- Email: [email protected]
Psychosurgery and Physical Brain Manipulation
Psychosurgery and Physical Brain Manipulation J-N Missa, Universite´ Libre de Bruxelles, Brussels, Belgium
ª 2012 Elsevier Inc. All rights reserved.
Introduction Psychosurgery – sometimes called functional neurosur gery for psychiatric disorders or psychiatric neurosurgery – is the treatment of psychiatric disorders by means of cerebral neurosurgery. From the time of the first operation in the 1930s until today, psychosurgery has been a con troversial treatment. The use of psychiatric surgery has been overshadowed by doubts about its usefulness, inade quate reporting of outcomes, and ethical questions. After its introduction by Egas Moniz in 1936, psychosurgery became popular in the 1940s and in the early 1950s. Then, the advent of effective psychotropic agents and the rise of sociopolitical views of the causation of mental dis orders led to the rapid decline of the surgical treatment. Today, psychosurgery is not a common practice. Psychiatric surgery is carried out in a few medical centers. With time, its indications have also changed. In the 1940s and 1950s, thousands of schizophrenic patients received surgery. It is now generally accepted that schizophrenia cannot be helped by psychosurgery. Today, deep brain stimulation represents a virtual renaissance in the surgical approach to psychiatric disorders. Its current main indi cations are for treatment-resistant mental disorders, particularly major depression, and obsessive–compulsive disorder.
Historical and Medical Aspects Physical Treatments for Mental Illness in the 1920s and 1930s In the field of biological psychiatry, the first half of the twentieth century was the period of the ‘‘great and despe rate cures’’ (Valenstein, 1986: i). In the 1920s and 1930s, extraordinary physical treatment for mental disorders was introduced, including insulin therapy, cardiazol therapy, and electric shock therapy. The theoretical principle of these therapies was very simple: In order to cure a mentally ill patient, it is necessary to give him or her a shock. In 1928, Manfred Sakel introduced insulin therapy. The Sakel method was a treatment of schizophrenia by means of an insulin coma. Insulin was used to induce hypoglycemic coma and seizures. In the 1930s, other violent somatic treatments were used in psychiatry. A new method of inducing convulsions by the use of cardiazol was introduced by Laszlo von Meduna. These
treatments were extremely risky, and many patients died. In this climate of shock therapy, it was natural that the idea should occur to someone that electricity could be applied to patients as a convulsive stimulus. In 1936, Ugo Cerletti, a physician in Rome, undertook electrical convulsion experiments on humans. It is interesting for our purpose to note that in this case of experimentation on humans, Cerletti did not think it necessary to obtain the consent of the patient. Like Moniz, Cerletti did not ignore the fact that ‘‘unexpected – perhaps terrible – surprises might be encountered with the new method of treatment’’ (Cerletti, 1950: 87). A schizophrenic approximately 40 years old was chosen for the first test. No one knew who he was. Nobody asked the patient for his permis sion. He had arrived in Rome from Milan by train without a ticket. The patient expressed himself in incomprehensible neologisms. According to Cerletti, ‘‘Preparations for the experiments were carried out in an atmosphere of fearful silence bordering on disap proval in the presence of various assistants and some outside doctors’’ (Cerletti, 1950: 87). For the first test, Cerletti and Bini used a reduced tension (70 V) for a duration of 0.2 s. The patient suddenly jumped on his bed, but he did not lose consciousness. Cerletti thought that the voltage had been held too low, and he wanted to continue the experiment with a second test. Someone got nervous and suggested that the subject should be allowed to rest until the next day. Suddenly, the patient exclaimed, ‘‘Not a second, it is deadly.’’ The assistants began to insist upon suspension of the proceedings. However, Cerletti did not want to be influenced by ‘‘those superstitions,’’ and he gave a second discharge of 110 V for half a second. That is how the first epileptic fit experimentally induced in humans through the electric stimulus took place. Electroshock was born. The initial enthusiasm among psychiatrists for somatic treatments waned rapidly. These treatments based on fanciful the ories were sometimes effective in bringing about a transitory improvement of psychotic symptoms. However, these therapies were violent and dangerous. Patients sometimes died after insulin therapy. Cardiazol therapy and electroshock caused significant morbidity due to fractures until curare was used to induce paraly sis. After 1936, psychosurgery was offered to those who had already failed to respond to shock therapy. Very often, electroshock was used before or after
667
668
Psychosurgery and Physical Brain Manipulation
psychosurgery. The history of electroshock is strongly connected with the history of psychosurgery.
Psychosurgery: A Historical Analysis Early psychosurgical interventions
In 1891, German psychiatrist G. Burckhardt removed the cortical areas responsible for language (Broca and Wernicke areas) from the brain of five persons suffering from psychoses. In 1910, Puusepp in Russia also carried out brain surgery for psychiatric reasons. However, the real story of psychosurgery began in 1935 with Egas Moniz, Professor of neurology at the University of Lisbon who inaugurated a surgical procedure in the treat ment of certain psychoses. Moniz was present at the Second International Neurological Congress in London in 1935. The central issue of the symposium was the frontal lobes. Fulton and Jacobsen reported their experi ments on the tranquilizing effect of frontal lobectomy in two chimpanzees. After the communication by Fulton and Jacobsen, Moniz asked if frontal lobe removal prevents the development of neuroses in animals, why would it not be feasible to relieve anxiety in humans by surgical means? Back in Portugal, Moniz asked his surgeon colla borator, Almeida Lima, to operate on psychotic patients from the Manicome Bombarda, a psychiatric hospital in London. He suggested that by interrupting some of the connections between the prefrontal lobes and other parts of the brain, some modifications might be brought about in the mental processes of psychotic individuals. The idea was to operate on the brain of the patient by interrupting the connecting fibers between cells of the prefrontal regions and the thalamus. The hypothesis underlying the procedure might be called into question. The surgical intervention might be considered very audacious. But Moniz, in the preface of his book, Tentatives Ope´ratoires dans le Traitement de Certaines Psychoses, published in 1936, justified his standpoint on the use of psychosurgery. In order to undertake his experiment, Moniz needed some patients. He asked Professor Sobral Cid, Director of the Manicome Bombarda, to help him choose some patients who were chronically ill. Moniz did not care to ask for the patients’ consent. However, he knew that there were some risks in operating on the brain. In the intro duction of his book, he explains his ethical principles: Even if our conception is true, we are acting as the blind in this therapy. We must progress carefully, but with decision, when we are sure we don’t jeopardize patient’s life. As the first experiments must be undertaken upon incurable cases, the fact we could spoil their mental life doesn’t matter. In the worse hypothesis, they keep on being insane persons. (Moniz, 1936: 1)
Walter Freeman, James Watts, and the standard prefrontal lobotomy
The neurosurgeon team of Walter Freeman and James Watts introduced Moniz’s intervention in the United States. By the end of 1936, they completed their first series of operations on 20 patients. They developed a new technique of prefrontal lobotomy, which became known as the standard prefrontal lobotomy. In this pro cedure, two burr holes are drilled laterally in the frontal bone, and incisions are made with a leucotome in the white matter of both frontal lobes to cut the connections between the thalamus and the frontal pole. Freeman and Watts advanced the hypothesis that ‘‘the frontal lobes are concerned with foresight and insight and the emotional component associated with these functions is supplied by the thalamus’’ (Freeman and Watts, 1950: 734). For the two neurosurgeons, the intervention cuts off the emo tional component concerned with the abnormal ideas of the psychotic patient. The crude intention of the opera tion is to break the connection between the patient’s thoughts and his or her emotions, thus relieving mental tension. Freeman and Watts admitted that prefrontal lobotomy was ‘‘an operation of last resort’’ that should be done with the knowledge of possible unfavorable results, including persistent inertia, flattening of emotional life, convulsive seizures, incontinence, and aggressive misbehavior. The long-term side effects were described as the ‘‘frontal lobe syndrome,’’ which includes inertia, apathy, decreased attention, social inappropriate ness, and seizures. In the late 1940s, prefrontal lobotomies were being adopted in many areas of the world, including the United States, Great Britain, continental Europe, Latin America, India, and New Zealand. This operation was used in the treatment of depression, obsessive–compulsive states, schizophrenia, and chronic anxiety syndromes and also in the treatment of pain due to organic diseases. Transorbital leucotomy and other new procedures
