social skills, and the ability to plan. The operation was used to control the mentally ill and others, such as uncontrollable children and political dissidents, whose behavior did not conform to society's standards. Arguments against the procedure were powerful: it permanently and severely damaged the brain and often produced unreactive, lifeless individuals whose personalities were forever destroyed. With the introduction of psychotherapeutic drugs—especially chlorpromazine (Thorazine)—in the mid-1950s, lobotomies fell out of fashion.

Psychosurgery today

No one advocates the use of classical lobotomies today as a treatment for mental disorders. However, a small minority of neurologists advocates the use of very precise surgical techniques to produce small lesions in defined areas of the brain to treat rare cases of severe mental illness such as life-threatening depression or incapacitating anxiety or obsessions. However, there is little need for such procedures today. Antipsychotic and antidepressant medications are the treatments of choice for treating mental disorders. Mainstream medicine now classifies psychosurgery as an experimental procedure, and many rules exist to protect patients who might be subjected to it. The majority of mental health professionals believe that psychosurgery is either never justified or should only be considered as a last resort, to be reserved for the most extreme cases of untreatable mental disease when all other therapies have failed.

Resources

BOOKS

Pressman, Jack D. Last Resort: Psychosurgery and the Limits of Medicine. New York, NY: Cambridge University Press, 1998.

Valenstein, Elliot S. Great and Desperate Cures, The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books, 1986.

Valenstein, Elliot S., ed. The Psychosurgery Debate. San Francisco: W.H. Freeman, 1980.

Woods, Michael and Mary B. Woods. Ancient Medicine, From Sorcery to Surgery. Minneapolis: MN: Runestone Press, 2000.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington D.C. 20005. <http://www.psych.org>.

Dean A. Haycock, Ph.D.

Psychosurgery

Definition

Purpose

Description

Resources

Definition

Psychosurgery is the treatment of a psychiatric disorder using surgical techniques to destroy brain tissue and is now rarely used.

Purpose

It is a last-resort treatment for extreme, debilitating, psychiatric disorders.

Description

Early psychosurgery—historical perspective

Ironically, brain surgery, a medical practice requiring extraordinary levels of skill and care, may be one of the oldest of all medical procedures. This surprising observation is supported by physical evidence dating back 40,000 years ago to Neolithic times. Archeologists have found numerous human skulls showing signs of a procedure called trepanation or trepanning—an operation in which a hole is cut through the bone that covers the brain (skull) in order to access the brain. A key feature of the wounds found in these ancient skulls is the smoothness and shininess around the edges of the holes. This is a clear sign of new bone growth and evidence that the person whose skull was opened not only survived the operation but lived months or even years afterwards while the bone regrew.

Having one’s skull opened in a modern surgical setting is not taken lightly, even with the most modern surgical techniques. The prospect of undergoing the operation in the late Stone Age may appear to us to imply certain death. However, the survival rate of the operation was quite high. Close examination of archeological findings suggests that 75% of those who underwent the procedure lived long enough for new bone to grow around the opening. That number is actually higher than the survival rate for brain surgery during the nineteenth century, when Stone Age trepanned skulls were first identified. Brain surgery during the mid-1860s frequently resulted in infections that killed up to 75% of patients.

Trepanned skulls have been found all over the world, including sites in Peru, China, India, and France, and parts of the Middle East and Africa. While trepanning is an effective surgical technique for relieving pressure on the brain caused by bleeding, most archeologists suspect the operation was carried out in the Stone Age to achieve a different goal. Trepanning, they suspect, was performed to release evil spirits or demons, which

the shamans or witch doctors of the time believed produced symptoms of what we know as mental disorders and, perhaps, diseases of the brain. The instruments used in trepanning were likely to have been made of obsidian, a very hard, glasslike, volcanic rock that can hold a very sharp cutting edge. There is also evidence that the end of a wooden stick, hardened by fire and turned back-and-forth rapidly while pressed against the skull may have served as a primitive, but effective, surgical drill.

Neuroscientist and author Elliot Valenstein believes that trepanning did not amount to intentional brain surgery. He quotes from the Latin text by the twelfth-century surgeon Roger of Salerno, who wrote: “For mania and melancholy, the skin of the top of the head should be incised in a cruciate fashion and the skull perforated to allow matter to escape.”

