August 6, 2003
ALLIANCE FOR HUMAN RESEARCH PROTECTION (AHRP)
A Come Back for Psychosurgery?
The Los Angeles Times reports that experimental psychosurgery is once again on
the rise—at Harvard’s Massachusetts General Hospital and Brown University. It
is acknowledged that "Researchers still do not fully understand how the
operations affect the brain, or why….. And doctors do not know for sure
whether surgery by itself relieves symptoms or produces a strong placebo
effect..”
Thus, these experimental psychosurgeries lack a scientific rationale or
ethical justification—since the risk is permanent brain damage. Indeed, the
LAT reports that “at least one operation has gone badly already, causing
permanent brain damage.”
However, as is their habit, psychiatrists dismiss the risks and harmful
outcomes stating: "these risks must be weighed against the 30% to 50% positive
response rate from surgery, and the devastating consequences of severe,
intractable OCD and other mood disorders..." Those who perform psychosurgery
claim a 38% improvement rate, but as the LAT reports, “The fate of those who
do not improve with surgery [62%] is less clear.”
Psychosurgery is performed under the looming shadow of lobotomy. Like
lobotomy, psychosurgery severs nerve connections, damaging healthy brain
tissue. Lobotomy caused permanent and irreversible brain damage, obliterating
personality--the very essence of a human being. Psychosurgery then and now is
performed for the purpose of behavior control.
The inventor of lobotomy (1935), Egaz Moniz a Portuguese neurosurgeon who won
the Nobel Prize, was shot and paralyzed in 1939 by one of his lobotomize
patients who didn't’t like the results and, in 1955, he was beaten to death by
another dissatisfied lobotomized patient.
Walter Freemen, an American, "streamlined" the procedure in 1936 by using an
ice pick to cut into the brain. Freeman called this barbaric procedure "mercy
killing of the psyche."
The promoters of lobotomy included prominent psychiatrists who assured
patients, families and the public that the risk was very low, that people
either improved or stayed the same, and that virtually no-one was harmed.
Those claims--as most other claims made by the profession--have been proven
false. Between 1946 and 1955 Lobotomy was performed on an estimated 100,000
men, women, and children— 50,000 in the U.S. Ironically, lobotomy was banned
in the Soviet Union on moral Grounds.
As the casualties of the lobotomy era demonstrate, to evaluate the “success”
of psychosurgery, one must have an independent assessment and long-term
follow-up record of patients--not self-assessment by psychosurgeons.
See: The Mind Manipulators A factual account by Alan W. Scheflin, Edward M.
Opton, Jr., and co-author Rodney Plotnick, 1978.
http://www.sntp.net/lobotomy/lobotomy.htm
See also: A brief history of lobotomy:
http://www.ship.edu/~cgboeree/lobotomy.html
Sadly, recent investigations reveal a widespread pattern of research abuse at
the nation's leading institutions . Therefore, the claim that psychosurgery
performed within a research university bestows "safeguards and oversight" is
demonstrably incorrect.
See: www.ahrp.org
www.ohrp.osophs.dhhs.gov/detrm_letrs/lindex.htm
ALLIANCE FOR HUMAN RESEARCH PROTECTION (AHRP)
http://www.ahrp.org
Contact: Vera Hassner Sharav
Tel: 212-595-8974
e-mail: veracare@ahrp.org
~~~~~~~~~~~~~~~~~
http://www.latimes.com/la-he-psychsurgery4aug04,0,1778577.story
LOS ANGELES TIMES
August 4, 2003
New surgery to control behavior
Long out of favor, operations on the brain as a way to treat psychiatric
illness are again attracting scientific attention.
By Benedict Carey
Times Staff Writer
To break the maddening cycle of their own thoughts, some psychiatric patients
have had wires surgically implanted inside their brains. Others have surgeons
burn tiny holes in the middle of their brains, for the same purpose. The
procedures are a last resort, an attempt to fix stubborn mental problems by
operating directly on the neural circuitry itself. And now, a small cadre of
doctors is starting to spread the word: Brain surgery, for some severe mood
and anxiety disorders, is a viable treatment.
In the decades since frontal lobotomy — a crude cut into the frontal lobe,
behind the forehead — was discredited as an ethically indefensible operation,
neurosurgeons say they have developed far more precise techniques to operate
on the brain, and a better understanding of how the organ functions. At
several institutions around the world, including hospitals affiliated with
Harvard and Brown universities' medical schools, surgeons have been operating
on dozens of patients each year with severe psychiatric problems, including
depression and, more commonly, obsessive-compulsive disorder, or OCD. The
results have been encouraging enough that the federal government this year
funded two brain-surgery research studies for OCD patients, and other major
medical centers, including UCLA, are interested in establishing a program.
