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Frontal view of normal human brain.
Photo: Photo: John A Beal, PhD. Dep't. of Cellular Biology & Anatomy, Louisiana State University Health Sciences Center Shreveport. Lobotomy, www.wikipedia.org.
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Psychosurgery can also be 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 one in four death rate) and undesirable side effects.
Side Effects of Psychosurgery, Lobotomy, and Modern Law
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.
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Ice picks were used in performing the lobotomy.
Photo: John Kloepper, at Central States Hospital, Milledgeville GA, 22DEC06
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Why and When Psychosurgery Was and Is Utilized
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," after psychosurgery. (Cosgrove, Rauch, 2005).
See the book, Great and Desperate Cures by Elliot Valnestein, where he explains how the treatment came to be accepted. Valnesteing 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 Use of Psychosurgery and Types of Disorders for Which it 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 nuerosurgery is performed are,
Parkinson's Disease
Epilepsy
Obsessive Compulsive Disorder (OCD)
Obsessive Neurosis
Additionally, psychosurgery has been performed, not as commonly, for,
Schizophrenia
Anxiety Neurosis
Modern Psychosurgery Techniques
Today, the rate of permanent damage to the brain has been substantially improved with psychosurgery in comparison to the historical use of psychosurgery procedures, and there are fewer severely detrimental side effects. However, serioius side effects can still be experienced by a significant percentage of those who undertake psychosurgery today and extreme caution is in order with any psychosurgery procedures.
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 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
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).
Capsulotomy - Psychosurgery Involving Drilling Small Holes in Skull
Originally developed in Sweden, capsultomy 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 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 obsessional 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
schizophrenics, four were
depressives and three
obsessives.
Percentages of Success and Failure with Capsulotomy Psychosurgery
Satisfactory Response to Capsultomy
Obesessional Neurosis - 48%
Anxiety Neurosis - 20%
Schizophrenia - 14%
Rated Worse After Capsultomy 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 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.
Deep Brain Stimulation Risks
Any surgical procedure carries risks including all types of brain surgery. Deep brain stimulation inolves brain surgery and is an especially risky procedure posing both risks within the brain from the surgery, as well as general health risks. The brain stimulation itself may cause severe side effects.
Possible surgical complications may include:
Bleeding in the brain
Stroke
Infection
Breathing problems
Nausea
Heart problems
Incision scarring
Possible side effects of deep brain surgery after surgery
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
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)
Conclusion of Effectives 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 prospectively 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, are 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, eta all, 1993, 1994).
Psychosurgery for OCD
50% experienced a 35% reduction in intensity of symptoms
No deaths occurred and increased risk of
suicide was not reported in this study.
Psychosurgery 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
4.
MGH Psychiatric Neurosurgery Committee, (May 11, 2005).
Massachusetts General Hospital.
5.
Neurosurgery Service, Functional and Stereotactic Surgery Center.
Massachusetts General Hospital.
