Psychosurgery: A Scientific Analysis PDF
Preview Psychosurgery: A Scientific Analysis
PSYCHOSURGERY To Maty and To William Morrison Carroll PSYCHOSURGERY A Scientific Analysis Mark A. J. O'Callaghan BA, BSc, MSc Clinical Psychologist, Department of Psychology, University of Birmingham District Psychology Services, Department of Psychology, Hollymoor Hospital, Birmingham, England and Douglas Carroll BSc, PhD Lecturer in Psychology, Department of Psychology, University of Birmingham, Birmingham, England :-.,.--( ~ tj MT PRESS LIMITED International Medical Publishers Published by MTP Press Limited Falcon House Lancaster, England British Library Cataloguing in Publication Data O'Callaghan, Mark A. J. Psychosurgery. I. Psychosurgery I. Title II. Carroll, Douglas 617' .481 RD594 ISBN-13: 978-94-010-9705-5 e-ISBN-13: 978-94-010-9703-1 DOl: 10.1007/ 978-94-010-9703-1 Copyright © 1982 M. A. J. O'Callaghan and D. Carroll Softcover reprint of the hardcover 1st edition 1982 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the publishers. Filmset by Northumberland Press Ltd, Gateshead Contents Acknowledgements VB Introduction IX 1 Historical introduction 2 Operative techniques 17 3 Quantitative evaluation of operative procedures 39 4 Patient populations undergoing psychosurgery 69 5 Adverse sequelae 95 6 Accuracy of operative techniques 117 7 Design and assessment of psychosurgical studies 127 8 Theoretical basis of psychosurgery 195 9 Ethical implications of psychosurgery 219 10 The regulation of psychosurgery 237 11 Sociopolitical aspects 255 12 Summary and conclusions 277 Bibliography 291 Author index 317 Subject index 325 Acknowledgements It has taken us over three years to complete this book. The variety and com plexity of the issues surrounding psychosurgery have simply defied a hasty analysis. However, we hope that our time and energies have been well spent and that the product is both reasonable and readable. Over the three years a host of people have, either wittingly or unwittingly, lent their assistance, support and even encouragement. At the risk of giving offence, we have had to be selective; a complete list of credits would run into several pages. First of all, we owe much to our colleagues and friends in the Departments of Psychology at the University of Birmingham and Hollymoor Hospital; we can envisage few better working environments. Second, we are deeply indebted to the various libraries at the University of Birmingham (the Barnes Medical Library, the Education Library, the Main Library and the Inter-Library Loan Service) and their unerringly helpful librarians; this debt extends also to the British Lending Library and the other libraries both in Britain and elsewhere that have contributed through the Inter-Library Loan Service. Third, a legion of typists have laboured pains takingly on our manuscript through the various stages of its development; they include Jill Bolton, Marie Chalmers, Shaheen Chowdrey, Sue Garvey, Barbara Hudson, Beverley Humphries, Lesley Leigh, Halina O'Callaghan and Edna Stanley. Fourth, illustrations are the careful work of Edward and Maureen Fellows of the Department of Physical Metallurgy, University of Birmingham. Fifth, we would like to acknowledge Dr. B. Barraclough for A" V111 ACKNOWLEDGEMENTS quotations from the Report of the Royal College of Psychiatrists' Research Committee (1977). Sixth, we would like to thank special friends for their tolerance, patience and indulgence over the past three years. These most important people are Anne, Christopher and Liam Carroll, Gail and Mike Phillips, Ioanna Nicolaidou, Helen Smith, and Matthew O'Callaghan. Finally, while each of us assumed initial responsibility for individual chapters (M. o'c. undertook Chapters 1-7, D. C. Chapters 8-12), our close collaboration throughout, and the various, and at times drastic, revisions undertaken ensured that all chapters represent an integration of our thinking and a product of our joint industry. Our ultimate contributions to the book, then, were for all intents and purposes equal, and the order of authorship reflects only the initial division of labour. Introduction Of all the therapies that comprise psychiatric practice, the use of brain surgery to modify behaviour is the most contentious. That such behavioural neuro surgery, or psychosurgery, provokes opposition is far from surprising. The paramount status of the brain seems to belie mechanical intervention. The irreversible nature of the intervention seems to aggravate the outrage. Thus, opponents of the practice contend that psychosurgical procedures constitute a grievous assault on the integrity of the personality. Its proponents, on the other hand, confidently testify that it is a valid and efficacious form of treat ment for many seemingly intractable psychiatric disorders. Argument and counterargument have pursued the practice since its initial upsurge in the 1940s, although the decline in its popularity in the 1960s occasioned a tem porary cease-fire. However, the recent resurgence of psychosurgery has ensured that it is once again a matter of controversy. In the United Kingdom the characteristically subdued tenor of the debate frequently obscures the popularity of the practice and the commitment of its opposition. A recent application by the Royal College of Psychiatrists to the Medical Research Council for funds to mount a large controlled trial of psychosurgical procedures was turned down. Several opposition lobbyists might claim some credit for the proposal's lack of success. The Schizophrenia Association of Great Bri tain clearly and publicly expressed their disapproval of the trial. The Patient's Protection Law Committee presented Parliament with a petition condemning the Royal College's submission. The most x INTRODUCTION significant opposition activity to date in the United Kingdom was the for mulation of a