Psychosurgery: new cutting edge or short sharp shock

The New York Times has an excellent article on how the development of new and more focused brain surgery techniques for the treatment of mental illness are leading to a tight-rope situation where doctors are trying to balance enthusiasm for a potential new treatment while avoiding its inappropriate use and bad publicity.

The use of neurosurgery for treatment of psychiatric disorders has a bad name. It is associated with the frontal lobotomy and leucotomy procedures which were carried out in large numbers in the 1940s, 50s and 60s on the basis on poor evidence and with very little oversight.

The dreadful excesses of this era have thankfully passed, and, with an increased understanding of brain circuity, it has been possible to trial the effect of very focused surgical interventions on certain neurological and psychiatric disorders.

Deep brain stimulation (DBS) is the most popular procedure, which is partly because the implanted brain electrode can be very accurately targeted, and partly because, in principle, the effect is reversible as it relies on electrical current for its effect, although the dangers of brain surgery still remain.

Neurosurgical procedures are also being used to permanently alter the brain by making cuts or lesions to specific areas.

This has been used for many years in Parkinson’s disease to treat tremors (the distinctive ‘shaking’) because the circuits that control movement are quite well understand and easy to study because there are many objective and accurate ways of measuring movements.

Although the numbers are still tiny, the same strategy is being increasingly to treat severe mental illness. Searching PubMed for its common scientific name – ‘functional neurosurgery’ – brings up studies where it has been used on everything from addiction to chronic pain.

And this is where people get nervous, because the procedures are quite experimental still and the researchers are well aware of the dangers of being labelled as ‘modern day lobotomists’ if something goes wrong.

As the article nicely outlines, the challenge is not so much the control of symptoms, which is relatively easy, it’s doing this while avoiding of adverse effects, like cognitive impairments, brain damage or additional mental instability.

Link to NYT piece ‘Surgery for Mental Ills Offers Both Hope and Risk’.

4 thoughts on “Psychosurgery: new cutting edge or short sharp shock”

  1. You’re quite optimistic… Would half of the people who had the surgery be so optimistic too? I doubt on that… The brain is still very unknown. Neuroscientists give the impression they know so much about it. But, the reality is different. Otherwise half of the patients wouldn’t suffer now from apathy and poor self-control. It’s still a quite risky surgery with far too many side-effects. Deleting that part of the article is a questionable decision.
    In a paper published last year, researchers at the Karolinska Institute in Sweden reported that half the people who had the most commonly offered operations for obsessive-compulsive disorder showed symptoms of apathy and poor self-control for years afterward, despite scoring lower on a measure of O.C.D. severity.
    “An inherent problem in most research is that innovation is driven by groups that believe in their method, thus introducing bias that is almost impossible to avoid,” Dr. Christian Ruck, the lead author of the paper, wrote in an e-mail message. The institute’s doctors, who burned out significantly more tissue than other centers did, no longer perform the operations, partly, Dr. Ruck said, as a result of his findings.
    In the United States, at least one patient has suffered disabling brain damage from an operation for O.C.D. The case led to a $7.5 million judgment in 2002 against the Ohio hospital that performed the procedure. (It is no longer offered there.)
    Most outcomes, whether favorable or not, have had less remarkable immediate results. The brain can take months or even years to fully adjust after the operations. The revelations about the people treated at Karolinska “underscore the importance of face-to-face assessments of adverse symptoms,” Dr. Ruck and his co-authors concluded.

  2. While I can see that the approaches for this type of treatment are quite limited, I have to admit this is very exciting for the future of biological psychology and neurology. More so for patients with chronic and debilitating psychological conditions such as PTSD and bipolar disorders.
    Although the above commenter raises some valid concerns, there are also concerns patients face with taking a lifetime of medication to treat their disorders. To either eliminate or limit the amount of psychoactive medications required for the treatment of these patients is a compelling reason to pursue research on this alternative treatment option.

  3. You mention the dangers of DBS – Karl Deisseroth’s lab recently published a study that provides a demonstration that parkinsons symptoms might be just as effectively ameliorated with direct stimulation of M1 as with DBS. M1 is motor cortex – easily accessible and right on the surface of the brain!
    TMS is also being used for treatments of a number of disorders; again, a noninvasive method (if you don’t count the magnetic fields ;).
    I think I’d prefer either of these experimental treatments to just having brain tissue ablated based on some cognitive neuroscientist’s half-baked flavor-of-the-week theory about functional anatomy.
    Aforementioned Deisseroth paper:

    Click to access Gradinaru%20Science%202009.pdf

  4. The types of patients who are undergoing these treatments are severe with almost no ability to function in society. The patients must be able to understand the risks, and that is why this is not offered to just anyone. Many people had to die before the first mechanical heart successfully kept people alive. Some of these people are so OCD they will exhaust themselves to death with meaningless activity. It really is that bad. These experimental trials are informed consent, which means it’s up to the surgeon to offer them or not, and to the patient to accept or decline knowing the possible and unknown risks. We are talking about people who may possibly die from their illness and who have failed every other type of treatment. If these procedures get approved, no doctor who cares about his medical license (or her) will offer this to someone who walks in the door the first time. Meaning, this is one more tool in a toolkit for that small group of patients who get no benefit from any other type of treatment. TMS is not appropriate for everyone, a motor threshold has to be established in order to use it, and that doesn’t always happen.

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