Psychosurgeries: Hack-Jobs Turned Brain-Hacks
Shawn Babitsky
Illustrations by Mindy Nguyen and Anna Bishop
The camera pans to Jack Nicholson’s lifeless expression: his slackened mouth hangs open just slightly and his body lays unreactive to the movements of his hospital cot. Randall McMurphy (one of Nicholson’s most famous film characters) is soon approached by his hospital pal, Chief, who hopes to be greeted by his friend. It’s immediately clear to Chief, however, that McMurphy isn’t truly there. Although he’s breathing and his eyes are open, he lies in the bed like a corpse in a tomb. McMurphy has had forced brain surgery; his unnervingly plain disposition suggests that he will never again recognize his friend sitting in front of him, much less behave like the person he once was. This disturbing scene, pulled from the award-winning 1975 movie adaptation of One Flew Over the Cuckoo’s Nest, depicts a previously common form of psychosurgery: the infamous lobotomy. The protagonist, McMurphy, is subject to the procedure as punishment for wreaking havoc in a psychiatric hospital; the surgery ultimately renders him incapable of physical movement and all forms of normal human behavior. Although McMurphy is still technically “alive,” it is clear to the audience that their beloved character is approaching a disastrous fate. McMurphy’s eerie tale is one of many popular media examples demonstrating psychosurgery stigmatization, and misconceptions of the procedure’s capabilities run rampant throughout society today due to such persisting concerns. Modern psychosurgeries, however, are a far cry from the infamous lobotomies of the past. In fact, many constitute safe and effective treatments for psychiatric conditions, especially for those resistant to other non-surgical interventions [1, 2].
The Un-nerve-ing History of Psychosurgery
Brain surgery that aims to address mental illness, or psychosurgery, has been practiced for nearly a century [3]. The first recorded case was the “ice-pick” lobotomy in the 1930s –– the surgery that Randle McMurphy received. This procedure involved inserting a small metal spike through the eye with the intention of disrupting faulty connections in the brain and would often leave patients with little to no brain function [4]. A well-known lobotomy example was that of John F. Kennedy’s sister, Rosemary, who was forcibly lobotomized in 1941 to treat her seizures and “erratic behavior,” the outcome of which was infamously disastrous. Rosemary lost most of her ability to walk and speak and was immediately institutionalized after the procedure [5]. These first attempts at surgically correcting mental illness were notoriously brutal and ineffective; the practice has understandably become stigmatized. And while modern psychosurgeries bear no resemblance to these lobotomies of the past, the current perception of these procedures continues to be stained by their historical manifestation in both real life and the media.
Unlike the “ice-pick” method, modern psychosurgeries are minimally invasive and capable of producing favorable results [6]. The surgery uses the minimum number of incisions, decreasing the risk of complications [6, 7]. Therefore, modern psychosurgeries take a much more precise approach than that of their origins in lobotomy, in which significant portions of brain tissue were damaged. Instead, surgeons use controlled electrical currents to create small lesions in a targeted brain region in order to disrupt dysfunctional neuronal signals [4]. All neurological functions are dependent on precise electrical signals; misfiring, or errors in the patterns of these signals, can result in mental illness [8]. Psychosurgical treatment can disrupt dysfunctional pathways in a controlled manner, thus healing the symptoms caused by previous misfiring [4]. The efficacy of these new treatments is evident in deep brain stimulation (DBS), a once-taboo psychosurgical procedure that has found significant clinical success in recent years [9].
DBS is a neurosurgical therapy that involves implanting a small device, also known as an electrode, that delivers constant electrical pulses to a specific area of the brain [9]. The implanted electrode can then alleviate symptoms associated with neural misfiring. During surgery, detailed imaging is used to implant the electrode in a precise region of the brain. The electrode is then connected to a pacemaker under the skin of the chest below the collarbone. Each pacemaker and electrode pair is specially programmed to counteract an individual's specific abnormal firing pattern, counteracting signals associated with tremors and faulty motor control [10].
Since its approval, DBS has revolutionized how certain diseases are treated [11]. For instance, individuals diagnosed with Parkinson’s, a severe neurodegenerative disorder, often experience dyskinesia, or involuntary muscle movements. This debilitating symptom can be almost entirely alleviated by implanting a DBS electrode near the part of the brain responsible for motor control. But, although DBS has been relatively successful for the treatment of Parkinson's disease, in its early days, the procedure was often compared to lobotomies in an effort to discredit the practice. For many years, members of the medical community considered DBS unethical due to the controversy surrounding its initial use [12]. In essence, despite its continuous evolution and potential to treat many impairing conditions, psychosurgery continues to face resistance due to its tragic roots [9].