In 1946, Freeman introduced in the United States a new technique of prefrontal leucotomy, called transorbital leucotomy, which was performed immediately after two applications of electroconvulsive therapy. This leu cotomy was first carried out by Fiamberti in Italy. Transorbital leucotomy was performed in the postcon vulsive coma following the electroshock without further anesthesia. The lesion is produced through the roof of the orbit of the eye with a transorbital leucotome (an ice picklike tool). The eyelid on one side is elevated, and the prefrontal cortex is cut through the orbit by the leuco tome. According to Freeman (1949: 734), the method is ‘‘simple, quick, and safe.’’ The entire operation is com plete in 10 min. Also, as the French neurosurgeon F. Ody said in 1956, ‘‘the patient will ignore if it is judged appro priate not to reveal to him that he has undergone a
Psychosurgery and Physical Brain Manipulation
leucotomy.’’ Freeman believed that transorbital leucot omy was best recommended for psychiatrists in mental hospitals where major neurosurgical procedures were not available. This technique was widely criticized, even by some neurosurgeons. When Freeman introduced transorbital leucotomy, Watts, his associate, decided to terminate his collaboration. Despite the objections, the influence of Freeman in the development of psychosur gery in the United States was considerable. In the late 1940s, J. L. Pool and W. B. Scoville described new, open procedures in which Brodmann’s areas 9 and 10 are removed or separated from the underlying white matter. In the early 1950s, lobotomies were being performed at the rate of 5000 per year in the United States. Dissent and decline
In the 1940s, the introduction of psychosurgery in the United States met vigorous opposition. Some physicians referred to it as medical sadism. The psychoanalysts objected to the lobotomy because it conflicted with their fundamental theoretical set. Even some nonpsychoana lysts were vehement in their opposition. Their claim is grounded on the adverse effects of psychosurgery (mod ification of the personality, apathy, infection, hemorrhage, and death) and on a lack of understanding of the relation between the mind and the structure of the brain. The debate about psychosurgery was emotionally charged, with some opponents comparing psychosurgical patients to ‘‘patients without soul’’ or to ‘‘decerebrated robots.’’ By the early 1950s, tens of thousands of individuals had undergone prefrontal leucotomy. Later in the 1950s, enthusiasm for psychosurgery began to fade. An editorial in Lancet stated in 1972, Such was the enormous pool of psychotic patients vege tating as chronic sick in the closed wards of mental hospitals, without effective drug control and without hope, that when it became possible to help them in any way, this new method was taken up with more enthu siasm than caution and with more technical skill than psychiatric and neurophysiological understanding.
A wave of reaction followed, and this was sustained by advances in drug therapy. When the French physician Henri Laborit introduced chlorpromazine, the therapeu tic situation changed fundamentally. Chlorpromazine was approved for use as an antipsychotic in 1952. With the availability of the major tranquilizers and antidepressants, psychoses and depressions ceased to be a primary indica tion for psychosurgery.
669
surgery, was introduced by Ernest Spiegel and Henry Wycis in the late 1940s. Stereotactic surgery ushered in the new era of psychosurgery by allowing destruction of relatively small, precisely located areas within the human brain. With this new technique, psychosurgery became more precise and focused on other regions of the brain. Lesions in the frontal lobes (bifrontal stereotactic subcau date tractotomy and capsulotomy) are still employed to treat anxiety states and obsessive–compulsive disorders. However, lesions in other areas, such as the temporal lobes, the limbic system (cingulotomy and limbic leucot omy), and the hypothalamus, have been introduced to treat affective disorders, violent behavior, hyperkinesis, and abnormal sexual behavior. Some of these indications were very dubious. Especially controversial was the attempt to control abnormal aggressiveness or sexual deviations by means of amygdalotomy or hypothalamotomy. Some neu rosurgeons, for instance, have been severely criticized for performing stereotactic neurosurgery (hypothalamotomy and amygdalotomy) in young children to cure ‘‘hyperkin esis’’ or ‘‘aggressive behaviors’’ (Balasubramanian, 1972). Psychosurgery in the 1980s and 1990s
In the 1980s and 1990s, four procedures were used in the treatment of intractable anxiety and affective disorders: capsulotomy, stereotactic subcaudate tractotomy, cingu lotomy, and limbic leucotomy. In these interventions, the neurosurgeon destroys some part of the frontal lobes or their connections to the limbic system. The patients selected for these procedures had severe, incapacitating, persistent, and treatment-resistant psychiatric illnesses, including anxiety states, obsessive–compulsive disorder, and major depression. Stereotactic psychiatric neurosurgery consists of pro ducing lesions in the brain by heating electrodes in the target areas to coagulate the tissue or by focused radiation utilizing either a linear accelerator radiation source or a focusable cobalt radiation source (the gamma knife). Contrary to the heating lesion, the radiation lesion requires no opening of the skull. The patient is simply exposed to a focused beam of radiation. By focusing the beams of hemispherically arrayed cobalt sources, the gamma knife delivers a high dose of radiation to a small target. In general, four surgical interventions have been uti lized. In these interventions, the neurosurgeon destroys some part of the frontal lobes or their connections to the limbic system (the prefrontal cortex and the limbic system play a prominent role in emotional and cognitive functions).
The advent of stereotactic psychosurgery
Capsulotomy
In the 1960s and 1970s, psychosurgery used new stereo tactic apparatus permitting the selective destruction of parts of the brain. This technique, called stereotactic
Capsulotomy is an established psychosurgical interven tion for anxiety disorders that are resistant to conventional treatments. The intervention was first
670
Psychosurgery and Physical Brain Manipulation
realized by T. Herner in 1961. Capsulotomy was used by P. Mindus (Karolinska Hospital, Stockholm) to treat anxiety disorder and obsessive–compulsive disorder. Frontolimbic connections contained in the anterior limb of the internal capsule are intersected by way of radiofrequency heat lesions or gamma irradiation. Subcaudate tractotomy
The target in subcaudate tractotomy was described by G. Knight in 1964. The lesions are made by implanting radioactive beads in the medio-posterobasal part of the frontal lobes. This procedure, a stereotactic variant of Scoville’s orbital undercutting procedure, is indicated for anxiety states, obsessional symptoms, and depression. Cingulotomy
Cingulotomy severs, through the administration of heat ing lesions, the anterior supracallosal fibers of the cingulate gyrus within the limbic system. This functional neurosurgical technique was popularized by H. Thomas Ballantine in the United States (Massachusetts General Hospital, Boston). Cingulotomy is used as a potentially effective treatment for patients with major affective dis orders and anxiety disorders and for those with severe and disabling obsessive–compulsive disorder. Limbic leucotomy
Limbic leucotomy combines cingulotomy with subcau date tractotomy.
Psychosurgery Today: The Advent of Deep Brain Stimulation Today, psychosurgery is no longer a common practice, and it is performed only to a limited extent in Europe and in the United States. However, we could well observe a development in the use of psychosurgery in the coming years. Two factors could play a role in the new interest in psychiatric surgery. The first factor is the change in the reaction to the use of psychosurgery: After the development of psycho pharmacology in the 1950s, psychosurgery saw a sharp decline. In the late 1970s and early 1980s, one might have expected the disappearance of psychosurgery. After 1980, however, the attitude toward psychosurgery changed. Some psychiatrists and neurosurgeons (including H. T. Ballantine, M. A. Jenike, P. Mindus, and P. K. Bridges) thought that psychosurgery was still useful to treat a small number of highly disturbed and suffering therapyresistant patients. H. T. Ballantine, of the Harvard Medical School, affirmed in 1988 that ‘‘there is a need for more surgical intervention in the treatment of intract able disorders of affect and more leadership in this direction from the psychiatrists’’ (Ballantine, 1988: 125).
