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Psychosurgery, also called neurosurgery for mental disorder ( NMD), is the neurosurgery of mental disorders. Psychosurgery has always been a controversial medical field. The modern history of psychosurgery begins in the 1880s under the Swiss psychiatrist Gottlieb Burckhardt. The first significant foray into psychosurgery in the 20th century was conducted by the Portuguese neurologist Egas Moniz who, during the mid-1930s, developed the operation known as leucotomy. The practice was enthusiastically taken up in the United States by the Neuropsychiatry Walter Freeman and the Neurosurgery James W. Watts who devised what became the standard prefrontal procedure and named their operative technique lobotomy, although the operation was called leucotomy in the United Kingdom. In spite of the award of the Nobel Prize to Moniz in 1949, the use of psychosurgery declined during the 1950s. By the 1970s the standard Freeman-Watts type of operation was very rare, but other forms of psychosurgery, although used on a much smaller scale, survived. Some countries have abandoned psychosurgery altogether; in others, for example the US and the UK, it is only used in a few centres on small numbers of people with depression or obsessive-compulsive disorder (OCD).Neurosurgery working group 2000 Neurosurgery for mental disorder. London: Royal College of Psychiatrists In some countries it is also used in the treatment of schizophrenia and other disorders.N. Zamiska 2007 In China, brain surgery is pushed on the mentally ill. Wall Street Journal, 2 November
Psychosurgery is a collaboration between psychiatrists and neurosurgeons. During the operation, which is carried out under a general anaesthetic and using stereotactic methods, a small piece of Human brain is destroyed or removed. The most common types of psychosurgery in current or recent use are anterior capsulotomy, cingulotomy, subcaudate tractotomy and limbic leucotomy. Lesions are made by radiation, thermo-coagulation, freezing or cutting. About a third of patients show significant improvement in their symptoms after operation. Advances in surgical technique have greatly reduced the incidence of death and serious damage from psychosurgery; the remaining risks include seizures, incontinence, decreased drive and initiative, weight gain, and Cognition and affective problems.
Currently, interest in the neurosurgical treatment of mental illness is shifting from Ablation psychosurgery (where the aim is to destroy brain tissue) to deep brain stimulation (DBS) where the aim is to stimulate areas of the brain with implanted .
Anterior cingulotomy was first used by Hugh Cairns in the UK, and developed in the US by H.T. Ballantine Jr. In recent decades it has been the most commonly used psychosurgical procedure in the US. The target site is the anterior cingulate cortex; the operation disconnects the thalamic and posterior frontal regions and damages the anterior cingulate region.
Anterior capsulotomy was developed in Sweden, where it became the most frequently used procedure. It is also used in Scotland and Canada. The aim of the operation is to disconnect the orbitofrontal cortex and thalamic nuclei by inducing a lesion in the anterior limb of internal capsule.
Subcaudate tractotomy was the most commonly used form of psychosurgery in the UK from the 1960s to the 1990s. It targets the lower medial quadrant of the frontal lobes, severing connections between the limbic system and supra-orbital part of the frontal lobe.
Limbic leucotomy is a combination of subcaudate tractotomy and anterior cingulotomy. It was used at Atkinson Morley Hospital London in the 1990s and also at Massachusetts General Hospital.
Amygdalotomy, which targets the amygdala, was developed as a treatment for aggression by Hideki Narabayashi in 1961 and is still used occasionally, for example at the Medical College of Georgia.
There is debate about whether deep brain stimulation (DBS) should be classed as a form of psychosurgery.
Modern techniques have greatly reduced the risks of psychosurgery, although risks of adverse effects still remain. Whilst the risk of death or vascular injury has become extremely small, there remains a risk of seizures, fatigue, and personality changes following operation.
A 2012 follow-up study of eight depressed patients who underwent anterior capsulotomy in Vancouver, Canada, classified five of them as responders at two to three years after surgery. Results on neuropsychological testing were unchanged or improved, although there were isolated deficits and one patient was left with long-term frontal psychobehavioral changes and fatigue. One patient, aged 75, was left mute and Hypokinesia for a month following surgery and then developed dementia.