A Tactical Strike Against Severe Mental Illness: The Anterior Cingulotomy
Picture a city’s public transport system: there are hundreds of tracks and trains, as well as passengers trying to get from station A to station B. Now imagine this busy scene unfolding in the brain, where the stations are located in different hemispheres of the brain. The cingulum is a part of the brain that acts as this entire transit system; its fibers are the individual trains, and the electrical signals trying to get from one hemisphere to the other are the passengers. The frontmost portion of the cingulum, near your forehead, is called the anterior cingulate cortex (ACC) [13]. The ACC exists in a vital physical position between two major brain structures: the limbic system and the prefrontal cortex. The limbic system is composed of multiple smaller structures that work together to process emotion, acting as a bridge between emotions and our ability to feel them. The prefrontal cortex, on the other hand, is a region of the brain which modulates cognitive processes [14]. Consequently, the ACC is responsible for both processing emotional responses and conveying those responses. Due to its unique position within the brain, any neuronal misfiring in the ACC could lead to psychiatric dysfunction [8].
Similar to DBS, the anterior cingulotomy is both a revolutionary and controversial modern psychosurgery [9, 14]. The anterior cingulotomy aims to alleviate symptoms of refractory (i.e. treatment-resistant) mental illness. The surgery uses a minimally invasive approach with a precise imaging system to surgically access and modify the ACC [13]. A surgeon then uses a small probe with a controlled electrical current to create small lesions around the ACC [2]. These lesions create an interruption in a dysfunctional brain circuit loop associated with psychiatric disorders, called the cortico-striatal-thalamic (CSTC) loop. When the CSTC loop is strategically disrupted in this way, the symptoms associated with misfiring neurons — such as obsessive compulsions or depression — are reduced [2].
Due to the fear that psychosurgery elicits in society, the anterior cingulotomy has not been widely used; however, all existing clinical trials for the procedure have yielded favorable results [2]. One clinical trial followed 64 patients for five years after undergoing cingulotomies to treat refractory obsessive-compulsive disorder (OCD). Thirty of those patients had all of their symptoms alleviated, and fourteen had some of their symptoms diminished [2]. The symptom relief experienced by these OCD patients following cingulotomies is also evident in those who had the procedure for the purpose of refractory depression treatment. Many trials of the procedure suggest that major depressive disorder (MDD) patients and OCD patients will. experience symptom relief after having the procedure [2]. Importantly, it appears that these improvements will persist for some time, as over 70% of both MDD and OCD patients continued to experience relief in the five years following surgery [15]. It’s important to note that those patients whose symptoms did not improve, did not have their symptoms worsen following surgery; therefore, no patients reported worsened conditions following the procedure [2].
Similar to any other neurosurgery, there are inevitable side effects and risks to this procedure; however, the likelihood of serious adverse effects is slim [14]. Some negative side effects from the anterior cingulotomy are possible in the long-term, but they remain rare. Individuals who receive the surgery may experience urinary incontinence (the inability to control urination) for a short period of time following the procedure [1, 2]. Additionally, people might exhibit a postoperative decline in memory and learning or decreased decisiveness [16]. However, in most cases, these effects resolve within just a few days after the surgery. During the recovery process, it takes approximately a month for soreness at incision sites to diminish, and it could take up to three months for potential motor or speech deficits to resolve [17]. Even so, these temporary effects are no different than those caused by any other brain surgery. Of course, this procedure is by no means a cure-all for mental illness; physicians should be cautious in presenting the anterior cingulotomy as an option to people before their condition proves to be treatment-resistant [2, 17, 18, 19]. It is essential that this option is presented only to the roughly 20% of people with major depressive disorder (MDD) and 30% of people with OCD who do not respond to alternative treatments and continue to suffer from their respective symptoms [18, 19].
One other psychosurgery exhibits favorable results with a similarly minimal risk. The amygdalotomy is a procedure used to treat symptoms of aggression associated with severe learning disabilities [20]. The amygdala, a structure of the limbic system, modulates neural responses associated with fear, anxiety, impulsivity, and aggression. Similar to other psychiatric disorders, overactivity in the CSTC loop can result in the aggression associated with severe learning disabilities. To treat this aggression, a surgeon will cut lesions around the amygdala in order to interrupt the CSTC loop and alleviate symptoms [20]. Akin to the cingulotomy, the amygdalotomy brings with it the typical risks and recovery complications of any neurosurgery, yet it offers a new horizon for those struggling with unnecessary or disruptive bouts of aggression.
(Ice-)Picking Away at the Stigma Surrounding Psychosurgery
From deep brain stimulation to the cingulotomy and the amygdalotomy, there is a long list of potentially revolutionary yet stigmatized psychosurgeries that offer great promise. In the future, research on psychosurgery should include more extensive clinical trials to improve surgical technique and increase response rates. It has been well established that these surgeries produce favorable results with minimal risk [6, 7]. Nevertheless, research on many of these procedures remains halted by an outdated fear of repeating the catastrophic lobotomy [4, 15]. However, as demonstrated, the cruelty and destruction essential to McMurphy’s horrifying demise bears no resemblance to present-day psychosurgeries. The medical community should continue to cautiously explore these procedures in order to make advances in psychiatric medicine. Exploring new psychosurgeries and perfecting those previously created is imperative if we wish to improve the lives of many people who currently find no hope in alternative treatments for their psychiatric disorders [18, 20].
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