In 1993, P. Mindus became enthusiastic about psychiatric surgery: Given the remarkable progress in the diagnosis and the treatment of anxiety disorders in recent years, it is prob able that, in the future, an even more refractory patient population will be referred for neurosurgical treatment.. . . In the heyday of lobotomy, it would appear that too many were operated on too soon. Today, as it would seem, too few are operated on too late. In both situations, the patient pays a price. It is therefore hoped that in this Decade of the Brain, physicians may over come outdated attitudinal barriers and more often consider surgical intervention in their desperately ill patients.’’ (Mindus, 1993: 31)
The second factor is the development of new technolo gies in brain surgery. Deep brain stimulation is a surgical treatment involving the implantation of a medical device that sends electrical impulses to specific parts of the brain. It is a neurosurgical treatment that stimulates the brain with mild electrical signals. This technique has provided therapeutic benefits for essential tremor and Parkinson’s disease. Developed in Europe, deep brain stimulation was approved by the U.S. Food and Drug Administration for Parkinson’s disease in 2002. More recently, deep brain stimulation has been used to treat various psychiatric disorders, including depression and obsessive–compulsive disorders. Researchers have reported that electrical sti mulation of a small area of the frontal cortex brought about a remission in patients suffering from major depres sion. Deep brain stimulation in psychiatric patients could be considered as a reversible form of psychosurgery. The advantage of deep brain stimulation is that it implies no lesion in the brain. Deep brain stimulation represents a virtual renaissance in the surgical approach to psychiatric disorders.
Ethical Aspects Psychosurgery: Cut the Brain to Save the Mind? Psychosurgery is the most radical technique of physical brain manipulation. What does psychosurgery do? This question raises the ethical issue of how to balance its benefits and hazards in making therapeutic judgments. Psychosurgery is a highly controversial therapy. Its pro mise to relieve great psychic pain must be balanced against the perils of impairing the personality, diminish ing affect and creativity, and the ordinary dangers of a surgical intervention. Peter Breggin has argued that psy chosurgery is the murder of the soul – that the physical destruction of any healthy brain tissue is an invasion of the sanctity of the person. I do not agree with those who insist that the intact brain should not be tampered with at
Psychosurgery and Physical Brain Manipulation
any cost. This conception, which is at once mystical and emotional, is a tribute to the idea that the human body is somehow inviolate, and that it is sacrilegious to experi ment on it. Here, the objection approaches the dogma of religious conviction. There is some validity to the argu ment that states that if someone is in pain and we can help him or her, we should do it even if we do not know exactly what we are doing. However, in the long term, we need to know what we are doing so that we can take responsibility for it. With reference to psychosurgery, this means that the relation between the somatic structures that are destroyed (or stimulated) and the mental struc tures thereby affected must be understood. This is not yet completely the case. Psychosurgery: An Experimental Therapy The story of psychosurgery is the story of an experimen tal therapy. Despite technical advances in psychiatric surgery, the procedures are still experimental. The term ‘experimental’ has two meanings. In one sense, an experi mental procedure stands in contrast to a therapeutic one: It is done with no expectation of benefit to the patient, but only to further knowledge. In the field of psychosurgery, there is no excuse for experimental procedure in this sense. Unfortunately, the story of psychosurgery offers some examples of such ‘cognitive experiments’ – for instance, the operation of bilateral occipital leucotomy that was undertaken by the Norwegian neurosurgeon Arne Torkildsen in 1948. Torkildsen cut all the white matter of the occipital lobes of a blind, schizophrenic patient who destroyed his eyes because he had heard the voice of God telling him to accomplish such an act. This experience was nonsense, even in the scientific con text of the 1940s. Of course, the results of the operation were negative: ‘‘The experience with this case shows that the disconnection of both occipital lobes has no influence as far as can be judged from the psychiatric observations’’ (Torkildsen, 1948: 705). In another sense, a procedure is experimental if its effects are unpredictable, its risks highly variable, its mechanisms poorly understood, and its usefulness subject to widespread debate in the medical community. Psychosurgery has always been an experimental procedure in this sense. The therapeutic effects of many of its procedures fall into a wide range of success and failure. The first opera tions were very dangerous. Many patients died directly or indirectly as a result of the operation. Especially hazar dous were the operations of stereotaxic amygdalotomy and hypothalamotomy for aggressive restless behaviors. In a report of 128 cases who had undergone stereotactic surgery over a period of 6 years (1964–70), 9 of the first 50 cases died after the operation. With the new stereotactic procedures (anterior capsu lotomy and subcaudate tractotomy) that were realized in
671
specialized units carrying out regular interventions, the incidence of complications for each procedure was rela tively low compared with the morbidity and mortality in the early period of psychosurgery. There were fewer somatic side effects (epileptic seizures and intracerebral hematoma). Psychosurgical operations can reduce dis abling symptoms such as obsession or anxiety with minimal cognitive changes. However, some behavioral side effects are still present. Perseverative behavior, for instance, often occurs after capsulotomy. The patient tends to repeat old patterns of behavior even in circum stances that demand change. This is not surprising because the surgical operation cut some connections with the prefrontal cortex and perseveration is a distinc tive disorder arising from prefrontal damage. The most distinctive disorder arising from prefrontal damage is the inability to initiate and carry out new and goal-directed patterns of behavior. The patient encoun ters trouble when forced to develop a new form of behavior based on deliberation and choice, especially if, in order to reach the goal, that behavior requires the organization of a novel sequence of acts. The frontal patient tends to repeat old patterns of behavior even in circumstances that demand change. Perseveration in old but inappropriate behavior is a distinctive trait of the performance of frontal patients in cognitive tasks. The risk of behavioral side effects must be weighed against the eventual clinical benefit of stereotactic psy chosurgery. Unfortunately, postoperative assessment of psychiatric disorders is most difficult. Partisans of psy chosurgery claim that the stereotactic procedure is followed by a significant improvement in measures of clinical morbidity and in psychosocial functioning, with preservation of personality. In approximately 30–60% of the cases of patients who suffer from obsessive–compul sive disorders, one of the modern forms of psychosurgery will bring relief. It may not eliminate the symptoms entirely, but they become less intrusive and they no longer dominate the patient’s life. What is disturbing in psychosurgery is that neurosur geons do not exactly know the mechanisms of the operations they undertake. The functions of the region of the brain that are destroyed (prefrontal cortex, limbic system, and amygdala) are far from completely known. In the modern forms of stereotactic surgery, the neurosurgeon destroys some part of the frontal lobes or the connections to the limbic system. The prefrontal cortex and the limbic system play a prominent part in emotional and cognitive functions. The relationship of these neural structures to emotions is accepted, but the specific functions of the various areas have not been identified with any certainty. Moreover, the neurophysiological mechanisms involved in affective disorders are poorly understood. Therefore, the rationale for selecting targets for psychosurgical proce dures is empirical. Our knowledge of the brain is still
672
Psychosurgery and Physical Brain Manipulation
relatively poor. Psychosurgery is an experimental therapy and, paradoxically, neuroscientists learn about the frontal lobe functions and other brain regions from neurosurgical treatment of intractable psychiatric disorders. The usefulness of psychiatric surgery is far from unanimously agreed upon. Today, psychosurgery is not a normal practice; it is used in few institutions. In most neuropsychiatric hospitals, psychosurgery has disap peared from the therapeutic armamentarium.
Assessment of the Effects of Psychosurgery Frequently, it has been pointed out that the assessments of the effects of psychosurgery are inadequate. In the first era of psychosurgery, studies on the long-term outcomes of patients who had undergone psychiatric surgery had serious methodological problems. The efficacy of psycho surgery performed in this era is doomed to remain in doubt. Since then, better research methods have been developed for evaluating psychiatric symptoms and therapeutic efficacy. Psychometric instruments and rating scales are used to assess psychiatric symptoms and cogni tive functions. Nevertheless, personality change and improvement of the psychiatric symptoms remain diffi cult to assess empirically. Nowhere does the relationship between mind and body take on a more practical aspect than in psychosurgery that pretends to alter the brain to improve the mind. The eventual improvement in mental health after a psychosur gical treatment is difficult to evaluate because of the dual aspect of the mind–brain. The mind–brain is one entity with two faces: an objective one, the brain, and a subjective one, the mind. It is an organ with both physical and mental aspects. The philosopher Thomas Nagel stated, There seem to be very different kinds of things going on in the world: the things that belong to physical reality, which many different people can observe from the out side, and those other things that belong to reality, which each of us experiences from the inside in his own case.
