Psychosurgery: BY STEWART

Some

A. SHEVITZ,

Current

Observations

M.D.

The term “psychosurgery” encompasses a wide variety of different neurosurgical procedures applied in the treatment of behavioral and psychiatric disorders. Arguments about the effectiveness and ethicality of psychosurgery are often based on studies using outdated procedures or inappropriate patient populations. The debate over psychosurgery is also obscured

by

the frequent

confusion

between

clinician.

scured

by

IS

one

of

the

most

It is also

debate

other behavioral in more controversial ior

and

violent

over

a context

the

disorders. areas behavior

use

The such in

frequently

use as

association

with

cles with

discussing different

different side effects,

behavior author so that based on

with

various

complex,

con-

troversial, and misunderstood areas of psychiatry today. Even the name is controversial; some authors prefer the terms “psychiatric surgery” (1), “mental surgery” (2), “functional neurosurgery” (3), or “the surgery ofthe emotions” (4). Arguments on the merits and ethics of psychosurgery tend to be colored with emotionalism, offering antithetical viewpoints substantiated by references to a voluminous but contradictory literature. One can easily become bewildered by articles that range from severe condemnation of all forms of psychosurgery (5-7) to others espousing considerable enthusiasm (4, 8-13). This state of affairs, in combination with the notoriety that psychosurgery has gained from reports in the lay press, contributes to the rejection of psychosurgery out of hand by many psychiatrists. The purpose of this paper is to offer the reader some guidelines with which to evaluate and put into perspective current efforts in the field. I will focus primarily on the use of psychosurgery in the treatment of traditional psychiatric illness. This admittedly is discussing psychosurgery in a very restrict-

results

criminately

bated. tant

when

I will variables

are the

merits

attempt that

psychosurgical for various often

to tease deserve

temporal

is that

together

psychosurgery

out

arti-

procedures, indications,

lumped of

in

of psychosurgery aggressive behav-

in

use

ob-

of psychosurgery

will be briefly touched upon. major difficulties in this area

TYPEOF PSYCHOSURGERY

the

lobe epilepsy One of the

its

classical psychiatric syndromes and in such controversial areas as aggression or violent associated with temporal lobe epilepsy. The believes that such factors need to be clarified practitioners can choose a personal position sound medical fact.

practicing

some

individual

and indis-

are

of these

de-

impor-

attention.

PROCEDURE

In the

40 years

since

Moniz’

first

prefrontal

lobot-

omy in 1936, a large variety of neurosurgical procedures have been employed in attempts to treat abnormal behavior. These include the standard lobotomy, transorbital lobotomy, cingulectomy, topectomy, gy-

rectomy, and bimedial leucotomy, among others (14). The frontal lobes have been assaulted by everything from scalpels to icepicks, from thermocoagulation to cryogenic

probes,

from

radiation

to ultrasound.

As

Knight (15) has said, one can see in retrospect that procedures such as the standard lobotomy of Freeman and Watts were developed by clinicians who were perhaps over-eager following Moniz’ demonstration that patients occasionally improved because lobotomy lessened lusions

the intensity oftheir emotional or hallucinations. This was

cause

adequate

physiological

and

reaction unfortunate anatomical

to debestudies

When this work was done, Dr. Shevitz was a resident in the Department of Psychiatry, Dartmouth Medical School, Hanover, N.H. He is now Chief of Psychiatry, Public Health Service Indian Hospital, Tuba City, Ariz. 86045.

of areas involved had not been performed. Hence, large areas of white matter were sacrificed in attempts to divide the unknown pathways involved. It was not possible to find specific areas in the prefrontal region responsible for clinical change following isolation or ablation. Clinical improvement and personality change appeared to correlate quantitatively with the amount of prefrontal cortex separated from its white matter. Marked blunting of the individual’s personality and frequent surgical complications were undesirable side effects that occurred all too often with the early procedures (14, 15).

The author gratefully acknowledges er, M.D., in the preparation of this

seen

ed

266

context,

but

Am

one

that

J Psychiatry

may

133:3,

be

most

important

the assistance paper.

March

of Gary

1976

to the

J. Tuck-

Recent

evidence

following

suggests

standard

that

lobotomy

the

beneficial

might

largely

effects

be at-

STEWART

tributable functional tex from

to the disconnection of areas of the orbital and intermediate limbic circuits nomic outflow pathways via the brainstem (4, 15, 16). Efforts are

relatively discrete, medial frontal corthat lead to autohypothalamus and now being made to

current

attack

these

achieve

DIAGNOSTIC

benefit cutting

without of other

is the

work

areas

the fibers

described

selectively

to

therapeutic

adverse effects of inadvertent (4, 10-12, 17, 18). One example by

Sykes

and

Tredgold

(10).

