PSYCHOSURGERY, MEDICAL AND HISTORICAL ASPECTS OF

Psychosurgery is the surgical removal or destruction of brain tissue with the intent of normalizing behavior in otherwise disabling psychiatric disorders. The patients selected for treatment generally have certain types of symptoms rather than being a part of entire nosological groups or diagnostic categories. Examples of such symptoms include phobias, anxieties, depressions, obsessive compulsions, and affective components of schizophrenia—behaviors that include, but are not limited to, incapacitating alterations in mood with loss of interest in usually pleasurable activities; persistent and irrational fear of an object, activity, or situation; or feelings of apprehension or dread about the future. Routine neurosurgical procedures are employed, including cutting, burning, or irradiation of brain tissue. Neurosurgical procedures for psychosurgical purposes are performed in the absence of definable, structural brain changes such as tumors, vascular malformations, or post-traumatic scarring. Surgical intervention in the brain for the purpose of treating a structural lesion, or other definable pathology such as an epileptic focus or tumor, would not be considered psychosurgery even if the procedure resulted in some behavioral alteration. Regarding pain relieving procedures employing some of these techniques, there is no clear consensus. Such procedures clearly are designed to alter the perception of pain, thereby altering the behavioral response to that pain. Pain relieving procedures have not been included in most discussions of psychosurgery unless they are specifically oriented toward altering an emotional or affective disorder associated with the pain.

Mechanisms

The best results of treating psychiatric disease by neurosurgical interventions follow destruction of some part of the frontal lobes or their connections to other brain structures. The limbic system—that portion of the brain including the white-matter fiber tracts (consisting of nerve fibers covered with myelin and hence white in appearance) of the corpus callosum (connecting the two hemispheres of the brain), the cingulate, the fornicate, and the angulate gyri, and the amygdala and hippocampus of the temporal lobes, as well as the deeper nuclei (consisting of cell bodies or gray matter), the thalamus, and the hypothalamus—is now generally accepted to control behavior and the emotions. While the relationship of these structures to behavior and emotions is accepted, the specific functions of the various segments have not been identified with any certainty. The present state of knowledge about the physiological mechanisms for the control of normal emotions, to say nothing of the mechanisms involved in affective disorders, can only be characterized as rudimentary and empirical. Hence, there is no pathophysiological rationale for selecting targets for psychosurgical procedures. There is no good answer at present to the question of how these treatments work. It is, therefore, of critical importance to prospectively evaluate outcomes of treatment in relation to the initial patient symptoms.

The Development of Psychosurgery

Psychosurgery began in the 1930s in the Yale University laboratory of neurophysiologist John Fulton. Based on a growing background of knowledge from animal experiments using selective destruction of frontal lobe areas, combined with behavioral training from a number of laboratories, and on a specific observation from Ivan Pavlov (1928) concerning the production of neurotic behavior in dogs presented with confusing reinforcement symbols, he and his colleague Carlyle Jacobsen conducted behavioral experiments on two chimpanzees trained to solve complex problems in order to obtain food rewards. When frustrated with attempts to obtain food, they became agitated and aggressive. Fulton and Jacobsen then performed frontal lobectomies, literally cutting out the anterior frontal lobes of the brain, and noted that the animals became immune to frustration, although they performed assigned tests slightly less well.

Fulton and Jacobsen reported their observations at a 1935 London neuroscience meeting (Fulton and Jacobsen; see also Fulton, 1942, 1951). In attendance was a noted Portuguese neuroscientist, Egas Moniz, who, with his neurosurgical colleague Almeida Lima, performed the first procedures in humans a few months thereafter. The initial operation involved placing two holes through the skull three centimeters from the midline over the frontal area, with injection of alcohol to destroy the brain substance. In subsequent operations a wire loop was used to cut the frontal lobe connections. Thus they modified the Fulton procedure, performing only a frontal lobotomy or, as Moniz termed it, a leukotomy (cutting of the white matter). Moniz was awarded the 1949 Nobel Prize for his discovery of the therapeutic value of prefrontal leukotomy in certain psychoses.