After a psychosurgical treatment, the neurosurgeon and the psychiatrist have to judge indirectly and behaviorally the therapeutic effects of the operation. They cannot see directly what happens in the mind of the patient. That is why the real effects of psychosurgery are so difficult to evaluate precisely.
Indications The patients selected for psychiatric surgery should have severe incapacitating, persistent, and treatment-resis tant psychiatric illnesses, including anxiety states, obsessive–compulsive disorder, and major depression. Theoretically, psychosurgery today is generally
considered a ‘treatment of last resort’ that is utilized when all other treatments have failed. Unfortunately, this condition is not always respected. In a long-term follow-up of 33 patients who had undergone cingulotomy as a treat ment for obsessive–compulsive disorder at Massachusetts General Hospital (Boston), only 3 had undergone beha vioral therapy. Most of these patients did not receive all potentially effective therapies for their disorder before surgery. Future candidates for psychosurgery should undergo trials of other treatments (psychotherapy, beha vioral therapy, and medications) before surgery. There are unacceptable indications. For instance, the operations of thalamotomy, hypothalamotomy, and amygdalotomy for aggressive behavior, sexual violence, and ‘sexual deviation’ seem unacceptable to most people. In these circumstances, the aim of the ‘treatment’ is to normalize the conduct of the patient, not to relieve his or her sufferings. Especially controversial was the attempt to cure aggressive or restless behaviors by amygdalotomy or by posterior hypothalamotomy. Some neurosurgeons (Narabayashi, Sano, and Ramamurthi), for instance, have been severely criticized for performing a surgical destruction of brain centers (hypothalamotomy and amygdalotomy) in young children. The rationale, the methodology, and the neurophysiological theories under lying these operations were particularly dubious.
Informed Consent and Psychosurgery In the field of psychosurgery, informed consent is very important and should be strictly observed. Does the patient consent to the treatment? Does he or she know the dangers of the treatment? However, a real informed consent is extremely difficult to obtain from psychiatric patients. Often, close members of their families are the sources of consent. Is proxy consent acceptable as a sub stitute? It must be remembered that the closest kin are likely to be the ones who have suffered the most from the patient’s behavior and hence may have the greatest motive to seek a more drastic solution than is necessary.
Necessity of an Ethical Regulation of Psychosurgery: Criteria for the Selection of Psychiatric Patients Psychosurgery should be considered as a kind of human experimentation; therefore, the psychosurgical operations and their theoretical background should be systematically examined by competent ethics committees. In practical terms, this means that a committee of some sort, com posed of neurosurgeons, psychiatrists, physicians, and ethicists, should be present to monitor the psychiatric or surgical treatment. National advisory committees should also formulate opinions about psychosurgery.
Psychosurgery and Physical Brain Manipulation
Most of the units carrying out regular psychosurgical operations have developed general guidelines, including the following: 1. It is a treatment of last resort. The patient is chroni cally disabled by a psychiatric illness that has not responded to all currently available therapies (psychotherapy, beha vioral therapy, medications, and electroconvulsive therapy). 2. The disorder is causing great suffering and a severe reduction in the patient’s psychosocial functioning. 3. The prognosis without psychosurgical intervention is considered poor. 4. The patient, along with his or her nearest relative, must be fully informed of the risks and benefits of the surgical intervention and must give informed consent. 5. The referring psychiatrist agrees to be responsible for the postoperative long-term management of the patient. These guidelines on psychiatric surgery are an example of the self-regulation of a delicate problem by profes sionals. Scientists have come to accept regulation of their work. The field of psychosurgery is highly contro versial and the one in which regular national and international guidelines is highly desirable. Because of its controversial aspects and its experimental nature, the practice of psychosurgery should be strongly regulated. See also: Crime and Society; Informed Consent; Neuroethics/Brain Imaging; Psychiatry, Coercive Treatment.
Further Reading Balasubramaniam V, Ramanujam PB, Kanaka TS, and Ramamurthi B (1972) Stereotaxic surgery for behavior disorders. In: Hitchcock E, Laittinen L, and Vaerner K (eds.) Psychosurgery: Proceedings of the Second International Conference on Psychosurgery, pp. 87–111. Springfield, IL: Charles C Thomas. Ballantine HT (1988) Historical overview of psychosurgery and its problematic. Acta Neurochirurgica Supplementum 44: 125–128. Cerletti U (1950) Old and new information about electroshock. American Journal of Psychiatry 107: 87–94. Comite´ Consultatif National d’Ethique (2002, April 25) Avis sur la Neurochirurgie Fonctionnelle d’Affections Psychiatriques Se´ve`res. http://www.ccne-ethique.fr/docs/fr/avis071.pdf. Fiamberti AM (1952) La me´thode transorbitaire de la leucotomie pre´frontale. Ence´phale 41: 1–13. Freeman W (1949) Transorbital lobotomy. American Journal of Psychiatry 105: 734–739. Freeman W and Watts JW (1942) Psychosurgery: Intelligence, Emotion and Social Behavior Following Prefrontal Lobotomy for Mental Disorders. Springfield, IL: Charles C Thomas. Mashour GA, Walker EE, and Martuza RL (2005) Psychosurgery: Past, present, and future. Brain Research Reviews 48: 409–419.
673
Mindus P (1993) Present-day indications for capsulotomy. Acta Neurochirurgica Supplementum 58: 31. Moniz E (1936) Tentatives Operatoires dans le Traitement de Certaine Psychoses. Paris: Masson. Narabayashi H, Nagao T, Saito Y, Yoshida M, and Nagahata M (1968) Stereotaxic amygdalotomy for behavior disorders. Archives of Neurology 9: 11–26. Ramamurthi B (1988) Stereotaxic operation in behaviour disorders. Acta Neurochirurgica Supplementum 44: 152–157. Sano K and Mayanagi Y (1988) Posteromedial hypothalamotomy in the treatment of violent, aggressive behavior. Acta Neurochirurgica Supplementum 44: 145–151. Schlaepfer TE and Lieb K (2005) Deep brain stimulation for treatment of refractory depression. Lancet 366(9495): 1420–1422. Torkildsen A (1949) Notes on the importance of the occipital lobes in a case of schizophrenia: Experience with a case of bilateral occipital leucotomy. Acta Psychiatrica et Neurologica 24: 705. Valenstein ES (1986) Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books.
Relevant Website http://www.dana.org – The Dana Foundation.
Biographical Sketch Jean-Noel Missa received a PhD in medicine in 1985 and a PhD in Philosophy in 1992. He is Research Director at the National Fund for Scientific Research (Belgium) and Professor at the Universite´ Libre de Bruxelles. He is specia lized in the history, ethics, and philosophy of biomedical sciences (specifically, neuroscience and biological psychia try). He is also Director of the Center for Interdisciplinary Research in Bioethics and a member of the Belgian Consultative Committee of Bioethics. In 2002 and 2003, he was a Fulbright visiting research scholar at New York University. He is Former President of the Belgian Society for Philosophy and Current President of the Society for the Philosophy of Technology. He is an expert member at the European Commission for the European Research Council Peer Review Evaluation (2009–11). He has published approximately 50 scientific articles and several books. In 2008, he was awarded the Frans Jonckheere distinction of the Belgian Royal Academy of Medicine for the history of medicine for his book Naissance de la Psychiatrie Biologique (PUF, 2006). In June 2009, he was elected member of the Belgian Royal Academy (Acade´mie Royale des Sciences, des Lettres et des Beaux-Arts de Belgique, Classe Technologie et Socie´te´). In November 2009, he was Invited Professor at the University of Bouake´ of Abidjan (Ivory Coast), and in May 2010, he was Invited Professor at the University Paris VII (Denis Diderot).
