Lobotomy

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News: Lobotomy

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Background information on Lobotomy [When available]

Psychosurgery is a term for surgeries of the brain or autonomic nervous system involving the severance of neural pathways to effect a change in behaviour, usually to treat or alleviate severe mental illness. The procedures typically considered psychosurgery are now almost universally shunned as inappropriate, due in part to the emergence of less invasive methods of treatment such as psychiatric medication. Although the term psychosurgery might imply a broad class of treatments, in reality, it is confined to variations on two themes:
  1. leucotomy/prefrontal lobotomy/cingulotomy - the intentional severing of the pre-frontal cortex from the thalamic region of the brain
  2. sympathectomy - the intentional severing of the sympathetic nerve trunk
Psychosurgery should not be confused with neurosurgery, though they may seem similar; neurosurgery is surgery intended to treat or alleviate neurological disorders, which may or may not manifest mental illnesses as symptoms. Psychosurgery should also not be confused with the practice of psychic surgery -- surgery purportedly performed by paranormal means.

History

There is evidence that trephining (or trepanning)—the practice of drilling holes in the skull for pseudo-medical reasons—has been in widespread, if infrequent, use since 5000 BCE. This may have been done in an attempt to allow the brain to expand in the case of increased brain fluid pressure, for example after head injuries; several documented cases of healed wounds indicate that such crude surgery could be survived back then. However, psychosurgery as understood today was not commonly practised until the early 20th century.

The first systematic attempts at psychosurgery in humans occurred from 1935, when the neurologist Egas Moniz teamed up with the surgeon Almeida Lima at the University of Lisbon to perform a series of prefrontal leucotomies - a procedure severing the connection between the prefrontal cortex and the rest of the brain. This procedure is commonly (and incorrectly) called a "lobotomy", although this name should refer to a whole class of unrelated surgeries (that is, a lobotomy should refer to the removal of a lobe of the brain, not merely the severing of interconnections).

Moniz and Lima claimed fair results, especially in the treatment of depression, although about 6% of patients did not survive the operation and there were often marked and adverse changes in the patients' personality and social functioning. Despite the risks the process was taken up with some enthusiasm, notably in the US, as a treatment for previously incurable mental conditions. Moniz received a Nobel Prize in 1949.

The initial criteria for treatment were quite steep, only a few conditions of "tortured self-concern" were put forward for treatment. Severe chronic anxiety, depression with risk of suicide and incapacitating obsessive-compulsive disorder were the main symptoms treated. The original leucotomy was a crude operation and the practice was soon developed into a more exact, stereotactic procedure where only very small lesions were placed in the brain.

The procedure was popularized in the United States when Walter Freeman invented the "icepick lobotomy" procedure, which literally used an icepick and rubber mallet instead of the standard surgical leucotome. Leaving no visible scars, the icepick lobotomy was heralded as a great advance in "minimally invasive" surgery, and was eventually done under only local anaesthesia.

In a minimally invasive procedure, Freeman would hammer the icepick into the skull just above the tear duct and wiggle it around. Between 1936 through the 1950s, he advocated lobotomies throughout the United States. Such was Freeman's zeal that he began to travel around the nation in his own personal van, which he called his "lobotomobile", demonstrating the procedure in many medical centres. He reputedly even performed a few lobotomies in hotel rooms.

Freeman's advocacy led to great popularity for lobotomy as a general cure for all perceived ills, including misbehaviour in children. Ultimately between 40,000 and 50,000 patients were lobotomised. A follow-up study of almost 10,000 patients claimed 41% were "recovered" or "greatly improved", 28% were "minimally improved", 25% showed "no change", 4% had died, while only 2% were made worse off (Tooth, et al 1961). Lobotomies gradually became unfashionable with the development of antipsychotics and are no longer performed. The era of lobotomy is now generally regarded as a barbaric episode in psychiatric history.

It is possible that some patients did benefit from the more precise psychosurgery, but there was a strong division amongst the medical profession as to the viability of the treatment and concern over the irreversible nature of the operation and the extension of the surgery into the treatment of unsuitable cases (drug or alcohol dependence, sexual disorders etc). Whatever the truth, psychosurgery was offered in only a few centres and by the 1960s the number of operations was in decline. The signal improvements in psychopharmacology and behaviour therapy gave the opportunity for more effective and less invasive treatment.

Neurological impact

The frontal lobe of the brain controls a number of advanced cognitive functions, as well as motor control. Motor control is located at the rear of the frontal lobe, and is usually unaffected by psychosurgery. The anterior or prefrontal area is involved in impulse control, judgement, language, memory, motor function, problem solving, sexual behaviour, socialization and spontaneity. Frontal lobes assist in planning, coordinating, controlling and executing behaviour.

Thus, the efficacy of psychosurgery was often related to changes in personality and reduced spontaneity (this included making the person quieter, and lowering their sex-drive). Certain processes related to schizophrenia are also believed to occur in the frontal lobe, and may explain some success. However, certain types of inappropriate behaviours increased, as a function of reduced impulse control (in some respects they became more child-like). Further, it decreased their ability to function as a member of the community by reducing their problem solving and planning abilities and making them less flexible and adaptive. It usually had no impact on IQ except with respect to problem-solving.

Present day

Psychosurgery today is almost entirely limited to endoscopic thoracic sympathectomy (ETS surgery). While this is normally used for somatic conditions, many patients with anxiety disorder report significant reduction in fear and alertness after this intervention (Teleranta, Pohjavaara, et al 2003,2004).

Today, lobotomy is very infrequently practised. It may be a treatment of last resort of OCD sufferers, and may also be used for people suffering chronic pain. In the latter case, the surgery does not act on the perception of pain, but leads to a lack of concern about the pain. The procedure usually involves a 2-3cm lesion in the cingulum, near the corpus callosum. The efficacy is not high, with improvement in 5 of 18 patients (Baer et al., 1995). Lobotomy is no longer used as a treatment for schizophrenia.

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