Neuropsychiatrist Walter Freeman of the United States also attended the London conference. He and his neurosurgical colleague James Watts introduced psychosurgery to the United States. They pioneered the lobotomy, in which frontal lobe connections to the surrounding brain were severed initially by an open neurosurgical approach called craniotomy, using suction to sever the fibers. The demographics of the over 600 patients reported on by Freeman and Watts are not easily summarized. Many were institutionalized but many others were cared for at home and referred by their psychiatrists. The majority were women. All of these patients were considered disabled by their illness. However, Freeman felt the procedure was too costly, being primarily governmentally funded through the state-run mental institutions, and required too much skill to use on a broad scale to empty the wards of the large mental institutions. Freeman was very much a community psychiatrist and saw it as his mission to empty the back wards of state mental hospitals.

Around 1945, Freeman introduced a procedure described by the Italian neurosurgeon Amarro Fiamberti, in which the surgeon introduced a sharp probe (originally an ice pick) through the roof of the eye socket (orbit) into the frontal lobe white matter and oscillated it back and forth, thus severing the nerve fibers; this was called a transorbital lobotomy (Freeman and Watts). Watts, who performed the traditional procedure, felt Fiamberti's procedure violated any sense of neurosurgical dignity. The so-called "ice pick lobotomy" could easily be performed, and it is estimated that by 1955 over 40,000 had been done in the United States. Freeman, a nonsurgeon, alone performed or supervised over 3,500 operations in 19 states and 10 foreign countries (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research). The indications were broad, including almost any patient confined to an institution, predominantly schizophrenics. While as effective as open craniotomy, the procedure was undertaken at a much greater risk of immediate complications resulting in neurologic sequelae, such as paralysis or epilepsy. Long-term psychological results were often associated with intellectual and emotional changes, such as a withdrawn and flattened affect. However, more patients were able to be discharged from the institutions because of the procedure than previously had been possible (Mettler; Tow; Petrie).

With the introduction of the drug chlorpromazine in 1952, use of psychopharmacologic agents (drugs designed to treat the symptoms of psychiatric illness) ended the era of lobotomies. Chlorpromazine resulted in the sedation of agitated patients and alleviation of psychotic behaviors, such that patients could be managed better both in and out of institutions. In the 1960s, with the advent of antidepressant medication, the number of psychosurgical procedures declined even further. Although they were performed far less frequently, they continued to be used from time to time because of their demonstrated beneficial effects in many intractable patients who were not helped by traditional therapy.

In 1947, Ernest Spiegel and Henry Wycis introduced a technique for precisely locating points or targets within the human brain, thereby allowing destruction of specific tissue with minimal disruption of the surrounding brain (Spiegel and Wycis). This technique, still the technique of choice, is called stereotaxic surgery. Stereotaxis employs precise calculation of locations within the brain using internal, radiographically determined reference points, thus allowing placement of a probe or beam of radiation with great accuracy. At about the same time, John Fulton reasoned that an optimum site of a lesion to treat psychiatric illness should be located in one quadrant of the frontal lobe and could be quite small. Stereotaxic surgery ushered in the modern era of psychosurgery by making possible treatment of psychiatric disease through very small, precisely located lesions.

As knowledge of the limbic structures became more precise, neurosurgeons began directing their efforts to cutting selected fiber tracts that connected the frontal lobes with specific limbic structures by using stereotaxis. Although surgeons could not specify how destruction of small brain areas worked to alleviate the symptoms of psychiatric disease, it did work. Complications from surgery declined significantly. The safety and efficacy of psychosurgery improved greatly. Stereotaxic psychosurgical technique gained in popularity by the late 1960s, when mental-health professionals recognized that the medications used to treat psychic disease did not help everyone and often had significant side effects.