ª 2012 Elsevier Inc. All rights reserved.
Introduction Psychosurgery – sometimes called functional neurosur gery for psychiatric disorders or psychiatric neurosurgery – is the treatment of psychiatric disorders by means of cerebral neurosurgery. From the time of the first operation in the 1930s until today, psychosurgery has been a con troversial treatment. The use of psychiatric surgery has been overshadowed by doubts about its usefulness, inade quate reporting of outcomes, and ethical questions. After its introduction by Egas Moniz in 1936, psychosurgery became popular in the 1940s and in the early 1950s. Then, the advent of effective psychotropic agents and the rise of sociopolitical views of the causation of mental dis orders led to the rapid decline of the surgical treatment. Today, psychosurgery is not a common practice. Psychiatric surgery is carried out in a few medical centers. With time, its indications have also changed. In the 1940s and 1950s, thousands of schizophrenic patients received surgery. It is now generally accepted that schizophrenia cannot be helped by psychosurgery. Today, deep brain stimulation represents a virtual renaissance in the surgical approach to psychiatric disorders. Its current main indi cations are for treatment-resistant mental disorders, particularly major depression, and obsessive–compulsive disorder.
Historical and Medical Aspects Physical Treatments for Mental Illness in the 1920s and 1930s In the field of biological psychiatry, the first half of the twentieth century was the period of the ‘‘great and despe rate cures’’ (Valenstein, 1986: i). In the 1920s and 1930s, extraordinary physical treatment for mental disorders was introduced, including insulin therapy, cardiazol therapy, and electric shock therapy. The theoretical principle of these therapies was very simple: In order to cure a mentally ill patient, it is necessary to give him or her a shock. In 1928, Manfred Sakel introduced insulin therapy. The Sakel method was a treatment of schizophrenia by means of an insulin coma. Insulin was used to induce hypoglycemic coma and seizures. In the 1930s, other violent somatic treatments were used in psychiatry. A new method of inducing convulsions by the use of cardiazol was introduced by Laszlo von Meduna. These
treatments were extremely risky, and many patients died. In this climate of shock therapy, it was natural that the idea should occur to someone that electricity could be applied to patients as a convulsive stimulus. In 1936, Ugo Cerletti, a physician in Rome, undertook electrical convulsion experiments on humans. It is interesting for our purpose to note that in this case of experimentation on humans, Cerletti did not think it necessary to obtain the consent of the patient. Like Moniz, Cerletti did not ignore the fact that ‘‘unexpected – perhaps terrible – surprises might be encountered with the new method of treatment’’ (Cerletti, 1950: 87). A schizophrenic approximately 40 years old was chosen for the first test. No one knew who he was. Nobody asked the patient for his permis sion. He had arrived in Rome from Milan by train without a ticket. The patient expressed himself in incomprehensible neologisms. According to Cerletti, ‘‘Preparations for the experiments were carried out in an atmosphere of fearful silence bordering on disap proval in the presence of various assistants and some outside doctors’’ (Cerletti, 1950: 87). For the first test, Cerletti and Bini used a reduced tension (70 V) for a duration of 0.2 s. The patient suddenly jumped on his bed, but he did not lose consciousness. Cerletti thought that the voltage had been held too low, and he wanted to continue the experiment with a second test. Someone got nervous and suggested that the subject should be allowed to rest until the next day. Suddenly, the patient exclaimed, ‘‘Not a second, it is deadly.’’ The assistants began to insist upon suspension of the proceedings. However, Cerletti did not want to be influenced by ‘‘those superstitions,’’ and he gave a second discharge of 110 V for half a second. That is how the first epileptic fit experimentally induced in humans through the electric stimulus took place. Electroshock was born. The initial enthusiasm among psychiatrists for somatic treatments waned rapidly. These treatments based on fanciful the ories were sometimes effective in bringing about a transitory improvement of psychotic symptoms. However, these therapies were violent and dangerous. Patients sometimes died after insulin therapy. Cardiazol therapy and electroshock caused significant morbidity due to fractures until curare was used to induce paraly sis. After 1936, psychosurgery was offered to those who had already failed to respond to shock therapy. Very often, electroshock was used before or after
667
668
Psychosurgery and Physical Brain Manipulation
psychosurgery. The history of electroshock is strongly connected with the history of psychosurgery.
Psychosurgery: A Historical Analysis Early psychosurgical interventions
In 1891, German psychiatrist G. Burckhardt removed the cortical areas responsible for language (Broca and Wernicke areas) from the brain of five persons suffering from psychoses. In 1910, Puusepp in Russia also carried out brain surgery for psychiatric reasons. However, the real story of psychosurgery began in 1935 with Egas Moniz, Professor of neurology at the University of Lisbon who inaugurated a surgical procedure in the treat ment of certain psychoses. Moniz was present at the Second International Neurological Congress in London in 1935. The central issue of the symposium was the frontal lobes. Fulton and Jacobsen reported their experi ments on the tranquilizing effect of frontal lobectomy in two chimpanzees. After the communication by Fulton and Jacobsen, Moniz asked if frontal lobe removal prevents the development of neuroses in animals, why would it not be feasible to relieve anxiety in humans by surgical means? Back in Portugal, Moniz asked his surgeon colla borator, Almeida Lima, to operate on psychotic patients from the Manicome Bombarda, a psychiatric hospital in London. He suggested that by interrupting some of the connections between the prefrontal lobes and other parts of the brain, some modifications might be brought about in the mental processes of psychotic individuals. The idea was to operate on the brain of the patient by interrupting the connecting fibers between cells of the prefrontal regions and the thalamus. The hypothesis underlying the procedure might be called into question. The surgical intervention might be considered very audacious. But Moniz, in the preface of his book, Tentatives Ope´ratoires dans le Traitement de Certaines Psychoses, published in 1936, justified his standpoint on the use of psychosurgery. In order to undertake his experiment, Moniz needed some patients. He asked Professor Sobral Cid, Director of the Manicome Bombarda, to help him choose some patients who were chronically ill. Moniz did not care to ask for the patients’ consent. However, he knew that there were some risks in operating on the brain. In the intro duction of his book, he explains his ethical principles: Even if our conception is true, we are acting as the blind in this therapy. We must progress carefully, but with decision, when we are sure we don’t jeopardize patient’s life. As the first experiments must be undertaken upon incurable cases, the fact we could spoil their mental life doesn’t matter. In the worse hypothesis, they keep on being insane persons. (Moniz, 1936: 1)
Walter Freeman, James Watts, and the standard prefrontal lobotomy
The neurosurgeon team of Walter Freeman and James Watts introduced Moniz’s intervention in the United States. By the end of 1936, they completed their first series of operations on 20 patients. They developed a new technique of prefrontal lobotomy, which became known as the standard prefrontal lobotomy. In this pro cedure, two burr holes are drilled laterally in the frontal bone, and incisions are made with a leucotome in the white matter of both frontal lobes to cut the connections between the thalamus and the frontal pole. Freeman and Watts advanced the hypothesis that ‘‘the frontal lobes are concerned with foresight and insight and the emotional component associated with these functions is supplied by the thalamus’’ (Freeman and Watts, 1950: 734). For the two neurosurgeons, the intervention cuts off the emo tional component concerned with the abnormal ideas of the psychotic patient. The crude intention of the opera tion is to break the connection between the patient’s thoughts and his or her emotions, thus relieving mental tension. Freeman and Watts admitted that prefrontal lobotomy was ‘‘an operation of last resort’’ that should be done with the knowledge of possible unfavorable results, including persistent inertia, flattening of emotional life, convulsive seizures, incontinence, and aggressive misbehavior. The long-term side effects were described as the ‘‘frontal lobe syndrome,’’ which includes inertia, apathy, decreased attention, social inappropriate ness, and seizures. In the late 1940s, prefrontal lobotomies were being adopted in many areas of the world, including the United States, Great Britain, continental Europe, Latin America, India, and New Zealand. This operation was used in the treatment of depression, obsessive–compulsive states, schizophrenia, and chronic anxiety syndromes and also in the treatment of pain due to organic diseases. Transorbital leucotomy and other new procedures
