Psychosurgery
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 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