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After discussion of the historical and neurophysiological bases of psychosurgery a report on personal experience in different indications is given. Finally, the present degree of informedness of doctors and the media on psychosurgery is discussed.
Egas Moniz received the Nobel Prize for Medicine in 1949 for his discovery and popularization of the prefrontal lobotomy. This radical surgery was the product of the progression in our understanding of mental illness, the prevailing attitudes of the times, and the professional rivalry between psychiatrists and neurologists. The prefrontal lobotomy and its modifications, later to be referred to collectively as psychosurgery, offered hope to the mental illness that were previously thought to be incurable. Fueled by "miracle stories" from the popular press, this surgery was performed until the late 1960S. The following article chronicles the early days of psychosurgery, including the factors responsible for its inception and the different techniques used through the years.
In 1935, Egas Moniz inaugurated a surgical procedure in the treatment of certain psychoses. By interrupting some of the connections between the prefrontal lobes and other parts of the brain, some benefits were brought to the psychotic individuals. He reported 20 cases of these procedures. The treatment of chronic psychotic patients by prefrontal leucotomy or lobotomy, was spread throughout the world by Walter Freeman. In Japan the psychosurgical operation was performed in 1939 by Nakada using prefrontal lobotomy. In April 1959, the 15th General Assembly of the Japan General Congress was held in Tokyo and the subject "Functional brain surgery" was taken up at one of the plenary sessions. In the early years, numerous operations were performed upon chronic disturbed psychotic patients who had not been relieved by various other somatic treatments in mental hospitals. Following the development of psychopharmacotherapy since the middle part of the 1950s marked decline in the number of psychosurgical operations was observed. Now this surgery has been interrupted because of the continued trouble faced by psychosurgery in Japan. Why did such a popularity and then a decline of psychosurgery occur in this short term?
A selection of articles that focus on psychosocial treatments, pharmacotherapy, and psychosurgery of anxiety disorders are reviewed. While some medications look clearly beneficial or potentially effective in the treatment of anxiety disorders, other compounds seem less promising or not effective. A combination of proven pharmacotherapies and psychotherapies may be the most clinically prudent approach to the treatment of anxiety disorders. Thermocapsulotomy may be an "extreme" option in selected cases of severe nonobsessive anxiety but may carry a significant risk of adverse effects indicative of frontal lobe functioning impairment. In spite of all the research and progress in studying relatively well-defined therapies, many patients suffering from anxiety and depression still use complementary and alternative therapies. The use of alternative and complementary is likely to increase as insurance coverage expands.
Gottlieb Burckhardt, a Swiss psychiatrist who practiced in the late 19th century, was the founder of modern psychosurgery. In 1891 he reported the results of cortical extirpations on six patients who evidently suffered from intractable psychiatric disease; two of these cases are discussed here to illustrate how Burckhardt employed contemporary brain models of language and cognition as the basis for removing specific areas of the cerebral cortex with the intention of ameliorating his patients' disturbed behavior.
In 1936, Egas Moniz published his first paper on frontal leucotomy for psychiatric illness. The initial enthusiasm for this innovative treatment of intractable psychiatric disorders and chronic pain was soon tempered by reports of undesirable side-effects, and neurosurgeons began a search for modifications of leucotomy which would increase safety without reducing efficacy. As a result of these clinical investigations, the original imprecise, radical frontal leucotomy has been superseded by precise, small stereotactically placed lesions in the limbic system and the descriptive phase "limbic system surgery" is replacing the out-moded word "psychosurgery". This presentation will document some of the more important contributions to a currently under-utilized, often criticized approach to the treatment of suffering individuals chronically disabled by psychiatric illness and pain.
A review on indications, target points and results of stereotactic operations for treatment of psychiatric diseases is given, based on personal experiences and reports in the literature. As a conclusion the author suggests that the anatomical target should be chosen selectively. There is strong evidence that different approaches lead to different results. Cingulotomy is effective for chronic pain with addiction and depression, anterior capsulotomy for obsessive-compulsive and anxiety neurosis, innominotomy for chronic and recurrent depression, and postero-medial hypothalamotomy for restless, aggressive and destructive behaviour. Therefore, the target should be selected according to the individual symptoms of the patient. The results of operation are usually good and most patients can return to a normal life. The side-effects are infrequent and seldom serious. Modern psychosurgery does not modify the personality of the patient. On the contrary it often relieves it from disturbing symptoms of illness.
As we contemplate the emerging era of neuromodulation and imagine the utility of deep brain stimulation for disease entities in neurology and psychiatry, our enthusiasm is immediately tempered by history. Just a generation ago, other confident investigators were heralding invasive somatic therapies like prefrontal lobotomy to treat psychiatric illness. That era of psychosurgery ended with widespread condemnation, congressional calls for a ban, and avow that history should never repeat itself. Now, just 30 years later, neurologists, neurosurgeons, and psychiatrists are implanting deep brain stimulators for the treatment of Parkinson's disease and contemplating their use for severe psychiatric illnesses, such as obsessive-compulsive disorder and the modulation of consciousness in traumatic brain injury.
This study presents results on hitherto unknown data on lobotomies performed at the former State Mental Hospital of Umedalen (from here on called simply "Umedalen") in the north of Sweden. More than 700 operations were carried out from 1947 through 1960, and we calculated the average rate of postoperative mortality to 7.4 percent, and that 63 percent of those who were operated were women. By considering annual hospital reports to the National Board of Health (Medicinalstyrelsen), we also made the first mapping of early psychosurgery in Sweden; approximately 4,500 lobotomies were performed between 1944 and 1966. Statistical analysis, qualitative content analysis, and discourse analysis were used. The study supports earlier findings of female preponderance in the number of lobotomy operations.