In 1946, Freeman introduced in the United States a new technique of prefrontal leucotomy, called transorbital leucotomy, which was performed immediately after two applications of electroconvulsive therapy. This leu cotomy was first carried out by Fiamberti in Italy. Transorbital leucotomy was performed in the postcon vulsive coma following the electroshock without further anesthesia. The lesion is produced through the roof of the orbit of the eye with a transorbital leucotome (an ice picklike tool). The eyelid on one side is elevated, and the prefrontal cortex is cut through the orbit by the leuco tome. According to Freeman (1949: 734), the method is ‘‘simple, quick, and safe.’’ The entire operation is com plete in 10 min. Also, as the French neurosurgeon F. Ody said in 1956, ‘‘the patient will ignore if it is judged appro priate not to reveal to him that he has undergone a
Psychosurgery and Physical Brain Manipulation
leucotomy.’’ Freeman believed that transorbital leucot omy was best recommended for psychiatrists in mental hospitals where major neurosurgical procedures were not available. This technique was widely criticized, even by some neurosurgeons. When Freeman introduced transorbital leucotomy, Watts, his associate, decided to terminate his collaboration. Despite the objections, the influence of Freeman in the development of psychosur gery in the United States was considerable. In the late 1940s, J. L. Pool and W. B. Scoville described new, open procedures in which Brodmann’s areas 9 and 10 are removed or separated from the underlying white matter. In the early 1950s, lobotomies were being performed at the rate of 5000 per year in the United States. Dissent and decline
In the 1940s, the introduction of psychosurgery in the United States met vigorous opposition. Some physicians referred to it as medical sadism. The psychoanalysts objected to the lobotomy because it conflicted with their fundamental theoretical set. Even some nonpsychoana lysts were vehement in their opposition. Their claim is grounded on the adverse effects of psychosurgery (mod ification of the personality, apathy, infection, hemorrhage, and death) and on a lack of understanding of the relation between the mind and the structure of the brain. The debate about psychosurgery was emotionally charged, with some opponents comparing psychosurgical patients to ‘‘patients without soul’’ or to ‘‘decerebrated robots.’’ By the early 1950s, tens of thousands of individuals had undergone prefrontal leucotomy. Later in the 1950s, enthusiasm for psychosurgery began to fade. An editorial in Lancet stated in 1972, Such was the enormous pool of psychotic patients vege tating as chronic sick in the closed wards of mental hospitals, without effective drug control and without hope, that when it became possible to help them in any way, this new method was taken up with more enthu siasm than caution and with more technical skill than psychiatric and neurophysiological understanding.
A wave of reaction followed, and this was sustained by advances in drug therapy. When the French physician Henri Laborit introduced chlorpromazine, the therapeu tic situation changed fundamentally. Chlorpromazine was approved for use as an antipsychotic in 1952. With the availability of the major tranquilizers and antidepressants, psychoses and depressions ceased to be a primary indica tion for psychosurgery.
669
surgery, was introduced by Ernest Spiegel and Henry Wycis in the late 1940s. Stereotactic surgery ushered in the new era of psychosurgery by allowing destruction of relatively small, precisely located areas within the human brain. With this new technique, psychosurgery became more precise and focused on other regions of the brain. Lesions in the frontal lobes (bifrontal stereotactic subcau date tractotomy and capsulotomy) are still employed to treat anxiety states and obsessive–compulsive disorders. However, lesions in other areas, such as the temporal lobes, the limbic system (cingulotomy and limbic leucot omy), and the hypothalamus, have been introduced to treat affective disorders, violent behavior, hyperkinesis, and abnormal sexual behavior. Some of these indications were very dubious. Especially controversial was the attempt to control abnormal aggressiveness or sexual deviations by means of amygdalotomy or hypothalamotomy. Some neu rosurgeons, for instance, have been severely criticized for performing stereotactic neurosurgery (hypothalamotomy and amygdalotomy) in young children to cure ‘‘hyperkin esis’’ or ‘‘aggressive behaviors’’ (Balasubramanian, 1972). Psychosurgery in the 1980s and 1990s
In the 1980s and 1990s, four procedures were used in the treatment of intractable anxiety and affective disorders: capsulotomy, stereotactic subcaudate tractotomy, cingu lotomy, and limbic leucotomy. In these interventions, the neurosurgeon destroys some part of the frontal lobes or their connections to the limbic system. The patients selected for these procedures had severe, incapacitating, persistent, and treatment-resistant psychiatric illnesses, including anxiety states, obsessive–compulsive disorder, and major depression. Stereotactic psychiatric neurosurgery consists of pro ducing lesions in the brain by heating electrodes in the target areas to coagulate the tissue or by focused radiation utilizing either a linear accelerator radiation source or a focusable cobalt radiation source (the gamma knife). Contrary to the heating lesion, the radiation lesion requires no opening of the skull. The patient is simply exposed to a focused beam of radiation. By focusing the beams of hemispherically arrayed cobalt sources, the gamma knife delivers a high dose of radiation to a small target. In general, four surgical interventions have been uti lized. In these interventions, the neurosurgeon destroys some part of the frontal lobes or their connections to the limbic system (the prefrontal cortex and the limbic system play a prominent role in emotional and cognitive functions).
The advent of stereotactic psychosurgery
Capsulotomy
In the 1960s and 1970s, psychosurgery used new stereo tactic apparatus permitting the selective destruction of parts of the brain. This technique, called stereotactic
Capsulotomy is an established psychosurgical interven tion for anxiety disorders that are resistant to conventional treatments. The intervention was first
670
Psychosurgery and Physical Brain Manipulation
realized by T. Herner in 1961. Capsulotomy was used by P. Mindus (Karolinska Hospital, Stockholm) to treat anxiety disorder and obsessive–compulsive disorder. Frontolimbic connections contained in the anterior limb of the internal capsule are intersected by way of radiofrequency heat lesions or gamma irradiation. Subcaudate tractotomy
The target in subcaudate tractotomy was described by G. Knight in 1964. The lesions are made by implanting radioactive beads in the medio-posterobasal part of the frontal lobes. This procedure, a stereotactic variant of Scoville’s orbital undercutting procedure, is indicated for anxiety states, obsessional symptoms, and depression. Cingulotomy
Cingulotomy severs, through the administration of heat ing lesions, the anterior supracallosal fibers of the cingulate gyrus within the limbic system. This functional neurosurgical technique was popularized by H. Thomas Ballantine in the United States (Massachusetts General Hospital, Boston). Cingulotomy is used as a potentially effective treatment for patients with major affective dis orders and anxiety disorders and for those with severe and disabling obsessive–compulsive disorder. Limbic leucotomy
Limbic leucotomy combines cingulotomy with subcau date tractotomy.
Psychosurgery Today: The Advent of Deep Brain Stimulation Today, psychosurgery is no longer a common practice, and it is performed only to a limited extent in Europe and in the United States. However, we could well observe a development in the use of psychosurgery in the coming years. Two factors could play a role in the new interest in psychiatric surgery. The first factor is the change in the reaction to the use of psychosurgery: After the development of psycho pharmacology in the 1950s, psychosurgery saw a sharp decline. In the late 1970s and early 1980s, one might have expected the disappearance of psychosurgery. After 1980, however, the attitude toward psychosurgery changed. Some psychiatrists and neurosurgeons (including H. T. Ballantine, M. A. Jenike, P. Mindus, and P. K. Bridges) thought that psychosurgery was still useful to treat a small number of highly disturbed and suffering therapyresistant patients. H. T. Ballantine, of the Harvard Medical School, affirmed in 1988 that ‘‘there is a need for more surgical intervention in the treatment of intract able disorders of affect and more leadership in this direction from the psychiatrists’’ (Ballantine, 1988: 125).
