History

The use of surgical techniques (such as trepanation of the skull) in people with mental illness is probably as old as medicine. Although various case reports of surgical procedures in patients with psychiatric disorders were published in the nineteenth century, (1) the modern era was ushered in by the Portuguese neurologist Egas Moniz and his neurosurgical colleague Almeida Lima. In 1935 they sought to damage connections to and from the frontal lobes in patients with 'psychoneuroses', possibly extrapolating from observations reported by John Fulton on the 'taming' effects of such lesions on two chimpanzees. (2)

Surprisingly, in today's eyes, this surgery was immediately thought to be useful in treating patients with psychiatric disorders. To put this in context it has to be remembered that there were no other effective therapies at the time. Other groups sought to carry out similar operations, and in 1936 Walter Freeman and James Watts modified Moniz's operative technique and introduced the standard prefrontal leucotomy, which is what the popular literature refers to when talking about 'prefrontal lobotomy'. The original operations were 'blind' (without visualization or imaging of the desired target) and 'free hand' (the introduction of a blunt instrument moved, with no mechanical constraint, by the surgeon's hand). In the subsequent two decades a call for more precise lesions, related to empirical results or to theories of brain function, resulted in the development of more circumscribed operations such as open cingulotomy, bimedial leucotomy, and orbital undercut. Between 1936 and 1961 some 50 000 patients underwent surgery in the United States and about 10 000 in the United Kingdom. (3) It was thought that about 20 per cent of patients with schizophrenia and between one-half and two-thirds of patients with affective disorder derived some benefit from surgery, and its popularity reflected frustration with the lack of available treatments for these disorders. High mortality (up to 4 per cent), severe abulia and amotivation (up to 4 per cent), troublesome personality change (up to 60 per cent), and postoperative epilepsy (up to 15 per cent) were accepted by many psychiatrists as worthwhile risks. No controlled studies were performed. While most reports recorded uncontrolled postoperative results, one later study in the United Kingdom found that, operated patients with schizophrenia did not have a better outcome than a non-surgical matched cohort at long-term follow-up. (4) There is a suggestion that a better outcome was related to a larger lesion,(5) but these findings have to be interpreted with great caution because of patient selection. These issues, as well as the neuropsychological findings from these procedures, are reviewed elsewhere.(6)

The use of surgery declined rapidly following the introduction of antipsychotic and antidepressant medication during the late 1950s. Since then, neurosurgery has only been used for severe treatment-resistant affective, obsessional, and anxiety disorders. Operative techniques have been refined to reduce side-effects and to localize the site of lesions, in line with the evidence linking particular brain areas with the experience of emotion. These changes resulted in the introduction of the four main operative techniques in use today: stereotactic subcaudate tractotomy, stereotactic anterior cingulotomy, stereotactic anterior capsulotomy, and stereotactic limbic leucotomy. These operations have been further, if only slightly, modified and are used rarely (on average, there have been no more than 20 operations a year in the United Kingdom over the last 20 years(7). Anatomical details of the operations have been reviewed by Mahli et al.(8)

Since the advent of these procedures, the mortality has dropped to less than 1 in 1000, postoperative epilepsy is well below 5 per cent, infections have not been reported, and intracranial haemorrhage is extremely rare.

However, there have been no controlled trials of these techniques, partly because of the ethical difficulties in performing sham operations in a sample of patients with severe illness and high suicidal drive (see below). Moreover, there has been little comparative evaluation of the effectiveness of these procedures for different diagnostic categories; the choice of indication and procedure being largely dependent on historical factors and the perceptions of a unit's experience rather than scientific evaluation. The largest surgical series relates to stereotactic subcaudate tractotomy, where over 1300 such procedures have been performed in London. (7)

Do Not Panic

Do Not Panic

This guide Don't Panic has tips and additional information on what you should do when you are experiencing an anxiety or panic attack. With so much going on in the world today with taking care of your family, working full time, dealing with office politics and other things, you could experience a serious meltdown. All of these things could at one point cause you to stress out and snap.

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