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Psychosurgery is a subset of neurosurgery (surgery of the brain) intended to modulate the performance of the brain, and thus effect changes in cognition, with the intent to treat or alleviate severe mental illness. It was originally thought that by severing the nerves that give power to ideas you would achieve the desirable result of a loss of affect and an emotional flattening which would diminish creativity and imagination; the idea being that those are the human characteristics that are disturbed. 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 have arisen as novel tools for psychosurgery.[citation needed]

Contents

History

There is evidence that trepanning (or trephining) — the practice of drilling holes in the skull — has been in widespread, if infrequent, use since 5000 BC.[citation needed] 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. However, psychosurgery as understood today was not commonly practiced until the early 20th century.[1]

The first systematic attempts at human psychosurgery occurred in the 1880s by psychiatrist Gottlieb Burckhardt[2] and then the more widely known work in 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 — 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 — 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 lobotomy 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.

"Ice pick lobotomy"

Close up of "ice picks"

Psychosurgery was popularised in the United States when Walter Freeman invented the "ice pick lobotomy", a procedure which literally used an ice pick and a rubber mallet instead of standard surgical equipment to perform a transorbital lobotomy. Leaving no visible scars, the ice pick lobotomy was heralded as a great advance in surgery, and was done under local anesthesia or, when performed in mental hospitals lacking surgical facilities, after using electroshock to render the patient unconscious.[3]

Freeman would hammer the ice pick into the skull just above the tear duct and wiggle it around. From 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.[4]

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 English and Welsh lobotomies performed between 1942 and 1954 claimed 41% of patients were "recovered" or "greatly improved", 28% were "minimally improved", 25% showed "no change", 4% had died, while only 2% were made worse off.[5]

Neurological effects

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 with everyday life and situations, 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 decreasing their craving to be sexually active). Certain processes related to schizophrenia are also believed to occur in the frontal lobe, and may explain some success.

Present day

Lobotomies gradually became unfashionable with the development of antipsychotic drugs and are rarely performed. The era of lobotomy is now generally regarded as a barbaric episode in psychiatric history. There was a strong division amongst the medical profession as to the efficacy of the treatment, and concern over both the irreversible nature of the operation and to its extension into the treatment of unsuitable cases (drug or alcohol dependence, sexual disorders, etc). Psychosurgery was offered in only a few centers, and by the 1960s the number of operations was in decline. Signal improvements in psychopharmacology and behaviour therapy provided the opportunity for more effective and less-invasive treatment.

Today, psychosurgery may be a treatment of last resort for OCD sufferers, and for anorexic patients in Chile, the United States, Sweden and Mexico. The efficacy is not high: one study of cingulotomy (which usually involves a 2–3 cm lesion in the cingulum near the corpus callosum) found improvement in 5 out of 18 patients.[6]

Psychosurgery is legally practiced in controlled and regulated U.S. centers, or in Finland, Sweden, Australia,[7] United Kingdom, Spain, India, Belgium and Netherlands. In France, 32 psychosurgical operations were made between 1980 and 1986 according to an IGAS report;[citation needed] about 15 each year in the UK, 70 in Belgium, and about 15 for the Massachusetts General Hospital of Boston.[8]

Some consider use of endoscopic sympathetic block (a form of endoscopic thoracic sympathectomy) for patients with anxiety disorder to be a psychiatric treatment, despite it not being surgery of the brain. There is also renewed interest in using it to treat schizophrenia.[9] ESB disrupts brain regulation of many organs normally affected by emotion, such as the heart and blood vessels. A large study demonstrated significant reduction in "alertness" and "fear" in patients with social phobia as well as improvement in their quality of life.[10] Most psychiatrists, however, prefer medication and counseling.[citation needed]

Legal restrictions

In 1977, the U.S. 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 lobotomy steadily grew, and countries such as Germany, Japan and several U.S. states prohibited it.[8]

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.[7]

The Soviet Union made lobotomies illegal in 1950.[11]