bill, for presentation before the House of Commons, to curtail psychosurgical operations, sponsored by Joyce Butler (1977). The bill, formally titled the Medical Experimentation Act, sought to: protect patients and others from being subjected to medical experiments upon them without their consent; and to prohibit experiments in the case of certain other persons, and to provide for penalties; and for purposes connected therewith. (p. 1) In the United States similar legislative restraints have been sought. Dr. Peter Breggin's (1972) presentation to the Congressional Record, The Return of Lobotomy and Psychosurgery, was seen by many as a milestone in this campaign. Generally, the American debate has been much more public than its British counterpart. The fray has not been confined mainly within the pages of academic outlets. More readily accessible presentation of the arguments has ensured a sensitized American public. While the opponents of psychosurgery are united in their primary aim, diverse rationales underlie this opposition. Distinct critical approaches can be discerned. Some, like Dr. Breggin, view psychosurgery as merely the most salient example of the many ideologically oppressive procedures that charac terize present psychiatric practice. Such opinion has attracted the label "anti psychiatry." Others are more circumscribed in their opposition: the efficacy and validity of psychosurgery is what they specifically challenge. In fact, representatives of this approach contend that the antipsychiatrists jeopardize the opposition case by relying on emotive description and polemic rather than on scientific objectivity and careful scholarship. Certainly, the proponents of psychosurgery possess little regard for the antipsychiatric lobby. As Mark and Ordia (1976) exemplified: Antipsychiatrists have not advanced scientifically valid arguments against the neurosurgical treatment of patients with abnormal aggres sion; most of the members of the movement are not board-certified in clinical neurology or neurosurgery. Their lack of information about the brain, coupled with the unfortunate results of their own campaign against the diagnosis and treatment of mentally ill patients, has dis qualified them as credible critics. (p. 728) Indeed, the contributions of both opponents and advocates of psychosurgery frequently offer little in the way of objective and scientific analyses. Clearly, only by avoiding the tempting pitfalls of subjectivity and polemic can any evaluation of psychosurgery acquire sufficient status to seriously influence the debate. So much of it at present is characterized by misrepresentation, misunderstanding and downright ignorance. Even the boundaries of the activities subsumed by the term "psycho surgery" do not attract a consensus. Mark and Ordia argued that psycho- INTRODUCTION xi surgery has become "a catchword intended to stir up emotions and produce irrational and harmful obstruction in the path of patients seeking treatment" (p. 725). For present purposes we shall abide by the definition given by Alan A. Stone (1975), Professor of Psychiatry and Law at Harvard University, in the Massachusetts Task Force Report on psychosurgery. Stone defined psychosurgery as: . .. any procedure which, by direct or indirect access to the brain, removes or destroys or interrupts the continuity of the brain tissue that is histologically normal (i.e. tissue that is normal as seen under a micro scope, though its physiological functions or properties might obviously be abnormal) for the purpose of altering behavior or treating a psychiatric illness. We include as psychosurgery the implantation of electrodes for either of these purposes, even without subsequent electro coagulation. We do not include neurosurgical procedures designed to diagnose or treat intractable physical pain or epilepsy where these conditions are clearly demoristrable. Nor do we include any other neurosurgical procedures used to diagnose or treat organic brain con ditions even though such procedures may also involve destruction of normal brain tissue. (pp. 27-28) Stone's definition is adopted because it is clear and precise and because it proved acceptable to all shades of opinion represented by the Task Force. However, it must be conceded that some outsiders would not accept Stone's exclusions. The use of surgery for the treatment of intractable pain, epilepsy and Parkinsonism has been designated as neurosurgery by some but included under the rubric of psychosurgery by others. Finally, it is important to note that it is not the techniques and physiological foci of surgical exercises per se which qualify them as examples of psychosurgery. The same procedures and foci characterize neurosurgery. It is the explicit intention of the surgery to promote behavioural change that is crucial. Psychosurgery, then, is brain surgery conducted explicitly to amend specific aspects of human behaviour. The success, scientific validity and social implications of such an enterprise comprise the subject of this book. The opening chapter traces the historical precursors of psychosurgery and charts the major landmarks in its more recent development. Chapter 2 describes the technical aspects of psychosurgery. Details of the common and more esoteric operative procedures are provided; the operative methods and brain areas of surgical interest are discussed. The next five chapters offer a detailed review of evidence relating to the efficacy of psychosurgical procedures. Chapter 3 provides a quantitative over view of the pertinent experimental and case studies. For the reader's con venience, the results of the various operative procedures are organized in tables. In Chapters 4-7, these studies receive critical scrutiny. Chapter 4 considers the make up of the populations selected for psychosurgical inter-
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