The History of Psychological Treatment: Psychosurgery

When you read this post’s title, you probably thought “Ah, lobotomy! Interesting!”. Well, while you’re right about all that. However, there is one distinction to be made: psychosurgery (also known as neurosurgery for mental illness), is what lobotomy was inspired by, or based on, if you will.

António Egas Moniz

Psychosurgery was officially introduced in 1935 by Portugese neurologist António Egas Moniz (1874-1955), but the treatment already had quite an extensive history. The very first form of psychosurgery was trepanning, which was already practiced in 5000 B.C.. The first more advanced attempt at psychosurgery was performed by a certain Swiss psychiatrist called Gottlieb Burckhardt in the 1880′s. He performed surgery on the brains of six patients; he cut out pieces of their cerebral cortex. One of the patients died only days later. He published a report and presented his findings at the Berlin Medical Congress, but the responses were adverse. Burckhardt did not perform any further psychosurgeries.

There were more attempts at psychosurgery in the early 20th century, but all had discouraging results.

The Invention of Leucotomy

Then, Egas Moniz came along. He introduced psychosurgery to mainstream psychiatric practice and gave it its name. He hypothesized that the mentally ill, particularly in “obsessive and melancholic” cases, had a disorder in their synaptic connections, which allowed unhealthy thoughts to roam their mind. He thought that if he cut these connections, they would be replaced by more healthy ones. In 1935, Moniz directed a neurosurgeon (Pedro Almeida Lima) to drill holes in a person’s skull and to inject ethanol into her brain, which would destroy small parts of white matter in the frontal lobe.

After a few of these surgeries, Moniz and Lima changed their technique and instead of using ethanol, they would now cut out pieces of brain tissue directly. They used a tool called a

An ad for leucotomes in the 1940's

leucotome and called the operation a leucotomy (which means “cutting of white matter”). After twenty of these surgeries, they reported their results and although the responses were generally hostile, it inspired a few psychiatrists, especially in Italy and the United States, to experiment with the technique themselves (which eventually resulted in leucotomy as we know it – lobotomy).

A Nobel Prize and the Rise and Decline of Psychosurgery

Psychosurgery (in any shape and form) became incredibly popular in the 1940′s. By the end of that decade, nearly 5000 operations were performed annually in the USA only, despite its significant risk of death and severe personality changes (although you might argue that those changes were not seen as damage but as repair).

In 1949, Egas Moniz received the Nobel Prize for Physiology or Medicine:

“for his discovery of the therapeutic value of leucotomy (lobotomy) in certain psychoses”

In the 1950′s, the popularity of psychosurgery declined due to the introduction of psychoactive drugs and a growing awareness of the long-term damage caused by the operation. Additionally, people began to doubt its efficacy. This doubt increased and in the 1960′s en 70′s, psychosurgery became the subject of public debate. This resulted in congressional hearings in the US. Against all expectations, in 1977 the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (quite a mouthful) allowed the continued limited practice of psychosurgery.

Psychosurgery in Recent Years

Psychosurgery is still performed on a small (and still declining) number of patients to this very day. Forms of psychosurgery in use today or in recent years all target the limbic system (in which structures such as the amygdala, hippocampus, hypothalamus are located). These structures all play a part in the regulation of emotion. An example is anterior cingulotomy, which has been the most used commonly used psychosurgical procedure in the US in recent decades. It is performed to relieve the symptoms of major depression, obsessive compulsive disorder and chronic pain. (To get all technical: it targets the anterior cingulate cortex. The operation severs the thalamic and posterior frontal regions and damages the anterior cingulate region.)

There is currently a debate going on whether or not Deep Brain Stimulation (DBS, surgical treatment involving the implementation of a brain pacemaker, sometimes used in patients that suffer from Parkinson’s Disease, major depression or chronic pain) should be categorized as psychosurgery.

What do you think of psychosurgery? Do you think DBS should be categorized as psychosurgery?

Next week I will discuss the practice of lobotomy. I promise, it’s going to get truly gruesome.