"There are some people who don't respond to other treatments at all," said Dr.
Wayne Goodman, a psychiatrist at the University of Florida in Gainesville, who
is directing one of the research studies for OCD. "And for the first time,
they have some hope."
But with hope comes risk. Researchers still do not fully understand how the
operations affect the brain, or why. There is not yet a consensus on which
surgical procedures produce the best results. And doctors do not know for sure
whether surgery by itself relieves symptoms or produces a strong placebo
effect — a self-fulfilling belief that the disease has been successfully
treated.
Caution and consent
Some experts who follow the emerging field are concerned that demand for these
operations could tempt less-experienced surgeons to try them, without the
safeguards or oversight of a research university. Given the history of this
field, known as psychosurgery, there's little margin for error. At least one
operation has gone badly already, causing permanent brain damage.
"At this point," said Dr. Joseph Fins, director of the medical ethics division
at Cornell University's Weill Medical College in New York, "we have to be
absolutely sure that desperation in and of itself does not lead patients to
consent to procedures that are still investigational."
In the early years of psychosurgery, after World War II, there was broad
support in the United States for the frontal lobotomy. By making a slash into
the frontal lobe, which is involved in impulse control and mood regulation,
doctors hoped literally to cut away violent, agonizing thoughts and behaviors.
The procedure often had just that effect, which for many deeply troubled
people and their families was a great relief. The scientific community was so
impressed that in 1949, the man who developed the procedure, Portuguese
neurologist Dr. Egas Moniz, won the Nobel Prize in medicine for his work in
psychosurgery.
In the years that followed, lobotomies were performed on about 50,000 people
in the U.S., prompting heated debates about mind control, social engineering
and the ethics of surgical psychiatry. The more practical problem was that
doctors had almost no idea what they were doing. The effect of the operation
was unpredictable: Lobotomized patients were less aggressive all right, but
many were reduced to listless shadows of their former selves. One of the most
enduring public images of psychosurgery is of McMurphy, the rebellious mental
patient played by Jack Nicholson in the 1975 movie "One Flew Over the Cuckoo's
Nest." Subdued in the end by brain surgery, he turned dull-eyed and absent.
That was then. Now, experts say, surgeons at research institutions have
stringent ethical standards limiting surgery only to patients who have failed
all other treatments, and who fully understand the risks. And physicians have
much more experience with similar surgeries for other conditions, such as
Parkinson's disease, and with brain imaging technology to pinpoint surgical
targets. Brain imaging research also has linked mental disorders such as OCD
and schizophrenia with abnormal function in specific regions of the brain. In
OCD, for example, a circuit linking portions of the orbital frontal cortex,
which is behind the eyes, to deeper structures, such as the thalamus, appears
to be more active than normal. Surgeries for OCD are meant to interrupt this
circuit. They include:
• Capsulotomy. Surgeons insert probes through the top of the skull and
down into the internal capsule, a region near the thalamus and part of the
circuit connecting to the cortex. They then heat the tips of the probes,
burning away raisin-sized portions of tissue. The operation can also be done
with external radiation, by shooting beams into the capsule, where they
converge to burn away tissue.
• Cingulotomy. In this operation, surgeons thread probes through the
top of the head down into the cingulum, a bundle of connective tissue near the
capsule that appears to regulate the circuit that's hyperactive in OCD
patients. They then burn away tissue by heating the probes' tips. The
procedure can be done with external radiation.
• Deep brain stimulation. In this operation, surgeons thread wires
through the skull and into the capsule. No tissue is destroyed. The wires,
which remain embedded in the brain, are connected to a battery pack implanted
in the chest. The batteries produce an adjustable, high-frequency current that
interrupts the circuitry implicated in OCD. Doctors have been using the
procedure for years to settle the tremors of Parkinson's disease. It's
reversible — if the stimulation doesn't work or causes problems, the current
can be turned off.
*
Early studies encouraging
Over the past decade and a half, several pioneering doctors have quietly built
a track record for capsulotomy and cingulotomy. In one 1996 study, published
in the journal Neurosurgery, doctors at Massachusetts General Hospital, a
Harvard-affiliated institution, followed 34 men and women who had
cingulotomies for OCD or other major mood disorders. The doctors found that 13
(or 38%) of the patients improved substantially in the months and years after
surgery. In a 2002 study in the American Journal of Psychiatry, the same team
reported that 20 of 44 OCD patients (45%) who had cingulotomies improved
significantly — meaning that they could manage their symptoms well enough to
make a significant change in their lives, such as resuming work.
At Butler Hospital in Providence, R.I., which is affiliated with Brown
University, doctors report similar response rates for capsulotomies using
radiation.