Individuals who underwent lobotomy

Fictional examples

  • In Episode 4, Season 4 of the TV show The X-Files, serial killer Gerry Schnauz performs lobotomies on women he intends to save from mental 'unrest.'
  • 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.[1] (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.
  • Session 9, a 2001 horror movie about a group of men hired to remove the asbestos from a defunct mental hospital.
  • 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.
  • In the novel Project 17 the Denver State Hospital is rumored to have been the founding of lobotomy.
  • In science fiction, psychosurgery is typically presented as far more advanced than its modern day counterparts, often including such things as selective memory erasure, direct alteration of thoughts, and generally having a higher effectiveness than in reality. Examples of it can be found in books by Alastair Reynolds, Richard Morgan, and others.
  • In Suddenly Last Summer (1959 adaptation of the Tennessee Williams play), a wealthy woman named Violet Venable (Katharine Hepburn) wants her niece Catherine Holly (Elizabeth Taylor) lobotomized to silence her talk about Violet's son Sebastian's homosexuality.
  • In From Hell (film), set in Victorian London, Queen Victoria herself (Liz Moscrop) is implicated in ordering lobotomies for several characters in order to "silence" them if they knew too much information. Characters who underwent these crude lobotomies (including Sir William Gull played by Ian Holm), were depicted with shaved heads and in vegetative states.
  • In the fourth season of Melrose Place, Kimberly - under the influence of one of her multiple personalities - has Peter committed to a mental institution under false pretenses. She begins to perform a lobotomy on Peter, but is interrupted by Amanda and Michael's rescue attempt.
  • In the short lived science fiction series Firefly, child prodigy, River Tam, is assumed to have undergone some form of lobotomy against her will. leaving her in a mentally unstable state
  • In the novel Shutter Island and its film adaptation it is indicated that the main character, Teddy Daniels, will undergoe a transorbital lobotomy.

See also

References

  1. ^ Berrios G E (1997) The Origins of Psychosurgery. History of Psychiatry 8: 61-82
  2. ^ http://thejns.org/doi/abs/10.3171/FOC/2008/25/7/E9
  3. ^ El-Hai, Jack (2005). The Lobotomist. Wiley. ISBN 0471232920. 
  4. ^ V. Mark Durand & David H. Barlow (2006). "Essentials of Abnormal Psychology, 4th edition". Thomson Wadsworth. http://www.wadsworth.com/cgi-wadsworth/course_products_wp.pl?fid=M20b&product_isbn_issn=0534605753&discipline_number=24. 
  5. ^ Tooth GC, and Newton, MP: Leukotomy in England and Wales 1942-1954. London, Her Majesty's Stationary Office, 1961.
  6. ^ Baer, L., et al. (1995). Cingulotomy for intractable obsessive-compulsive disorder. Archives of General Psychiatry, 52, 384-392
  7. ^ a b Victorian Psychosurgery Review Board www.prb.vic.gov.au
  8. ^ a b "La neurochirurgie fonctionnelle d'affections psychiatriques sévères". Comité Consultatif National d'Ethique. April 25, 2002. http://www.ccne-ethique.fr/francais/avis/a_071.htm. 
  9. ^ Teleranta T. Psychoneurological applications of endoscopic sympathetic blocks (ESB)
  10. ^ Pohjavaara P. Social phobia: aetiology, course and treatment with endoscopic sympathetic block (ESB)
  11. ^ Mental Health Research Centre of the Russian Academy of Medical Sciences. Retrieved on 10 July 2009
  12. ^ Dully, Howard; Charles Fleming (2008). My Lobotomy. London: Vermilion. ISBN 9780091922191. 
  • G. Rees Cosgrove, Scott L. Rauch: "Psychosurgery" Neurosurg. Clin. N. Am. 1995; 6:167-176 online version
  • Davison, G. C., & Neale, J. M. (1998) Abnormal Psychology (7th Ed.). New York, John Wiley.
  • Pohjavaara P, Telaranta T, Vaisanen E. The role of the sympathetic nervous system in anxiety: Is it possible to relieve anxiety with endoscopic sympathetic block? Nord J Psychiatry 2003;57:55-60. PMID 12745792.
  • Valenstein, Elliot S. (1986). Great and desperate cures the rise and decline of psychosurgery and other radical treatments for mental illness. New York, NY: Basic Books.
  • Fins JJ. From Psychosurgery to Neuromodulation and Palliation: History’s Lessons for the Ethical Conduct and Regulation of Neuropsychiatric Research. Neurosurgery Clinics of North America 2003;14(2): 303-319.

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