Defining Psychosurgery
Psychosurgery is a treatment in which brain tissue is destroyed with the aim of alleviating the symptoms of a psychological disorder. It has also been called "functional neurosurgery." Psychosurgery is a drastic step typically only taken in the absence of any other successful treatment (and sometimes not even then), because it is a major challenge to remove harmful tissue without impacting the brain tissue necessary to retain full neural function.
There are many types of psychosurgery. Many end in "-omy," the Latin root used in surgeries to indicate the removal of something.
Cingulotomy
Cingulotomy is a surgical procedure that severs the supracallosal fibers of the cingulum bundle, which pass through the anterior cingulate gyrus. This surgery is used to treat obsessive-compulsive disorder (OCD) and depression.
Subcaudate Tractotomy
Subcaudate tractotomy is a surgery to sever the fibers connecting the orbitofrontal cortex to the hypothalamus. It is used primarily for depression and OCD.
Limbic Leucotomy
The limbic leucotomy combines the cingulotomy and subcaudate tractotomy procedures. It was hypothesized that making two lesions would produce better results, but the rate of effectiveness is still approximately the same as the subcaudate tractotomy procedure alone.
Corpus Callosotomy
Corpus callosotomy is a palliative surgical procedure for the treatment of seizures, as seen in epilepsy. Because the corpus callosum is critical to the spread of epileptic activity between brain hemispheres, the goal of this procedure is to eliminate this pathway. The corpus callosum is severed, after which the brain has much more difficulty sending messages between the hemispheres, although some limited interhemispheric communication is still possible.
Deep-Brain Stimulation
In deep-brain stimulation (DBS), a device like a pacemaker is implanted into a part of the brain to send electrical impulses to that area of the brain. It is used primarily for Parkinson's disease, essential tremor, and major depression, although it has been used for a number of other disorders as well.
History of Psychosurgery
This treatment approach began in the late 1800s under the Swiss psychiatrist Gottlieb Burckhardt, and continued into the mid 1930s under Portuguese neurologist Antonio Egas Moniz with the leucotomy. A leucotomy is the cutting of white nerve fibers in the brain, and is also known as a prefrontal lobotomy. In the United States, neuropsychiatrist Walter Freeman and neurosurgeon James W. Watts devised what became the standard prefrontal procedure and named their operative technique "lobotomy." In spite of Moniz's Nobel Prize in 1949, the use of psychosurgery declined during the 1950s. By the 1970s the standard lobotomy was very rare, but other forms of psychosurgery were occurring on a smaller scale.
Lobotomy
Dr. Walter Freeman, left, and Dr. James W. Watts study an X-ray before a psychosurgical operation. Freeman and Watts developed a lobotomy technique that became the standard.
Efficacy of Psychosurgery
Psychosurgery has a low rate of efficacy relative to the risks of the procedures. For example, cingulotomies have been found to be only about 30% percent effective. Subcaudate tractotomies have been found to be effective about 50% of the time, as have limbic leucotomies.
Advances in surgical techniques have greatly reduced the incidence of death and serious damage from psychosurgery. However, the risks include but are not limited to seizures, incontinence, decreased drive, personality changes, cognitive problems, and affective problems. Currently, interest in the neurosurgical treatment of mental illness is shifting to deep-brain stimulation (DBS), in which the aim is to stimulate areas of the brain with implanted electrodes.
Criticism of Psychosurgery
Psychosurgery has always been highly controversial. In 1977 the US Congress, during the presidency of Jimmy Carter, created the National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgery—including lobotomy techniques—were used to control minorities and restrain individual rights. The committee concluded that some extremely limited and properly performed psychosurgery could have positive effects. However, public opinion of psychosurgery is wary at best, and literary and film works such as One Flew Over the Cuckoo's Nest have portrayed lobotomies as dangerous forms of punishment rather than useful treatments.
The reason for the decline of psychosurgery was not only related to ethical concerns and the low rates of efficacy; it was also related to the advancement of more effective and minimally invasive treatments such as psychiatric medications. Through the use of some psychiatric medications, the same areas of the brain are able to be targeted and suppressed without the need to surgically create lesions or remove parts of the brain. Psychiatric medications also are able to provide effective treatment in a number of other ways, such as stimulating neural pathways.
There have been calls in the early 21st century for the Nobel Foundation to rescind the prize it awarded to Moniz for developing the lobotomy, a decision that has been called an astounding error of judgment at the time and one that psychiatry might still need to learn from, but the foundation declined to take action and has continued to host an article defending the results of the procedure.