A

form of orbital undercutting first developed by Scoville and Wilk (19) and modified by Knight (10, 20) is employed. By direct vision through burr holes, the orbital cortex (the ventral surface of the brain overlying the bony roof of the orbit and encompassing Walker’s areas 13 and 14) is undercut at thejunction ofthe white and gray matter. Such a procedure has a mortality rate of 1.5% and a postoperative epilepsy rate of 16% (well controlled by medication in most cases). Most importantly, only 5% of the 177 patients intensively studied by Sykes and Tredgold (10) were considered by them to have developed adverse behavioral effects following the operation, a marked improvement over the results of older procedures. A further modification using radioactive yttrium implants stereotactically placed has also been developed by Knight (4). This procedure was originally thought to involve the substantia innominata; it is now termed a “stereotactic subcaudal tractotomy.” In addition to a mortality rate of less than 1% from the operation, two reports reveal a postoperative epilepsy rate of only 1% to 2.2% (8, 9). Behavioral and psychological disturbances were lasting and troublesome in only 3% and 7% ofthe patients; 86% and 93% showed no undesirable symptoms at all. These are but two examples of “modified” procedures. A number of other modified procedures involving cingulate and orbital regions have been described in the literature (11-13, 17, 18). The important point to realize is that one must make distinctions between the various psychosurgical procedures before one can evaluate them. The standard open lobotomy that isolated 160 square centimeters of frontal cortex is markedly different from a stereotactic tractotomy in which only 8 square centimeters oforbital cortex (and possibly some fibers from the antenor cingulate gyrus) may be affected (4). Lesions produced in the cingulate or orbital regions do not appear to cause the severe emotional blunting or impairment ofintellectual function that the older, more extensive procedures often did (4, 10, 18). Most practitioners concur that the detrimental effects of the standard lobotomy and its variants certainly outweighed the benefits (of which there were some) and have discarded these techniques. These techniques should be considered of historical interest only and not as evidence that subsequently developed procedures must invariably result in the same adverse effects. The difficulties with human heart transplantation did not invalidate all surgical approaches to the treatment of coronary heart disease. Similarly, the evaluation of

psychosurgical

procedures

should

merits and should of their predecessors.

own individual adverse effects

available

(14,

21).

rest

on

bejudged

their

by the

was originally aimed at major tranquilizers were

Today

be considered

schizophrenia

a prime

or chronic

schizophrenia

Psychiatrists

for such

depression has little

and

deterioration

should

indication

dures (8-10). Except when iety are prominent, lobotomy chronic

not

SHEVITZ

CATEGORIES

Much prefrontal surgery schizophrenic patients before

longer

A.

no

proce-

or severe anxto offer in acute

certainly

cannot

reverse

(14). often

fail

nents of psychosurgery method for schizophrenia.

to recognize

that

many

do not advocate this The best follow-up

propo-

treatment studies

on psychosurgery from a psychiatric point of view are found in the British literature. Table 1 summarizes resuits from three such reports (8-10) mentioned previously.

The

the total who were

table

shows

the

number

of patients

out

of

patient either

population by diagnostic category fully recovered or had only minimal symptoms following leucotomy Follow-up occurred over a period of years following the operations. The .

best

results

fering

were

from

obtained

with

intractable

patients with also improved,

patients illness.

affective

severe obsessional although not

previously A number

or anxiety frequently

as

the relatively lation,

the

intractable results

illnesses

are

neuroses depres-

as

sive patients. Results are also shown for the ophrenic patients operated on. When one

sufof

few schizconsiders

in this patient

popu-

noteworthy.

It is evident that althQugh psychosurgery was originally employed extensively in treating schizophrenia, its effectiveness is now better evaluated with intractable depression, anxiety states, and obsessional neuroses. One is reminded of the history of imipramine, which

was

originally

ter antipsychotic

developed

in the

compound.