Some patients who were almost completely disabled by OCD before surgery are
now leading fuller, more normal lives, said Dr. Benjamin Greenberg, chief of
outpatient services at Butler and an associate professor of psychiatry at
Brown. One formerly severely ill man has gone on to graduate school. Greenberg
is now working with doctors at the Cleveland Clinic , the University of
Florida and Massachusetts General to test the effectiveness of deep brain
stimulation for both OCD and depression.
Several doctors involved in these programs were either hesitant to discuss the
issue or asked not to be quoted by name. Some explained that they are wary
because the shadow of lobotomy still haunts public perceptions of the field,
despite all the advances. "There is history to deal with, and it's not a good
history," Greenberg said. "We don't like to call it psychosurgery anymore, so
much has changed. It's neurosurgery for severe psychiatric illness."
*
Patients' interest growing
Word of the advances is reaching patients. Last month, Greenberg discussed the
Butler program at the annual meeting of the OCD Foundation, a group that
includes doctors, researchers and patients. "There's a whole lot of interest
in surgery now among patients," said Patty Perkins, the foundation's director.
"I think there are many who at least would consider it."
Ann M. Lenkewicz was one of them. Lenkewicz, 47, a nurse living in Providence,
considered having brain surgery several years ago to treat her OCD. Her
compulsions were religious: She believed she had to repeat a variety of
prayers, painstakingly and exhaustively throughout the day, to avoid an
unnamed disaster. "It plagued every part of my life for almost 30 years: my
job, my family, my relationships," she said. She was spared the decision on
surgery after finding an antipsychotic drug that, in combination with
psychotherapy, kept her anxieties in check. "It was a big relief; brain
surgery is a very serious thing."
The family of Mary Lou Zimmerman would agree. In 1998, Zimmerman, a former
bookkeeper who was then 58, visited the Cleveland Clinic to have surgery to
relieve severe OCD. Zimmerman suffered from one of the most common
compulsions, a fear of contamination. She spent hours every day showering and
washing her hands, and neither drugs nor counseling could break the cycle.
A surgeon at the Cleveland Clinic performed two procedures in combination — a
cingulotomy and a capsulotomy — burning four holes in her brain. More
typically, surgeons perform one procedure, making two holes. It was soon clear
that the patient had suffered crippling brain damage, either from the surgery,
from an infection or from both, said the woman's attorney, Robert Linton, of
the Cleveland law firm Linton & Hirshman. In June 2002, a jury in Ohio awarded
Zimmerman and her husband, Sherman, $7.5 million in damages. "She is
completely disabled and needs full-time care," said Linton. "This is an
example of what can happen when an experimental procedure goes awry. There are
real risks."
In a statement released immediately after the verdict, the Cleveland Clinic
said it "was outraged" by the decision. "This case exemplifies the need to
make the distinction between a complication leading to a bad outcome and
negligent care Our physician provided an excellent standard of care," the
statement said. A spokesperson contacted last week would say only, "the
Cleveland Clinic appealed the jury verdict, and all disputed issues concerning
the matter have been resolved."
Doctors say that any open brain surgery has a complication rate, a 1% to 3%
risk of hemorrhage, seizure, infection or other problems. In the medical
literature there are also scattered reports of "apathy" or "indifference" in
patients after psychosurgery; the incidence is estimated to be less than 1%,
according to a recent review of all reported procedures through 2001.
Psychiatrists, however, said these risks must be weighed against the 30% to
50% positive response rate from surgery, and the
devastating consequences of severe, intractable OCD and other mood disorders,
which can cause a lifetime of misery.
Some patients have turned to private clinics for the surgery. At San Diego
Gamma Knife Center, a radiation surgery center affiliated with Scripps
Memorial Hospital in La Jolla, doctors have done eight procedures for OCD,
said Dr. Kenneth Ott, the clinic's medical director, and at least one of the
patients has improved significantly. Ott said the clinic consults with
patients' psychiatrists to make sure they are good candidates for surgery and
have exhausted all other treatments. Moreover, radiation surgery does not have
the same infection risk as open surgery — the beams are external, like an
X-ray.
The fate of those who do not improve with surgery is less clear. Some have a
repeat procedure, each with its small risk of complications and the
possibility that it too won't remedy the problem. Yet in modern neurosurgery
these risks are taken with the patients' consent. As awful as they are, severe
cases of OCD and depression rarely rob people of their intellectual capacity
to make an informed, reasoned decision. And it is the desires and suffering of
these people, more than anything else, that will fuel continued study of
psychosurgery.
"Our society uses words like 'malignant' to describe cancer, but severe mental
illness is the most malignant disease you can have," said Fins, of Cornell's
medical school. "These are horrifying illnesses and, as doctors, we have an
obligation not only to protect patients but to investigate procedures that
might benefit them."
Last Updated on
04/14/04
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