A curious example of what might be called pseudo-psychosurgery occurred during the Middle Ages. Some unscrupulous individuals wandered across Europe convincing gullible people that mental disorders were caused by a “stone of madness.” To fool others, these quacks faked operating on the brains of mentally ill individuals and, using sleight-of-hand, appeared to produce a real stone from the victim’s head, thus “proving” their claim and effecting a “cure.” No doubt, these frauds quickly moved on to other towns before their patients showed signs of continuing psychiatric symptoms.

The impetus for developing a radical treatment

Unfortunately, effective treatments for mental illnesses remained unavailable until the second half of the twentieth century. Before then, psychiatric “care” consisted mostly of imprisonment, neglect, restraint, and/or punishment. During the eighteenth century, more humane conditions of confinement were introduced, but effective treatments remained unavailable. Physicians were desperate for treatments that might make it easier to control violent and deranged patients.

By the end of the nineteenth century, researchers became aware of the role played by the frontal cortex— a part of the brain located behind the forehead—in behavior control. They discovered from the results of animal experiments and observing humans who suffered damage to this part of the brain that the frontal lobes affect emotions and behavior. This bit of knowledge, combined with the development of effective anesthesia, led to the first modern instances of psycho-surgery during the 1890s. A Swiss surgeon named Gottlieb Burkhardt deliberately damaged the frontal lobes of six psychiatric patients in hopes of relieving psychiatric symptoms; at least one of his subjects died and the experimental surgery was discontinued amid criticism from other physicians.

Psychosurgery in the twentieth century

PREFRONTAL LEUCOTOMY

In 1900, an Estonian surgeon, Lodivicus Puusepp, picked up where Burkhardt left off. He cut nerve tracks leading from the frontal lobes to other parts of the brain in psychiatric patients, with unimpressive results. A decade later, he injected tissue-destroying chemicals into the frontal lobes of mentally ill patients through holes drilled over the frontal lobes. Although the procedure accomplished little or nothing in the way of therapy, Pussepp remained optimistic about the ability of this procedure to improve the condition of psychiatric patients. Interest in the frontal lobes as a target for treating mental disorders continued on a small scale until the heyday of psychosurgery began in the 1930s.

In 1935, researchers in the United States reported that damaging the frontal lobes and a nearby region of the brain called the prefrontal cortex could pacify a previously aggressive chimpanzee. A Portuguese psychiatrist, Antonio Egas Moniz, learned of these results and recruited neurosurgeon Almeida Lima to operate on some humans suffering from severe psychoses. Moniz’s aim was to disconnect nerve pathways running from the frontal lobes to a part of the brain called the thalamus, which is located closer to the center of

the brain. By cutting these connections, Moniz hypothesized that he could disconnect a neural circuit that ran from the frontal cortex to the thalamus and then to other parts of the brain’s surface. He hoped that interrupting this pathway would disrupt the repetitive thoughts that Moniz believed were responsible for psychotic symptoms.

But as Elliot Valenstein writes in his book Great and Desperate Cures, The Rise and Decline of Psycho-surgery and Other Radical Treatments for Mental Illness, “Although Moniz’ rationale for prefrontal leucotomy was so vague as to constitute no theory at all, his explanation was repeated so often that it—like the emperor’s new clothes in Hans Christian Andersen’s famous story—acquired a veneer of truth and was accepted (or at least repeated) by many other people.” The truth is that psychiatrists were so desperate for a treatment for severe cases of mental illness that they allowed themselves to support the use of a procedure that was unproven and increasingly subject to abuse.

Moniz and Lima called their procedure leucotomy. It involved trepanning the skull, one hole on each side of the head, inserting a wire knife and cutting the targeted nerve fibers. Results were mixed enough for Moniz to recommend that the procedure be reserved only for the most seriously mentally ill patients for whom no other course of care or treatment worked. Nevertheless, after 1936, use of the technique spread rapidly, with equally unimpressive results overall. With little evidence of effectiveness and facing opposition from many psychiatrists, particularly psychotherapists, the technique would probably have been abandoned were it not for a pair of American physicians who revived the questionable procedure.

