Psychosurgery

Psychosurgery is a term for surgeries of the brain involving procedures that modulate the performance of the brain, and thus effect changes in cognition, with the intent to treat or alleviate severe mental illness. Historically, the procedure typically considered psychosurgery, prefrontal leukotomy is now almost universally shunned as inappropriate, due in part to the emergence of less-invasive or less-objectionable methods of treatment such as psychiatric medication and modified electroconvulsive therapy. In modern neurosurgery however, more minimally invasive techniques like gamma knife irradiation and foremost deep brain stimulation has arisen as a novel tool for psychosurgery.

Psychosurgery should not be confused with the practice of psychic surgery&mdash;surgery purportedly performed by paranormal means.

History
There is evidence that trephining (or trepanning)&mdash;the practice of drilling holes in the skull for pseudomedical reasons&mdash;has been in widespread, if infrequent, use since 5000 BC. 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 practiced until the early 20th century.

The first systematic attempts at human psychosurgery occurred from 1935, when the neurosurgeon Egas Moniz teamed up with the surgeon Almeida Lima at the University of Lisbon to perform a series of prefrontal lobotomies (leukotomies) &mdash;a procedure severing the connection between the prefrontal cortex and the rest of the brain.

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 U.S., as a treatment for previously incurable mental conditions. Moniz received a Nobel Prize in 1949.

The initial criteria for treatment were quite steep&mdash;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 popularised in the United States when Walter Freeman invented the "ice pick lobotomy" procedure, which literally used an ice pick and rubber mallet instead of the standard surgical leukotomy. Leaving no visible scars, the ice pick 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 ice pick 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.

Legal restrictions
In 1977, the US Congress created a National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research to investigate allegations that psychosurgery, including lobotomy techniques, was used to control minorities, restrain individual rights or that it had unethical after-effects. It concluded that, in general, psychosurgery had positive effects. However, concerns about leukotomy steadily grew, and countries such as Germany, Japan and several US states prohibited it.

In Australia, psychosurgery is performed by a select group of neurosurgeons. In Victoria, each individual operation must receive the consent of a Review Board before it may proceed.

Neurological effect
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 childlike). 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 bearing on IQ except with respect to problem solving.

Present day
Today, lobotomy is not as frequently practiced as it was in the 1930s, 40s, 50s and 60s. It may be a treatment of last resort for OCD sufferers; and anorexic patients in Chile, the United States, Sweden and Mexico.

In the case of people suffering chronic pain, 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 2–3 cm lesion in the cingulum near the corpus callosum. The efficacy is not high, with improvement in 5 of 18 patients (Baer et al., 1995).

Leukotomy is legally practiced in controlled and regulated US centers, or in Finland, Sweden, United Kingdom, Spain, India, Belgium and Netherlands. In France, 32 lobotomies were made between 1980 and 1986 according to a IGAS report; about 15 each year in the UK, 70 in Belgium, and about 15 for the Massachusetts General Hospital of Boston.

Some consider use of endoscopic thoracic sympathectomy (ETS surgery) for patients with anxiety disorder to be psychosurgery, despite it not being surgery of the brain. ETS surgery disrupts brain regulation of many organs normally affected by emotion, such as the heart. A large study demonstrated significant reduction in "alertness" and "fear". Although ETS for anxiety is mass marketed by surgeons on the internet, most psychologists now use medication and counseling.

Famous people who underwent lobotomy

 * Phineas Gage: Famously suffered an accident in 1848 which severely damaged his frontal lobe. The effects were comparable to a surgical lobotomy.
 * Josef Hassid: Polish violin prodigy and schizophrenic who died at 26.
 * Rosemary Kennedy: Sister of John F. Kennedy.
 * Rose Williams: Sister of Tennessee Williams.

Fictional examples

 * Frances Farmer: Though Farmer is the person perhaps best associated in the public mind with lobotomy due to its depiction in the fictionalized biographical film Frances, archival medical and other records have conclusively proven Farmer never underwent the procedure. The author who initially alleged the lobotomy later admitted in court he had made it up. (Footnoted site contains court transcripts which are also available through LexisNexis.
 * Ken Kesey's famed fictional character, Randle Patrick McMurphy, in One Flew Over the Cuckoo's Nest who was, in the movie, played by Jack Nicholson.
 * J. Frank Parnell, erratic driver of the radioactive Chevy Malibu in the movie Repo Man.
 * A Hole in One, a 2004 movie about a young lady who wants an ice pick lobotomy during the height of its popularity.
 * Rat Korga, major character in Samuel R. Delany's science fiction novel Stars in My Pocket Like Grains of Sand, voluntarily opts for psychosurgery to make him content to be a slave.
 * Several victims of a serial killer named Gerry Schnauz in an episode of The X-Files entitled "Unruhe".
 * Session 9, a 2001 horror movie about a group of men hired to remove the asbestos from a defunct mental hospital. Without spoiling the movie, it can be said that lobotomies are involved.
 * Hannibal, in which Hannibal Lecter lobotomizes Paul Krendler, played by Ray Liotta.
 * In the book The Bell Jar by Sylvia Plath, the character Esther Greenwood meets a girl named Valerie in the asylum who has had a lobotomy.
 * Iron Maiden's famous fictional mascot, Eddie, was lobotomised on-stage during one of Maiden's live shows; this concert was filmed for German TV but that particular segment was cut out due to being deemed "Too violent". The cover of their fourth album Piece of Mind (and many of the following releases) shows Eddie after being lobotomised.
 * In the book Cyteen by C.J. Cherryh, psychosurgery involves the use of drugs that bring the mind into a state where it is very receptive to audio and/or visual cues, which help the psychosurgeon to reprogram the individual. This procedure is non-invasive, and involves administering drugs versus actual surgery.
 * In the television miniseries Kingdom Hospital, the character Mary was killed by a botched lobotomy. In the companion book, The Journals of Eleanor Druse, Eleanor had a transorbital lobotomy in her childhood.