In 1993, P. Mindus became enthusiastic about psychiatric surgery: Given the remarkable progress in the diagnosis and the treatment of anxiety disorders in recent years, it is prob able that, in the future, an even more refractory patient population will be referred for neurosurgical treatment.. . . In the heyday of lobotomy, it would appear that too many were operated on too soon. Today, as it would seem, too few are operated on too late. In both situations, the patient pays a price. It is therefore hoped that in this Decade of the Brain, physicians may over come outdated attitudinal barriers and more often consider surgical intervention in their desperately ill patients.’’ (Mindus, 1993: 31)
The second factor is the development of new technolo gies in brain surgery. Deep brain stimulation is a surgical treatment involving the implantation of a medical device that sends electrical impulses to specific parts of the brain. It is a neurosurgical treatment that stimulates the brain with mild electrical signals. This technique has provided therapeutic benefits for essential tremor and Parkinson’s disease. Developed in Europe, deep brain stimulation was approved by the U.S. Food and Drug Administration for Parkinson’s disease in 2002. More recently, deep brain stimulation has been used to treat various psychiatric disorders, including depression and obsessive–compulsive disorders. Researchers have reported that electrical sti mulation of a small area of the frontal cortex brought about a remission in patients suffering from major depres sion. Deep brain stimulation in psychiatric patients could be considered as a reversible form of psychosurgery. The advantage of deep brain stimulation is that it implies no lesion in the brain. Deep brain stimulation represents a virtual renaissance in the surgical approach to psychiatric disorders.
Ethical Aspects Psychosurgery: Cut the Brain to Save the Mind? Psychosurgery is the most radical technique of physical brain manipulation. What does psychosurgery do? This question raises the ethical issue of how to balance its benefits and hazards in making therapeutic judgments. Psychosurgery is a highly controversial therapy. Its pro mise to relieve great psychic pain must be balanced against the perils of impairing the personality, diminish ing affect and creativity, and the ordinary dangers of a surgical intervention. Peter Breggin has argued that psy chosurgery is the murder of the soul – that the physical destruction of any healthy brain tissue is an invasion of the sanctity of the person. I do not agree with those who insist that the intact brain should not be tampered with at
Psychosurgery and Physical Brain Manipulation
any cost. This conception, which is at once mystical and emotional, is a tribute to the idea that the human body is somehow inviolate, and that it is sacrilegious to experi ment on it. Here, the objection approaches the dogma of religious conviction. There is some validity to the argu ment that states that if someone is in pain and we can help him or her, we should do it even if we do not know exactly what we are doing. However, in the long term, we need to know what we are doing so that we can take responsibility for it. With reference to psychosurgery, this means that the relation between the somatic structures that are destroyed (or stimulated) and the mental struc tures thereby affected must be understood. This is not yet completely the case. Psychosurgery: An Experimental Therapy The story of psychosurgery is the story of an experimen tal therapy. Despite technical advances in psychiatric surgery, the procedures are still experimental. The term ‘experimental’ has two meanings. In one sense, an experi mental procedure stands in contrast to a therapeutic one: It is done with no expectation of benefit to the patient, but only to further knowledge. In the field of psychosurgery, there is no excuse for experimental procedure in this sense. Unfortunately, the story of psychosurgery offers some examples of such ‘cognitive experiments’ – for instance, the operation of bilateral occipital leucotomy that was undertaken by the Norwegian neurosurgeon Arne Torkildsen in 1948. Torkildsen cut all the white matter of the occipital lobes of a blind, schizophrenic patient who destroyed his eyes because he had heard the voice of God telling him to accomplish such an act. This experience was nonsense, even in the scientific con text of the 1940s. Of course, the results of the operation were negative: ‘‘The experience with this case shows that the disconnection of both occipital lobes has no influence as far as can be judged from the psychiatric observations’’ (Torkildsen, 1948: 705). In another sense, a procedure is experimental if its effects are unpredictable, its risks highly variable, its mechanisms poorly understood, and its usefulness subject to widespread debate in the medical community. Psychosurgery has always been an experimental procedure in this sense. The therapeutic effects of many of its procedures fall into a wide range of success and failure. The first opera tions were very dangerous. Many patients died directly or indirectly as a result of the operation. Especially hazar dous were the operations of stereotaxic amygdalotomy and hypothalamotomy for aggressive restless behaviors. In a report of 128 cases who had undergone stereotactic surgery over a period of 6 years (1964–70), 9 of the first 50 cases died after the operation. With the new stereotactic procedures (anterior capsu lotomy and subcaudate tractotomy) that were realized in
671
specialized units carrying out regular interventions, the incidence of complications for each procedure was rela tively low compared with the morbidity and mortality in the early period of psychosurgery. There were fewer somatic side effects (epileptic seizures and intracerebral hematoma). Psychosurgical operations can reduce dis abling symptoms such as obsession or anxiety with minimal cognitive changes. However, some behavioral side effects are still present. Perseverative behavior, for instance, often occurs after capsulotomy. The patient tends to repeat old patterns of behavior even in circum stances that demand change. This is not surprising because the surgical operation cut some connections with the prefrontal cortex and perseveration is a distinc tive disorder arising from prefrontal damage. The most distinctive disorder arising from prefrontal damage is the inability to initiate and carry out new and goal-directed patterns of behavior. The patient encoun ters trouble when forced to develop a new form of behavior based on deliberation and choice, especially if, in order to reach the goal, that behavior requires the organization of a novel sequence of acts. The frontal patient tends to repeat old patterns of behavior even in circumstances that demand change. Perseveration in old but inappropriate behavior is a distinctive trait of the performance of frontal patients in cognitive tasks. The risk of behavioral side effects must be weighed against the eventual clinical benefit of stereotactic psy chosurgery. Unfortunately, postoperative assessment of psychiatric disorders is most difficult. Partisans of psy chosurgery claim that the stereotactic procedure is followed by a significant improvement in measures of clinical morbidity and in psychosocial functioning, with preservation of personality. In approximately 30–60% of the cases of patients who suffer from obsessive–compul sive disorders, one of the modern forms of psychosurgery will bring relief. It may not eliminate the symptoms entirely, but they become less intrusive and they no longer dominate the patient’s life. What is disturbing in psychosurgery is that neurosur geons do not exactly know the mechanisms of the operations they undertake. The functions of the region of the brain that are destroyed (prefrontal cortex, limbic system, and amygdala) are far from completely known. In the modern forms of stereotactic surgery, the neurosurgeon destroys some part of the frontal lobes or the connections to the limbic system. The prefrontal cortex and the limbic system play a prominent part in emotional and cognitive functions. The relationship of these neural structures to emotions is accepted, but the specific functions of the various areas have not been identified with any certainty. Moreover, the neurophysiological mechanisms involved in affective disorders are poorly understood. Therefore, the rationale for selecting targets for psychosurgical proce dures is empirical. Our knowledge of the brain is still
672
Psychosurgery and Physical Brain Manipulation
relatively poor. Psychosurgery is an experimental therapy and, paradoxically, neuroscientists learn about the frontal lobe functions and other brain regions from neurosurgical treatment of intractable psychiatric disorders. The usefulness of psychiatric surgery is far from unanimously agreed upon. Today, psychosurgery is not a normal practice; it is used in few institutions. In most neuropsychiatric hospitals, psychosurgery has disap peared from the therapeutic armamentarium.
Assessment of the Effects of Psychosurgery Frequently, it has been pointed out that the assessments of the effects of psychosurgery are inadequate. In the first era of psychosurgery, studies on the long-term outcomes of patients who had undergone psychiatric surgery had serious methodological problems. The efficacy of psycho surgery performed in this era is doomed to remain in doubt. Since then, better research methods have been developed for evaluating psychiatric symptoms and therapeutic efficacy. Psychometric instruments and rating scales are used to assess psychiatric symptoms and cogni tive functions. Nevertheless, personality change and improvement of the psychiatric symptoms remain diffi cult to assess empirically. Nowhere does the relationship between mind and body take on a more practical aspect than in psychosurgery that pretends to alter the brain to improve the mind. The eventual improvement in mental health after a psychosur gical treatment is difficult to evaluate because of the dual aspect of the mind–brain. The mind–brain is one entity with two faces: an objective one, the brain, and a subjective one, the mind. It is an organ with both physical and mental aspects. The philosopher Thomas Nagel stated, There seem to be very different kinds of things going on in the world: the things that belong to physical reality, which many different people can observe from the out side, and those other things that belong to reality, which each of us experiences from the inside in his own case.