THE PREFRONTAL LOBOTOMY

American neurologist Walter Freeman and neurosurgeon James Watts began operating on patients in 1936 and soon began aggressively promoting its effectiveness. Eventually, they overcame doubts expressed by their colleagues who somewhat reluctantly accepted the procedure now referred to as prefrontal lobotomy. In 1946, Freeman simplified Moniz’s leucotomy procedure, reducing it to a less complicated, less messy, and less time-consuming operation known as the “ice-pick lobotomy.” This allowed Freeman to literally line up patients and, under local anesthesia, tap an ice pick through the thin bone on the roof of their eye sockets. With the ice pick in the brain, Freeman would sweep it back and forth to cut the frontal lobe’s connections to the rest of the brain. This in-and-out procedure required no hospital-ization but many physicians viewed it with alarm. Watts himself refused to cooperate with Freeman after this technique was developed.

Still, in the 1940s, U.S. physicians performed an estimated 18,000 lobotomies. It was equally popular in other countries where more than 50,000 operations were conducted during the same period. Sadly, Moniz’s warning was forgotten. The procedure was not reserved for the most hopeless cases but instead applied to “difficult” patients and became a way to control behavior rather than to relieve symptoms of mental disorder. The abuse often bordered on the criminal. And yet Moniz received the 1949 Nobel Prize for Medicine and Physiology for pioneering the procedure.

Fortunately, but still too late, critics of the operation began to convince others that there was no scientific proof that lobotomies helped mentally ill patients. It could certainly calm violent patients but it did so at a terrible cost. As one nurse who recently treated an aged patient who had been lobotomized years before said, “You look in her eyes and you see there is no one there.” Victims of the procedure lack emotions, ambition, social skills, and the ability to plan. The operation was used to control the mentally ill and others, such as uncontrollable children and political dissidents, whose behavior did not conform to society’s standards. Arguments against the procedure were powerful: it permanently and severely damaged the brain and often produced unreactive, lifeless individuals whose personalities were forever destroyed. With the introduction of psychotherapeutic drugs—especially chlorpromazine (Thorazine)—in the mid-1950s, lobotomies fell out of fashion.

Psychosurgery today

No one advocates the use of classical lobotomies today as a treatment for mental disorders. However, a small minority of neurologists advocates the use of very precise surgical techniques to produce small lesions in defined areas of the brain to treat rare cases of severe mental illness such as life-threatening depression or incapacitating anxiety or obsessions. However, there is little need for such procedures today. Antipsychotic and antidepressant medications are the treatments of choice for treating mental disorders. Mainstream medicine now classifies psychosur-gery as an experimental procedure, and many rules exist to protect patients who might be subjected to it. The majority of mental health professionals believe that psychosurgery is either never justified or should only be considered as a last resort, to be reserved for the most extreme cases of untreatable mental disease when all other therapies have failed.

KEY TERMS

Frontal lobes —A region of the brain that influences higher mental functions often associated with intelligence, such as the ability to foresee the consequences of actions, planning, comprehension, and mood.

Leucotomy or leukotomy —White matter cutting— severing the white matter of the frontal lobe of the brain.

Lobotomy —A surgical procedure involving the cutting of nerve fiber bundles in the brain.

Trepanation or trepanning —Surgical removal of a piece of the skull to expose the brain.

Resources

BOOKS

Pressman, Jack D.Last Resort:Psychosurgery and the Limits of Medicine. New York, NY: Cambridge University

Press, 1998. Valenstein, Elliot S., ed. The Psychosurgery Debate. San Francisco: W.H. Freeman, 1980.

Valenstein, Elliot S. Great and Desperate Cures, The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books, 1986.

Woods, Michael and Mary B. Woods. Ancient Medicine, From Sorcery to Surgery. Minneapolis: MN: Runestone Press, 2000.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington D.C. 20005. http://www.psych.org

Dean A. Haycock, Ph.D.