TABLE 1 Proportion of Postleucotomy Patients Minimal Symptoms at Follow-Up

Study

Sykes and Tredgold(I0) Strom-Olsen and Carlisle (8) Goktepe and associates (9) *

Numbers ceived

in parentheses

search

Although

it was

for

a bet-

found

Who Were Recovered

or Had

Diagnosti

c Category

Depression (all types)

Obsessional States

Anxiety

Schizophrenia

68(98)*

6(20)

11(25)

4(13)

10 (20)

19(46)

0 (5)

9 (18)

15(24)

0 (4)

42

(75)

53 (78) represent

the total

population

of patients

to

who

re-

leucotomies.

Am

J Psychiatry

133:3,

March

1976

267

PSYCHOSURGERY

be ineffective for psychosis, its mood-elevating properties in certain depressed patients were noted to be remarkable, and it has developed into one of our most effective antidepressant agents. The value of imipramine in treating depression is not invalidated by its ineffectiveness chosurgery’s

in treating unsuitability

Similarly,

schizophrenia. for the

dromes accepted as disease entities by the medical community. One must have established the validity of the illness being treated before the efficacy of treatment becomes a meaningful question.

psy-

treatment of schizophrenia today does not negate the possibility that it may be of value in other psychiatric disorders. It is important to consider such factors when one is appraising a particular study from the literature on psy-

ABUSE

chosurgery.

in choosing their cases (5). It would appear that not all employ the rigid standards of patient selection that would be demanded by many psychiatrists or by other

the

Often,

efficacy

cation

studies

quoted

of lobotomy

of the

standard

(22,

as

evidence

23) have

lobotomy

against

used

procedure

a modifiof Freeman

and Watts or similar extensive procedures that cause broad lesions of variable extent and placement. Also, as pointed out by Post and associates (24), the subjects in

many

of

these

studies

were

hospitalized

which

USE

WITH

BEHAVIOR

is currently

being

investigated.

DISORDERS

Psychosurgery, like many new treatment techniques, has been advocated for a wide variety of disorders. These have ranged from ulcerative colitis to drug addiction to hypochondriasis (14). Much of the current

controversy

regarding

psychosurgery

to its use with aggressive and violent ticularly the treatment of temporal amygdalotomy. This area has been the lay press, especially the efforts

in the

indications

This

CRITERIA

FOR

relates

behavior (6), parlobe epilepsy by well publicized in of Mark and asso-

included

to

2. The sonality. 3. The

in the

forms

of violent

amygdala.

Such

behavior

control the epilepsy that presumably is causing the violent behavior. Whether the behavior in question is actually secondary to the epileptic discharges is a subject of intense debate, as is the issue of side effects from

this

surgical haviors for

particular

operation.

Similarly,

psycho-

procedures that may

example,

are sometimes used to control beor may not be considered “illness,” criminal behavior (6) and sexual devia-

tions (28). It is important to distinguish between the use of psychosurgery in these controversial areas and its use for such classical, well-defined psychiatric illnesses as involutional melancholia or severe obsessional neuroses. The controversy over a treatment modality such as psychosurgery should not be confused with the controversy over whether or not certain disorders for which it might be advocated are valid illnesses. The validity of psychosurgery should be considered with respect to its use in classical, clear-cut psychiatric syn268

Am J Psychiatry

133:3,

March

1976

criteria

that

not,

on psychosurgery is a wide variation psychosurgeons

however,

standards

are

PATIENT

the following

highly controversial and certainly has to be considered experimental at this time. The term “psychosurgery” is often applied to the lesions made in the amygdala

discharges

some

literature that there

use

invalidate

studies

met.

SELECTION

The current consensus seems to be that psychosurgery is not the treatment of choice for any psychiatric illness (14). The continuing debate centers on the fact that some practitioners do consider it a treatment of last resort in certain very specific cases. To be even considered for psychosurgery a patient should have proven to be unresponsive to all other appropriate psychiatric treatment modalities and he should be disabled to the point that any potential hazards from the operation are felt to be equal to or less than the disability suffered as a result of his illness. The probability of future remission without further treatment should also be considered nil (2). Lehmann (29) has described his personal criteria for referring a patient for a psychosurgical procedure. He

is

to epileptic

to relate

should

higher

work

(25-27)

and

in which

1. The anxiety, order.

ciates

BY SURGEONS

chronic

patients.

psychosurgery

PSYCHOSURGERY

A review of the world quickly makes one realize

surgeons.

Such studies substantiate the the older procedures are not of great value when used with schizophrenic patients, but these procedures and that patient population are not the areas in

schizophrenic fact that

OF

two

criteria:

disease should be a chronic tension depression, or obsessive-compulsive patient

should

patient

must

have have

a good been

state, dis-

premorbid

disabled

per-

for

at least

years.