Psychosurgery suffered a dramatic decline in the United States, similar to that coinciding with the advent of psychotropic medication, beginning in the 1970s. Those who viewed psychosurgery as mutilation of the brain leveled much criticism at those who were performing the procedures. The most vocal opponent was Peter Breggin (Breggin, 1972). Trained in a tradition that denied the authenticity of mental illness as a disease, he argued vehemently that all surgical treatments mutilated the brain and destroyed function. No scientific data were presented to substantiate his claims, but they did serve to raise public awareness about psychosurgery. The case against psychosurgery was aided by the speculation of Vernon Mark and Frank Ervin that the techniques might be helpful in controlling criminal or violent behavior, thereby raising the specter of political control (Mark and Ervin).

The debate generated a politically stressful environment, with the most vocal groups being against the treatment. There developed a desire on the part of American psychiatrists and neurosurgeons to avoid controversy over this form of treatment. The result was a dramatic decline in the use of psychosurgery techniques. Between 1949 and 1952, approximately 5,000 lobotomies were performed each year in the United States, largely by itinerant physicians lacking neurosurgical training. The commission established by Congress to investigate psychosurgery estimated that in 1971 and 1972, 140 neurosurgeons had performed a total of approximately 400 to 500 operations a year (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research). In 1987, Harvard University neurosurgeon Thomas Ballantine reported on a group of 474 psychosurgical patients treated over the previous twenty-five years (about 18 per year); most procedures had occurred in the late 1960s and early 1970s (Ballantine and Giriunas). More specific reports from which the current incidence of psychosurgical procedures in the United States might be calculated are lacking.

Current Safety and Effectiveness

Psychosurgery, in spite of declining frequency due to nonmedical reasons, benefited from the more precise definition and understanding of the types of patients who were likely to be helped by this surgery. This process occurred simultaneously with the development of psychosurgery, as psychiatry made advances in the understanding of mental illness. One important consideration is consent to treatment. Informed consent for mentally ill patients may be possible if the impairment does not extend to rendering the patient "incompetent" in the legal sense. But whether a mentally ill or incarcerated person can ever give a voluntary informed consent is doubtful, as mental competence and autonomy are such arbitrary notions. The integrity of the physician is the most effective guarantee of a patient's rights.

Currently, in selecting who should be treated, an appropriate psychiatric diagnosis revealing symptoms amenable to relief by psychosurgery is required. Appropriate candidates include chronically and severely depressed individuals with a preexisting history of obsessive-compulsive personality traits; chronically anxious patients whose psychic pain is incapacitating; and increasingly incapacitating obsessive-compulsive neuroses associated with depression. All other treatments deemed appropriate for the diagnosis, including the use of appropriate doses of psychopharmacologic medication, should be tried before psychosurgery is contemplated. Incapacity produced by the illness should be disabling and persistent. There should be no contraindications, either physical or mental, to the performance of the procedure.

Technique

Modern stereotaxic psychosurgery consists of producing lesions by heating electrodes in the target areas to coagulate the tissue or, more recently, by the destruction of a target area by focused radiation utilizing either a linear accelerator radiation source or a focusable cobalt radiation source known as the gamma knife. Either technique requires fixing a head frame to the patient's skull with pins, inserted under local anesthesia. Some type of imaging—magnetic resonance scanning, computed tomographic scanning, or the introduction of air into the fluid space of the brain for contrast and using radiographs (ventriculography)—defines the target within the brain. When heat is used, the surgeon places a burr hole through the skull over the target area and introduces a probe into the target. A radio frequency current is applied to the probe and the lesion is produced. The production of the lesion is painless. The radiation lesion technique requires no opening of the skull. The patient is transported to the instrument used and is exposed to a focused beam of radiation. This also is painless. Following the production of the lesion, the patient is returned to the hospital room and usually discharged the following day. The onset of the effects of the heat lesion is virtually immediate, while the radiation may take as long as six months to produce the final result. Both lesions are irreversible.

