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. 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.
There is evidence that trepanning (or trephining)—the practice of drilling holes in the skull for pseudomedical reasons—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 —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"
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 eventually done under local anesthesia accomplished through electroshock administered to the patient moments before the procedure.
In what is now widely considered to be a highly invasive procedure, 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. 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).
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. 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.
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 centres, 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 (Baer et al., 1995).
Psychosurgery is legally practiced in controlled and regulated U.S. centers, or in Finland, Sweden, United Kingdom, Spain, India, Belgium and Netherlands. In France, 32 psychosurgical operations were made between 1980 and 1986 according to an 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 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.. 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 . ESB for anxiety is advocated as an alternative by surgeons on the internet , most psychologists, however, prefer medication and counseling.
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.
Individuals 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.
- Howard Dully: One of Walter Freeman's youngest victims, author of My Lobotomy (2007)
- 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.
- 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.
- Baer, L., et al. (1995). Cingulotomy for intractable obsessive-compulsive disorder. Archives of General Psychiatry, 52, 384-392.
- 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.
- Renato M.E. Sabbatini: The History of Psychosurgery. Brain & Mind, September 1997.
- Pohjavaara P (2004): "Social Phobia, Etiology, Course and Treatment with Endoscopic Sympathetic Blockade (ESB)" 
- 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.
- "Oral Histories" from Psychosurgery.org
- Website dedicated to Walter Freeman and the "Ice-Pick Lobotomy"
- New England Journal of Medicine article
- Brain surgery to cure the mind - BBC Radio 4 documentary on modern psychosurgery
- "Father of the Lobotomy"
- Lobotomy Criticism
- A Brief History of the Lobotomy
- Rotten Library Article on the Lobotomy
- "My Lobotomy" - a 22-minute piece from National Public Radio's All Things Considered about a 56-year-old man exploring a lobotomy he had at the age of 12.
- "Shedding Light on Shadowland" - in-depth essay exploring the propagation of the Frances Farmer lobotomy legend
- "Lobotomy's back - controversial procedure is making a comeback"
- Wall Street Journal. November 2, 2007 The surgeon,... says he has performed nearly 1,000 such procedures(brain surgery), mostly for schizophrenia.
Medicine > Psychiatry
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