4.

Treatment

dalities

by

that

were

any

of the following

considered

mo-

proved

un-

therapist for six such as chlordiazepoxide hydrochloride in doses up to 100 mg per day for at least two months; c) imipramine, 250 mg per day for six weeks; d) chlorpromazine, 1000 mg per day for two to three months; e) one or two courses of ECT (10 to 15 treatments per course); and a trial of lithium for one year if there is recurrent depression or bipolar illness. Certainly every psychiatrist and surgeon would have his own modifications and additions for such a successful:

list;

a)

it is offered

psychotherapy months; b)

treatment

appropriate

as an example

by an experienced antianxiety drugs

of one

It should also be recognized that cians who would not recommend any circumstance.

person’s

there are many psychosurgery

opinion.

physiunder

STEWART

ETHICS

in the field. More the best interests

The

other

major

chosurgery

procedures. sue at length each

area

concerns

verse.

ethics

The

One

of

range

the

Breggin,

regarding

and

I will not address because it is such

practitioner.

surgery,

of controversy

the

morality

most

prolific

considers

such

critics

of

isfor

such

seat

a fashion

of man’s

because

he

humanity.

ill individual

who

feels

Others

is terribly

feel

disabled

to

be

a

they

represent

.

that

an intractably

2. 3.

but

can

oath.

Marks IM, Birley JLT, Gelder vere agoraphobia: a controlled 112:757-769, 1966 Psychosurgery

termed

Roche

Report:

Frontiers

Brown

BS,

spective Health,

the

still voluntarily consent to such a procedure should not be denied the possibility oftherapeutic benefit. In any event, one’s position on this matter is probably not determined by rationality and deductive reasoning but rather by one’s inner values and ethical interpretation ofone’s role as a medical practitioner under the Hippocratic

I

psycho-

by illness

can

REFERENCES

di-

horrible mutilation ofman’s highest function (5-7, 30). He abhors the idea of the frontal lobes being attacked in

important, only in this manner of our patients be served.

such

is extremely operations

SHEVITZ

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this very important an individual matter

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One reason for the precipitous decline in the popularity of psychosurgery that followed the wave of enthusiasm it inspired in the late 1940s was the frequent complications-especially

changes-found of that era. such

those

with Another

the more reason was

comprehensive that

frontal

cortex.

associates involved

modern

selected

Perhaps

psychosurgery’s

the

fall from

chemotherapy

schizophrenic

as those

(31)

partial

most

important

(major

was

the

tranquilizers).

population-at

which

of Co-

factor

in

advent

of

It was

the

scrutiny.

Along

with

cal investigation,

the

formidable

the problems

difficulties

of adequate

control

and

10 to 12 years finitive

studies

answer tainly

the questions such

irreversible

verest scrutiny. I have attempted factors that need its of this therapeutic

raised

by critics

procedures

to isolate to be weighed modality.

some

is evident. the

of the

important

in evaluating The

Cer-

deserve

purpose

the of this

se-

to advocate psychosurgery. It is a plea to every physician concerned with the subject to base his position on sound medical fact and practice. Only in this manner can we do proper justice to those working per

is not

neuropsychiatric

undercutting:

illness

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merpa-

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for

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psychosurgery

had been originally aimed-for which these new drugs were most effective. Today the possible merits of certain psychosurgical procedures for some disorders have once again brought the area under intense public and professional

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of the

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popularity

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my.

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PSYCHOSURGERY

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surgery

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DE:

for Quizzing

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resurging

Prompt

sexual

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the expert: Feb:24-3l,

menace

of

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Br

Med

J

clinical criteria 1973 brain

Roche

Report:

Frontiers

of Psychiatry

2(l6):I,2,8,

mutilation.

Policy like to remind priority

authors

of an idea,

who are particularly reveal

innovative

results

interested

of new

in early

research,

publication

or for other

pressing reasons) of its prompt publication policy. Under this policy, short (maximum of six double-spaced pages) manuscripts will be considered for publication in the Brief Communications section of the first available issue. These manuscripts must still undergo expert scrutiny before being time required

Authors this

270

Am

accepted, and for publication

who would

two months must be allowed for the printing process. of these short articles can be lessened considerably.

like to have their manuscripts considered under this policy reasons for it, when they submit their manuscripts.

desire,

as well

as the

J Psychiatry

133:3,

March

1976

1972

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However,

should

the

indicate