Biological Therapy: Psychosurgery

What is the biological view of treating mental disorders?

Biological psychologists believe all behaviour is determined by biological factors and that mental illness has a physiological cause and should be treated as an illness like any other.

We can use biological treatments to treat a variety of mental disorders such as depression and OCD.

How does psychosurgery link to the Biological Approach?

The biological approach focuses on links between the brain and behaviour.

The cerebral cortex is divided into four lobes each with its own specific function called localisation.

Changes in behaviour can be associated with changes in the structure of the brain.

The aim of psychosurgery is to change the structure of the brain, damaging healthy tissue with the sole purpose of changing behaviour.

What is Psychosurgery?

Psychosurgery is an extreme form of biological treatment.

It involves the cutting of neural tissue in the brain to change behaviour and was designed to alter the symptoms of severe psychological disorders.

The term psychosurgery is not used when there is a known physical cause for a problem such as a brain tumour or epilepsy. This is called brain surgery.

Psychosurgery is used to describe the process of removing or destroying functioning parts of the brain in order to bring about a change in behaviour.

What is the aim of Psychosurgery & when is it used?

The aim of psychosurgery is to relieve stress, anxiety and depression in patients who have not responded to any other treatment.

It works by destroying parts of the brain or by severing the connections between areas of the brain.

Psychosurgery is a treatment of last resort, used only in extreme cases when other treatment methods have failed and where, because of the disorder, the person is likely to cause harm to themselves or others.

What is a Lobotomy?

There are nerves that connect the frontal lobes to the rest of the brain.

The idea behind psychosurgery, later proven to be invalid, was that these nerves were somehow malformed or damaged, and if they were severed they might regenerate into new, healthy connections.

The purpose was to alleviate some of the severe symptoms of mental illness. Operations were performed, initially on patients with depression, and OCD and schizophrenia (less successful).

The severity of the symptoms was more of a reason for this treatment rather than type of illness.

What can Psychosurgery be traced back to?

Psychosurgery can be traced back to an ancient treatment called trepanning.

Holes (of about 4cm) were cut into the skull of a living person using a knife. The aim was to release evil spirits and was common in Ancient Greece.

What did Egas Moniz invent?

In the 1930's Egas Moniz, an ambitious Portuguese neurosurgeon, invented the modern lobotomy.

The first procedure was called "prefrontal leucotomy" and the instrument he used was named a leucotome.

A leucotomy involved drilling holes in the skull in order to access the brain. Once visible, the surgeon would sever the nerves using a pencil-sized tool called a leucotome.

How did the Leucotomy work?

The Leucotome had a slide mechanism on the side that would deploy a wire loop or loops from the tip.

The idea was to be able to slide the "pencil” into the pre-drilled holes in the top of skull, into the brain, then use the slide to make the loop(s) come out.

The surgeon could sever the nerves by removing “cores” of brain tissue, slide the loop back in, and the operation was complete.

What did Dr. Walter Freeman do?

Dr. Walter Freeman of George Washington University and Dr. James Watts of Yale brought Moniz's leucotomy to the US and immediately began to select and experiment on humans.

Freeman amended the technique and developed the transorbital lobotomy.

What is the Transorbital Lobotomy?

The infamous transorbital lobotomy was a "blind" operation in that the surgeon did not know for certain if he had severed the nerves or not.

A sharp, icepick like object would be inserted through the eye socket between the upper lid and eye.

When the doctor thought he was at about the right spot, he would hit the end of the instrument with a hammer.

What is Stereotactic Psychosurgery?

More recently developed methods are far more precise ways of surgically treating mental illness that fail to respond to other treatments such as CBT or psychotherapy.

Instead of removing large sections of the frontal lobe, surgeons now use computer based stereotactic imaging such as MRI scans to locate precise points within the brain and sever the connections.

Example of treating OCD

OCD - the circuit linking the orbito- frontal cortex to deeper structures in the brain such as the thalamus is seen as being more active than normal.

The bilateral cingulotomy is designed to surgically interrupt this circuit by burning the tissue away or using a gamma knife, which is non-invasive, to focus beams of radiation on the target site.

In a Capsulotomy, surgeons insert a probe through the top of the skull and down into the capsule, near the thalamus. Heating the tips of the probes burns away tiny portions of tissue.

What is Deep Brain Stimulation (DBS)?

An alternative to psychosurgery is deep brain stimulation (DBS).

An experimental procedure in which a hole about 14 mm in diameter is drilled in the skull, surgeons insert a thin electrode into the thalamus, a part of the brain where pain sensation occurs.

