Psychosurgery

Psychosurgery is brain surgery carried out to relieve a patient's suffering by changing mood or behaviour. Latest UK figures indicate that only seven operations were done for the 2-year period 2004-5 (Schulze-Rauschenbach et al., 2005). It has thus become a near obsolete-treatment, probably carried out for only the most intractable cases of obsessive-compulsive disorder.

The history of psychosurgery serves to illustrate the way that the relative influences of the biological and the psychological approaches to psychiatry have varied over time. During the early decades of the twentieth century, psychological theories predominated, in particular the various schools of psychoanalysis.

However, their results in the treatment of psychiatric patients proved disappointing, particularly in relation to the rapid progress being made in other branches of medicine.

This led to a renewed search for what became known as physical treatments (including convulsive therapy, either electrically or chemically induced; psychosurgery; insulin coma; and electrosleep). Of these methods, only ECT has been shown to be effective in prospective, randomized, controlled trials, and the rest have now fallen out of use. Psychiatrists' enthusiasm for these and other unproven physical treatments, often used without informed consent, was a major reason for the emergence of the 'antipsychiatry' movement in the 1960s.

Moniz introduced psychosurgery in Portugal in 1935. During the next 20 years, many patients in mental hospitals all over the world underwent lobotomy, entailing large-scale, blind destruction of brain tissue. Some responded well, but others gained no benefit, suffered marked unwanted effects, or even died. The introduction in the 1950s of an effective antipsychotic drug (chlorpromazine) was followed by a secular decline in psychosurgery.

It is conceivable that psychosurgery may return in the future in a modified form, with the more precise use, for example, of fine electrodes precisely implanted and available for 'deep brain stimulation' (DBS).

References

Butler, R. et al. (2006). Depressive disorders. Clinical Evidence (15th edn), pp. 1366-1406. London: BMJ Books. http://www.clinicalevidence.com/ceweb/conditions/meh/1003/1003_ I9.jsp.

NICE (National Institute for Health and Clinical Excellence) (2003). Electroconvulsive therapy

(ECT). http://www.nice.org.uk/page.aspx?o=TA059guidance. Royal College of Psychiatrists (2005). The ECT Handbook (2nd edn). http://www.rcpsych.

ac.uk/publications/coHegereports/cr/cr128.aspx. Schulze-Rauschenbach, S. C., Harms, U., Schlaepfer, T. E. et al. (2005). Distinctive neurocog-nitive effects of repetitive transcranial magnetic stimulation and electroconvulsive therapy in major depression. Br J Psychiatry 186, 410-416.

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