Targets

Primarily four areas of the limbic system are currently utilized as targets. The procedures, named for the target areas, are cingulotomy, subcaudate tractotomy, limbic leukotomy, and amygdalotomy. Cingulotomy places the lesion in the cingulate gyrus of the brain, located on the inside of the frontal lobes. One or both of these structures may be lesioned, primarily for relief of depression and/or obsession; the procedure has a reported 75 percent recovered or markedly improved result in depression and 56 percent in obsession. Subcaudate tractotomy is performed just below the nucleus of the brain, called the caudate nucleus, in the white-matter fiber tracts connecting with frontal lobe structures. The primary indications for this procedure are depression, anxiety, and obsession; it has a recovered or improved rate of 68 percent for depression, 63 percent for anxiety, and 53 percent for obsession. Limbic leukotomy is a lesion placed in the white-matter tracts of the frontal lobe connecting to the nucleus called the thalamus. This lesion has been used for depression, anxiety, and obsession, with recovery or improvement in 61 percent for depression, 63 percent for anxiety, and 84 percent for obsession. Amygdalotomy places a lesion in the amygdaloid nucleus of cell bodies located in the temporal lobe and integrally connected to the limbic system structures. Unlike the other targets, amygdalotomy is used primarily for aggression, with a 76 percent markedly improved or recovered outcome (Maxwell).

Complications

The incidence of complications for each procedure is extremely low when compared with the morbidity and mortality of the old frontal leukotomy of Freeman and Watts (Mettler; Tow; Petrie). Significant neurologic complications, such as paralysis or epilepsy, and psychological complications, such as persistent behavioral or personality changes, occur in much less than 1 percent of cases (Ballantine and Giriunas).

The one aspect of the old frontal lobotomy that has remained in the minds of those caring for these patients is the generally placid affect, loss of initiative, and decline in intellectual function that was frequently seen. Reports of neuropsychological studies of patients undergoing modern psychosurgical procedures have indicated no significant damage to higher brain functions such as recognizable personality. Relief of disabling and intractable behavioral symptoms is followed by impressively improved overall function with preservation of personality (Mindus and Jenike; Bridges). However, neuropsychological instruments designed to measure cognition may not be sensitive enough to detect subtle emotional impairments. Currently available methods of testing support the conclusion that limited procedures such as cingulotomy, subcaudate tractotomy, limbic leukotomy, and amygdalotomy result in minimal intellectual and cognitive changes for the patient while reducing disabling symptoms such as depression.

Issues of Patient Selection

In the 1970s, amid concern about violence in the ghettos, some political activists, black and white, made accusations that psychosurgery was being used as a tool of the establishment to exercise political and social control, specifically of minorities and women (Mason; Carver). These accusations arose from publicity regarding proposed but never undertaken research projects, to be supported by federal funds, that focused on the psychosurgical treatment of irrational and spontaneously violent behavior arising from epilepsy in the limbic system. In addition, the issue of social control and racism in the application of psychosurgery became public when, with the establishment in Los Angeles of a Center for the Prevention of Violence, one of the researchers who had proposed a study of psychosurgery and violence joined the staff. At about this time, reports of psychosurgery performed on black patients in Mississippi were published (Andy and Jurko). These were institutionalized, severely disturbed, mentally retarded children; the neurosurgeon defended the practice on the basis that the psychosurgery was indicated medically as a treatment of last resort, and that the preponderance of black patients reflected the composition of the total patient group and not prejudice. There were those in the psychiatric community who felt that the levels of psychiatric care, the availability of qualified staff, and the availability of alternative treatment in this facility were below even minimal standards, thus calling into question the use of psychosurgery. The possibility of de facto racism existed.

No reliable evidence to support charges of intentional racism in the use of psychosurgery has been presented. There is no case of a responsible individual or group claiming that psychosurgery has actually been used for purposes of political action, social control, or acting out of personal prejudices against minority groups or women. However, there are no reliable data with respect to the incidence of psychosurgery performed on whites or blacks, males or females; such reports as are available give no support to the charge that minority groups of any category have been subjected to operations specifically on the basis of membership in such a group.