Psychosurgery

Definition

Psychosurgery involves severing or otherwise disabling areas of the brain to treat a personality disorder, behavior disorder, or other mental illness. Modern psychosurgical techniques target the pathways between the limbic system (the portion of the brain on the inner edge of the cerebral cortex) that is believed to regulate emotions, and the frontal cortex, where thought processes are seated.

Purpose

Lobotomy is a psychosurgical procedure involving selective destruction of connective nerve fibers or tissue. It is performed on the frontal lobe of the brain and its purpose is to alleviate mental illness and chronic pain symptoms. The bilateral cingulotomy, a modern psychosurgical technique which has replaced the lobotomy, is performed to alleviate mental disorders such as major depression, bipolar disorder, or obsessive-compulsive disorder (OCD), which have not responded to psychotherapy, behavioral therapy, electroshock, or pharmacologic treatment. Bilateral cingulotomies are also performed to treat chronic pain in cancer patients.

Precautions

Psychosurgery should be considered only after all other non-surgical psychiatric therapies have been fully explored. Much is still unknown about the biology of the brain and how psychosurgery affects brain function.

Description

Psychosurgery, and lobotomy in particular, reached the height of use just after World War II. Between 1946 and 1949, the use of the lobotomy grew from 500 to 5,000 annual procedures in the United States. At that time, the procedure was viewed as a possible solution to the overcrowded and understaffed conditions in state-run mental hospitals and asylums. Known as prefrontal or transorbital lobotomy, depending on the surgical technique used and area of the brain targeted, these early operations were performed with surgical knives, electrodes, suction, or ice picks, to cut or sweep out portions of the frontal lobe.

Today's psychosurgical techniques are much more refined. Instead of going in "blind" to remove large sections on the frontal lobe, as in these early operations, neurosurgeons use a computer-based process called stereotactic magnetic resonance imaging to guide a small electrode to the limbic system (brain structures involved in autonomic or automatic body functions and some emotion and behavior). There an electrical current burns in a small lesion [usually 0.5 in (1.3 cm) in size]. In a bilateral cingulotomy, the cingulate gyrus, a small section of brain that connects the limbic region of the brain with the frontal lobes, is targeted. Another surgical technique uses a non-invasive tool known as a gamma knife to focus beams of radiation at the brain. A lesion forms at the spot where the beams converge in the brain.

Preparation

Candidates for cingulotomies or other forms of psychosurgery undergo a rigorous screening process to ensure that all possible non-surgical psychiatric treatment options have been explored. Psychosurgery is only performed with the patient's informed consent.

Aftercare

Ongoing behavioral and medication therapy is often required in OCD patients who undergo cingulotomy. All psychosurgery patients should remain under a psychiatrist's care for follow-up evaluations and treatment.

Risks

As with any type of brain surgery, psychosurgery carries the risk of permanent brain damage, though the advent of non-invasive neurosurgical techniques, such as the gamma knife, has reduced the risk of brain damage significantly.

Normal results

In a 1996 study at Massachusetts General Hospital, over one-third of patients undergoing cingulotomy demonstrated significant improvements after the surgery. And, in contrast to the bizarre behavior and personality changes reported with lobotomy patients in the 1940s and 1950s, modern psychosurgery patients have demonstrated little post-surgical losses of memory or other high level thought processes.

Resources

ORGANIZATIONS

Massachusetts General Hospital. Functional and Stereotactic Neurosurgery Cingulotomy Unit. Fruit St., Boston, MA 02114. (617) 726-2000. 〈http://neurosurgery.mgh.harvard.edu/cingulot.htm〉.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. 〈http://www.nami.org〉.

National OCD Headquarters. P.O. Box 70, Milford, CT 06460. (203) 878-5669.

KEY TERMS

Gamma knife— A surgical tool that focuses beams of radiation at the head, which converge in the brain to form a lesion.

Lesion— Any discontinuity of tissue. Often a cut or wound.

Limbic system— A portion of the brain on the inner edge of the cerebral cortex that is thought to regulate emotions.

Psychosurgery— Brain surgery performed to alleviate chronic psychological conditions such as obsessive-compulsive disorder (OCD), depression, and bipolar disorder.

Stereotactic technique— A technique used by neurosurgeons to pinpoint locations within the brain. It employs computer imaging to create an external frame of reference.