After a psychosurgical treatment, the neurosurgeon and the psychiatrist have to judge indirectly and behaviorally the therapeutic effects of the operation. They cannot see directly what happens in the mind of the patient. That is why the real effects of psychosurgery are so difficult to evaluate precisely.
Indications The patients selected for psychiatric surgery should have severe incapacitating, persistent, and treatment-resis tant psychiatric illnesses, including anxiety states, obsessive–compulsive disorder, and major depression. Theoretically, psychosurgery today is generally
considered a ‘treatment of last resort’ that is utilized when all other treatments have failed. Unfortunately, this condition is not always respected. In a long-term follow-up of 33 patients who had undergone cingulotomy as a treat ment for obsessive–compulsive disorder at Massachusetts General Hospital (Boston), only 3 had undergone beha vioral therapy. Most of these patients did not receive all potentially effective therapies for their disorder before surgery. Future candidates for psychosurgery should undergo trials of other treatments (psychotherapy, beha vioral therapy, and medications) before surgery. There are unacceptable indications. For instance, the operations of thalamotomy, hypothalamotomy, and amygdalotomy for aggressive behavior, sexual violence, and ‘sexual deviation’ seem unacceptable to most people. In these circumstances, the aim of the ‘treatment’ is to normalize the conduct of the patient, not to relieve his or her sufferings. Especially controversial was the attempt to cure aggressive or restless behaviors by amygdalotomy or by posterior hypothalamotomy. Some neurosurgeons (Narabayashi, Sano, and Ramamurthi), for instance, have been severely criticized for performing a surgical destruction of brain centers (hypothalamotomy and amygdalotomy) in young children. The rationale, the methodology, and the neurophysiological theories under lying these operations were particularly dubious.
Informed Consent and Psychosurgery In the field of psychosurgery, informed consent is very important and should be strictly observed. Does the patient consent to the treatment? Does he or she know the dangers of the treatment? However, a real informed consent is extremely difficult to obtain from psychiatric patients. Often, close members of their families are the sources of consent. Is proxy consent acceptable as a sub stitute? It must be remembered that the closest kin are likely to be the ones who have suffered the most from the patient’s behavior and hence may have the greatest motive to seek a more drastic solution than is necessary.
Necessity of an Ethical Regulation of Psychosurgery: Criteria for the Selection of Psychiatric Patients Psychosurgery should be considered as a kind of human experimentation; therefore, the psychosurgical operations and their theoretical background should be systematically examined by competent ethics committees. In practical terms, this means that a committee of some sort, com posed of neurosurgeons, psychiatrists, physicians, and ethicists, should be present to monitor the psychiatric or surgical treatment. National advisory committees should also formulate opinions about psychosurgery.
Psychosurgery and Physical Brain Manipulation
Most of the units carrying out regular psychosurgical operations have developed general guidelines, including the following: 1. It is a treatment of last resort. The patient is chroni cally disabled by a psychiatric illness that has not responded to all currently available therapies (psychotherapy, beha vioral therapy, medications, and electroconvulsive therapy). 2. The disorder is causing great suffering and a severe reduction in the patient’s psychosocial functioning. 3. The prognosis without psychosurgical intervention is considered poor. 4. The patient, along with his or her nearest relative, must be fully informed of the risks and benefits of the surgical intervention and must give informed consent. 5. The referring psychiatrist agrees to be responsible for the postoperative long-term management of the patient. These guidelines on psychiatric surgery are an example of the self-regulation of a delicate problem by profes sionals. Scientists have come to accept regulation of their work. The field of psychosurgery is highly contro versial and the one in which regular national and international guidelines is highly desirable. Because of its controversial aspects and its experimental nature, the practice of psychosurgery should be strongly regulated. See also: Crime and Society; Informed Consent; Neuroethics/Brain Imaging; Psychiatry, Coercive Treatment.
Further Reading Balasubramaniam V, Ramanujam PB, Kanaka TS, and Ramamurthi B (1972) Stereotaxic surgery for behavior disorders. In: Hitchcock E, Laittinen L, and Vaerner K (eds.) Psychosurgery: Proceedings of the Second International Conference on Psychosurgery, pp. 87–111. Springfield, IL: Charles C Thomas. Ballantine HT (1988) Historical overview of psychosurgery and its problematic. Acta Neurochirurgica Supplementum 44: 125–128. Cerletti U (1950) Old and new information about electroshock. American Journal of Psychiatry 107: 87–94. Comite´ Consultatif National d’Ethique (2002, April 25) Avis sur la Neurochirurgie Fonctionnelle d’Affections Psychiatriques Se´ve`res. http://www.ccne-ethique.fr/docs/fr/avis071.pdf. Fiamberti AM (1952) La me´thode transorbitaire de la leucotomie pre´frontale. Ence´phale 41: 1–13. Freeman W (1949) Transorbital lobotomy. American Journal of Psychiatry 105: 734–739. Freeman W and Watts JW (1942) Psychosurgery: Intelligence, Emotion and Social Behavior Following Prefrontal Lobotomy for Mental Disorders. Springfield, IL: Charles C Thomas. Mashour GA, Walker EE, and Martuza RL (2005) Psychosurgery: Past, present, and future. Brain Research Reviews 48: 409–419.
673
Mindus P (1993) Present-day indications for capsulotomy. Acta Neurochirurgica Supplementum 58: 31. Moniz E (1936) Tentatives Operatoires dans le Traitement de Certaine Psychoses. Paris: Masson. Narabayashi H, Nagao T, Saito Y, Yoshida M, and Nagahata M (1968) Stereotaxic amygdalotomy for behavior disorders. Archives of Neurology 9: 11–26. Ramamurthi B (1988) Stereotaxic operation in behaviour disorders. Acta Neurochirurgica Supplementum 44: 152–157. Sano K and Mayanagi Y (1988) Posteromedial hypothalamotomy in the treatment of violent, aggressive behavior. Acta Neurochirurgica Supplementum 44: 145–151. Schlaepfer TE and Lieb K (2005) Deep brain stimulation for treatment of refractory depression. Lancet 366(9495): 1420–1422. Torkildsen A (1949) Notes on the importance of the occipital lobes in a case of schizophrenia: Experience with a case of bilateral occipital leucotomy. Acta Psychiatrica et Neurologica 24: 705. Valenstein ES (1986) Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books.
Relevant Website http://www.dana.org – The Dana Foundation.
Biographical Sketch Jean-Noel Missa received a PhD in medicine in 1985 and a PhD in Philosophy in 1992. He is Research Director at the National Fund for Scientific Research (Belgium) and Professor at the Universite´ Libre de Bruxelles. He is specia lized in the history, ethics, and philosophy of biomedical sciences (specifically, neuroscience and biological psychia try). He is also Director of the Center for Interdisciplinary Research in Bioethics and a member of the Belgian Consultative Committee of Bioethics. In 2002 and 2003, he was a Fulbright visiting research scholar at New York University. He is Former President of the Belgian Society for Philosophy and Current President of the Society for the Philosophy of Technology. He is an expert member at the European Commission for the European Research Council Peer Review Evaluation (2009–11). He has published approximately 50 scientific articles and several books. In 2008, he was awarded the Frans Jonckheere distinction of the Belgian Royal Academy of Medicine for the history of medicine for his book Naissance de la Psychiatrie Biologique (PUF, 2006). In June 2009, he was elected member of the Belgian Royal Academy (Acade´mie Royale des Sciences, des Lettres et des Beaux-Arts de Belgique, Classe Technologie et Socie´te´). In November 2009, he was Invited Professor at the University of Bouake´ of Abidjan (Ivory Coast), and in May 2010, he was Invited Professor at the University Paris VII (Denis Diderot).