With respect to legally committed or otherwise involuntarily institutionalized patients, the issue of valid or proxy consent is a difficult one. However, it is generally acknowledged that there are some patients in this category who may benefit from psychosurgical procedures. As issues of autonomy versus community are studied and elaborated, new ethical grounds for consent in this population should arise (Beauchamp et al.).

Recent Developments

Since the mid-1990s, the use of functional neurosurgery to access the cingulate gyrus, subcaudate tractotomy, limbic leukotomy, and anterior capsulotomy targets has seen a renaissance of interest (Christie; Lichterman; Snaith). Although efficacy continues to be estimated at 30 to 70 percent of persons treated, depending on diagnosis, the difficulty of evaluating the efficacy of such procedures cannot be overemphasized and researchers have placed an emphasis on developing methods to better assess efficacy (Binder and Iskandar). Several factors have made these determinations difficult. Most reports have been long-term retrospective analyses using methods that did not remain constant over the period studied. Most evaluations since the mid-1990s describe shorter follow-up periods but are prospective in design, and feature more well-defined diagnostic populations, but suffer from the problem that the persons selecting the patients and performing the outcomes analysis also selected the persons to be treated. Estimates of outcomes have been difficult to compare between studies. The most difficult problem has been determining appropriate control groups. A randomized, double blind, prospective study of surgical versus non-surgical treatments is definitely needed. The ability to perform such a procedure is constrained by the ethics of withholding treatment in the population of persons selected for treatment, the practical difficulty of identifying controls with severe disease who are not surgical candidates, and the ethics of sham open neurosurgical procedures, which carry significant risk. In the absence of such studies, the best current evidence of efficacy remains in the pre- and post-operative evaluation of individuals.

With the increased interest in psychosurgical procedures, now more favorably referred to as functional neurosurgery for psychiatric disorders, clinical practice guidelines have been developed to assist physicians who are contemplating surgical intervention for their patients (March et al.). Such guidelines identify the availability of surgical therapy for psychiatric disorders and the make explicit the order of treatment. The guidelines help referring psychiatrists with selection criteria and indications. Obsessive-compulsive disorders, treatment resistant affective disorders, and anxiety were the accepted indications for surgical treatment in the early 2000s. Personality disorders and psychotic disorders are relative contraindications.

Several technical advances have contributed to the increasing interest in these procedures. More precise delineation of the anatomical substrate of psychiatric disorders has been progressing, for example the relationship of the amygdala to human fear (Adolphs et al.). Researchers have compared the activation of certain structures during obsessive-compulsive states to resting states using imaging techniques, and similar studies have been done for psychosis and bipolar disorder. Such information begins to confirm that the targets selected for functional neurosurgery are indeed related to the diseases being treated. Such information is also teaching that surgical destruction of brain target areas may not be the only way to affect these anatomical locations. Surgical interventions that might augment nervous system function such as electrical stimulation, implantation of mini-pumps or drug-secreting capsules, transplantation cells, and implantation of genetically modified vectors for gene delivery are all being explored. Researchers have also performed deep brain electrical stimulation for obsessive-compulsive disorder and Tourette's syndrome.

Conclusion

There is substantial evidence that twenty-first century stereotaxic techniques, involving smaller, more discrete lesions in the brain, avoid the unwanted outcomes seen in many patients treated by earlier psychosurgical procedures. In addition, there is sufficient evidence that certain procedures do offer potential benefit to the patient who has failed to respond to other known therapies. These procedures do not appear to produce adverse psychological changes.

john c. oakley (1995)

revised by author

SEE ALSO: Autonomy; Coercion; Deep Brain Stimulation; Electroconvulsive Therapy; Holocaust; Informed Consent: Issues of Consent in Mental Healthcare; Insanity and Insanity Defense; Institutionalization and Deinstitutionalization; Mental Illness: Conception of Mental Illness; Mental Illness: Cultural Perspectives; Mental Institutions, Commitment to; Mistakes, Medical; Narrative; Paternalism; Patients' Rights; Psychiatry, Abuses of; Psychosurgery, Ethical Aspects of; Race and Racism; Technology; Women, Historical and Cross-Cultural Perspectives

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