Psychosurgery is also used in the treatment of schizophrenia, depression, and other mental disorders. One patient diagnosed with schizophrenia underwent as many as 10 surgeries, without effect on the condition but leaving him with a partially limp right arm and slurred speech. The use of psychosurgery in China has been criticised in the West.
According to the Wall Street Journal, psychosurgery for drug addiction is banned in China since 2004, but other forms of the surgery were not as of 2007. Science reports that psychosurgery was only allowed for refractory OCD, depression, and brain disorders since 2008, and that neurosurgeons were pushing to reverse the ban in 2011.
The ban appears to have been lifted for schizophrenia some time before 2017, when People's Daily Online reposted an article about psychosurgery for schizophrenia in Shanghai from Xinmin Evening News. In 2024, Chinese scholars published the Chinese Expert Consensus on Surgical Treatment of Mental Illnesses (2024), with intervention method and targets and evidence/recommendation levels listed for several conditions.
In France about five people a year were undergoing psychosurgery in the early 1980s. In 2005 the Health Authority recommended the use of ablative psychosurgery and DBS for OCD.
In the early 2000s in Spain about 24 psychosurgical operations (capsulotomy, cingulotomy, subcaudate tractotomy, and hypothalamotomy) a year were being performed. OCD was the most common diagnosis, but psychosurgery was also being used in the treatment of anxiety and schizophrenia, and other disorders.
In the UK between the late 1990s and 2009 there were just two centres using psychosurgery: a few stereotactic anterior capsulotomies are performed every year at the University Hospital of Wales, Cardiff, while anterior cingulotomies are carried out by the Advanced Interventions Service at Ninewells Hospital, Dundee. The patients have diagnoses of depression, obsessive-compulsive disorder, and anxiety. Ablative psychosurgery was not performed in England between the late 1990s and 2009, although a couple of hospitals have been experimenting with DBS. In 2010, Frenchay Hospital in Bristol performed an anterior cingulotomy on a woman who had previously undergone DBS.
In Russia in 1998 the Institute of the Human Brain (Russian Academy of Sciences) started a programme of stereotactic cingulotomy for the treatment of drug addiction. About 85 people, all under the age of 35, were operated on annually. In the Soviet Union, leucotomies were used for the treatment of schizophrenia in the 1940s, but the practice was prohibited by the Ministry of Health in 1950.
In Mexico, psychosurgery is used in the treatment of anorexia and aggression.
In Canada, anterior capsulotomies are used in the treatment of depression and OCD.
In the US, psychosurgery was taken up and zealously promoted by neurologist Walter Freeman and neurosurgeon James Watts. They started a psychosurgery program at George Washington University in 1936, first using Moniz's method but then devised a method of their own in which the connections between the prefrontal lobes and deeper structures in the brain were severed by making a sweeping cut through a burr hole on either side of the skull. They called their new operation a lobotomy.
Freeman went on to develop a new form of lobotomy which could be dispensed without the need for a neurosurgeon. He hammered an ice pick-like instrument, an orbitoclast, through the eye socket and swept through the frontal lobes. The transorbital or "ice pick" lobotomy was done under local anesthesia or using electroconvulsive therapy to render the patient unconscious and could be performed in mental hospitals lacking surgical facilities. Such was Freeman's zeal that he began to travel around the nation in his own personal van, which he called his "lobotomobile", demonstrating the procedure in psychiatric hospitals. Freeman's patients included 19 children, one of whom was 4 years old.
The 1940s saw a rapid expansion of psychosurgery, in spite of the fact that it involved a significant risk of death and severe personality changes. By the end of the decade, up to 5000 psychosurgical operations were being carried out annually in the US. In 1949, Moniz was awarded the Nobel Prize for Physiology or Medicine.
Beginning in the 1940s various new techniques were designed in the hope of reducing the adverse effects of the operation. These techniques included William Beecher Scoville's orbital undercutting, Jean Talairach's anterior capsulotomy, and Hugh Cairn's bilateral cingulotomy. Stereotactic techniques made it possible to place more accurately, and experiments were done with alternatives to cutting instruments such as radiation. Psychosurgery nevertheless went into rapid decline in the 1950s, due to the introduction of new drugs and a growing awareness of the long-term damage caused by the operations, as well as doubts about its efficacy. By the 1970s, the standard or transorbital lobotomy had been replaced with other forms of psychosurgical operations.
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