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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.

August 04, 2003|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.

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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:

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