A stimulation device attached to the electrode delivers low-grade electrical signals in an attempt to override pain signals.

Effectiveness of Psychosurgery: What did Wilkinson et al report?

Initial evidence suggested that there was a high success rate for these procedures.

Wilkinson et al (2000) reported improvements in 72% of patients treated for chronic pain supporting the effectiveness of psychosurgery. However other findings found problems such as difficulty in speaking and concentration.

However, unfortunately these operations have a nasty tendency to leave the patient vegetablized or ‘numb' with a flat personality, brain seizures, shuffling movements etc. due to their inaccuracy.

When is Psychosurgery used?

Surgery is used only as a last resort, where the patient has failed to respond to other forms of treatment and their disorder is very severe.

This is because all surgery is risky and the effects of neurosurgery can be unpredictable.

Also, there may be no benefit to the patient and the effects are irreversible.

What did Moniz and Freeman claim?

Both Moniz and Freeman claimed high success rates for their operations. Initial evidence supported this:

Pippard (1995) reported improvements in 62% of leuctomised depressed patients, and 50% with mood disorders.

However, Comer (2002) found a fatality rate of 6% and severe physical side effects such as brain seizures and lack of emotional responsiveness which suggests that these procedures were inappropriate and ineffective.

How many people were lobotomised in the 1940s and 50s?

In the end, at least fifty thousand people were lobotomised by the psychosurgeons in the 1940s and 50s. The transorbital patients were often the most functional since there was a reasonable possibility that the doctor had missed their nerves all together.

The less fortunate victims were warehoused in institutions, or they returned to families who were often unable to cope with such severely disabled people.

What is an alternative to Psychosurgery?

The advent of psychoactive drugs to treat mental disorders meant that the operation became unfashionable and psychosurgery became a rare treatment form the 1960s onwards.

Why is a Bilateral Cingulotomy more favourable?

Bilateral cingulotomy has an advantage over lobotomies and leucotomies as the procedure is very accurate and the skull is not cut into.

However, these procedures are still used as a last resort for patients suffering from disorders such as bipolar and depression and only used when all other therapies have failed.

What did Cosgrove and Rauch find?

Cosgrove and Rauch (2001) found that cingulotomy was effective in 56% of OCD patients and Capsulotomy in 67%.

However, only 25 patients are currently treated annually in the US so the number of studies is very small as surgery is very much used as a last resort, therefore it is less effective as the percentage is based on a small number of people.

In addition, Bridges et al (1994) have pointed out that, as a treatment of last resort, no controlled trial against a comparable treatment is possible, therefore, it is difficult to measure its effectiveness.

Is Psychosurgery limited in its use & What did Szasz criticise?

Psychosurgery is limited in its uses. For example, it is rarely used to treat phobias, and even then, only in very extreme cases. It is not used for to treat schizophrenia, although there have been calls for trials.

Szasz (1978) criticised psychosurgery as a person's psychological self is not physical and therefore it is illogical to suggest it can be operated on.

Real life Application of Pyschosurgeries

Mary Lou Zimmerman received psychosurgery for uncontrollable OCD.

She underwent a cingulotomy and a capsulotomy, but the operation resulted in crippling brain damage rather than a cure. Her family sued the clinic that treated her for lack of informed consent claiming they were not told of the dangers of the procedure. A court awarded millions of dollars in damages.

Ethical Issues: Consent

Early psychosurgery techniques were used in mental asylums on patients who had not given their valid consent to the operation.

Even today, Patients with severe depression are arguably in no fit state to give consent. In 1983, the Mental Health Act incorporated more stringent procedures to gain consent for psychosurgical procedures.

Ethical Issues: Irreversible Damage

Psychosurgery cannot be reversed. Early procedures resulted on patients' cognitive abilities being significantly impaired.

This included memory loss, and, in some cases blunting of emotion. Procedures like the prefrontal lobotomy led to patients returning to their communities' zombie like.

Modern methods have reduced the risk of severe damage to the brain because the techniques are more precise, focusing on specific locations. However, they are not without risk as procedures such as DBS carry a risk of long term seizures and altered mood.

Conclusion: The Effectiveness of Psychosurgery

In conclusion, psychosurgery is an effective therapy, however, there is evidence that mental illness not only stems from physical issues but also from childhood trauma and faulty thinking.

This means that psychosurgery should not be used on its own because it will not be effective for everyone. It should be used with non-physical treatments so that physical symptoms and underlying causes can both be treated.