One of the most serious and difficult-to-treat conditions in child and adolescent psychiatry is self-injurious behavior (SIB). SIB can be associated with a number of psychiatric disorders, including mental retardation, schizophrenia, borderline personality disorder, pervasive developmental disorders, stereotypic movement disorder, and Tourette's Disorder. A variety of neurosurgical procedures have been used to treat both intractable SIB and severe Tourette's Disorder. Understandably, there are few reports concerning psychosurgery in children and adolescents for any condition or disorder. This report describes the use of cingulotomy and subsequent limbic leucotomy in an adolescent boy with Tourette's Disorder for SIB. His repetitive and medically serious SIB and failure of all other treatments prompted this intervention after careful, comprehensive review and discussion. Following the second surgery, the severity and frequency of his SIB were reduced.
All cases from an urban population treated by psychosurgery over a 20 year period were followed up; 44 out of 47 were available for study, and 33 of these were interviewed. Outcome was measured on a five-point scale, and follow-up was from 1 to 20 years, with a mean of 11; almost all patients previously had had severe, disabling and intractable illnesses. Operations were non-stereotactic (36), stereotactic (6), with double procedures in one case: outcome was better in the non-stereotactic group. On a five-point scale of outcome, 25 of the 33 interviewed patients were placed in the two best categories, as were eight patients of the 11 who were assessed by case records. Adverse effects were reported in 14 cases, but most were not serious. Only one death could definitely be related to operation. Depression, agoraphobia, obsessional neurosis, and certain aspects of schizophrenia all responded well in the majority of cases. Leucotomy should remain available as a treatment of last resort for some intractable psychiatric disorders.
At the present time, psychosurgery is used very sparingly. This article reviews its current status with regard to indications, complications, frequency of utilization, and ethical and legal issues.
The use of surgical procedures to alter mental states raises many issues. Surgery on the brain has been known for thousands of years, but procedures developed in the 1930s, '40s and '50s, and the reasons for them, raised many ethical issues that remain with us today. The following article touches on the history of psychosurgery, the conditions treated, the literature on the subject, and the ethical and legal issues.
The aim of the study was to explore the way psychiatric symptoms might influence independent psychiatric assessment of outcome one year after stereotactic subcaudate tractotomy. In a sample of 34 patients consecutively accepted for psychosurgery the results showed that both 'good' and 'poor' outcome groups improved overall. No patients were significantly worse and the symptoms which improved most were nervous tension, depressed mood and somatic anxiety. It was not possible to identify symptomatic predictors of outcome because the preoperative symptom profiles of both groups were so similar. The reason why symptomatic outcome is so variable despite a basically identical psychosurgical technique is discussed.
Samples of ventricular CSF were taken from 52 consecutive patients admitted for psychosurgery for intractable depression. Concentrations of asparagine, aspartate, glutamine, glutamic acid, and serine were determined. Glutamate and aspartate concentrations, implicated in excitotoxic brain damage, were not affected by various types of psychotropic drug treatment. Serine, a modulator of glutamate responses, was significantly elevated in samples from subjects receiving antidepressants. These subjects responded poorly to the operation. Psychotropic drugs are unlikely to be neurotoxic. Nevertheless, antidepressants may influence excitatory neurotransmission.
The results obtained in a casuistic of 170 patients with mental diseases and behavior disturbances treated by neurosurgical procedures are reported. The authors call attention to the advantages of the atraumatic stereotaxic psychosurgery over the major surgical procedures on the frontal lobes for the treatment of psychoses and intractable psychoneurosis.
AIMS: To obtain an up to date review of the different possible surgical approaches in the management of certain psychiatric disorders that are refractory to conservative treatment (pharmacotherapy, psychotherapy, electroconvulsive therapy). METHOD: In order to conduct this research we reviewed the work published by centres with the most experience in this type of surgery, mainly in North America and Europe, since its beginnings in the 1930s, with the controversy concerning prefrontal leucotomy, until the appearance of modern stereotactic techniques. We analyse the anatomophysiological bases, their main clinical indications, the surgical techniques used and their results, as well as perspectives for the future of this neurosurgical treatment. CONCLUSIONS: The most noteworthy progress in psychosurgery in recent years has been the combination of a more rigorous selection of patients and the higher degree of specificity with which treatment is performed on the brain structures involved in psychiatric disease. The most widely employed psychosurgical procedures at present are cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy and postero medial hypothalamotomy, with favourable responses in about 35 70% of cases. The psychiatric diagnoses where the best results are to be found are obsessive compulsive disorder, chronic anxiety states and major depression. Current progress in neuroimaging techniques, increased neurophysiological knowledge and the revolutionary neuromodulation techniques, especially deep brain stimulation, offer an even more promising future for psychiatric neurosurgery.
Brain operations for psychiatric illness were in the past the centre of public controversy. Fear of untoward side-effects and an exaggerated use of the procedure including treatment of societal aspects of the disease process caused a virtual cessation of psychosurgical operations. With the introduction of techniques that could accurately lesion specific areas in the brain, especially in the limbic system, psychosurgical procedures were revived. Psychiatric syndromes, such as obsessive-compulsive affective disorders, were shown to have benefited from such intervention, without giving rise to untoward side-effects. Given societal supervision it is appropriate to reconsider the use of psychosurgery in well-defined clinical entities of mental disease that do not respond to alternative therapy.