Prefrontal lobotomy and hypofrontality in patients with schizophrenia: an integration of the findings

A transnational perspective on psychosurgery: beyond Portugal and the United States

The history of psychosurgery is most often recounted as a narrative wherein Portuguese and American physicians play the leading role. It is a traditional narrative in which the United States and, at times, Portugal are central in the development and spread of psychosurgery. Here we largely abandon the archetypal narrative and provide one of the first transnational accounts of psychosurgery to demonstrate the existence of a global psychosurgical community in which more than 40 countries participated, bolstered, critiqued, modified and heralded the treatment. From its inception in 1935 until its decline in the mid-1960s, psychosurgery was performed on almost all continents. Rather than being a phenomenon isolated to the United States and Portugal, it became a truly transnational movement.

Psychosurgery for schizophrenia: history and perspectives

Following the early studies of Moniz and Lima, psychosurgery had considerable scientific credibility until the advent of modern antipsychotics in the mid 1950s. Thereafter, psychosurgery was almost abandoned in large medical centers as a common treatment for schizophrenia, although is still used for some affective and anxiety disorders. We reviewed relevant papers cited in the Medline/Index Medicus, Cochrane, and Scielo databases from 1930 to 2012. In our review of the literature, we show from recent studies that there are still many patients with schizophrenia who have serious deficits even after being treated with current noninvasive therapies. The value of psychosurgery remains controversial. There are no data available to support the use of stereotactic procedures for schizophrenia. Well designed controlled trials are needed to establish the effectiveness of psychosurgery in patients with schizophrenia.

Regional cerebral glucose metabolism in never-medicated patients with schizophrenia

OBJECTIVE

The purpose of this study was to assess regional cerebral glucose metabolism in patients with schizophrenia who had never received antipsychotic medication and whose olfactory identification ability had been assessed. Two hypotheses were examined. First, the patients were compared with normal controls to determine whether differences in regional cerebral metabolism were apparent. Second, regional rates of metabolism were correlated with olfactory ability and the relation between them determined.

METHODS

The patient (n = 26) and control (n = 32) subjects were scanned at rest using positron emission tomography (PET) after administration of 18F-fluorodeoxyglucose (FDG). In addition, the University of Pennsylvania Smell Identification Test was administered to each patient.

RESULTS

Patients with schizophrenia had reduced rates of glucose metabolism in the right and left thalamus that reached significance if not corrected for multiple comparisons. However, if a Bonferroni correction was applied over the 27 regions of interest, the differences were not significant. Scores on the Smell Identification Test were negatively correlated with 8 regions of interest. When scores were analyzed using multiple regression, the left frontal cortex and the medial parietal cortex were significant predictors.

CONCLUSIONS

The finding of reduced metabolism in the thalami is consistent with some of the previous literature, whereas the negative correlations between specific regions and olfactory function are not consistent with studies using activation paradigms.

An autopsy case of the schizophrenic 32 years after lobotomy

An autopsy case is reported here of a 69-year-old patient with schizophrenia, who was known retrospectively to have had a prefrontal lobotomy 32 years previously. The patient was diagnosed as schizophrenic at the age of 24 and the lobotomy was undertaken 13 years later. The patient was recently found outside in a dehydrated condition and admitted to a general hospital, where he died of respiratory failure. Bilateral cystic lesions were found in the deep white matter of the frontal lobe. The cyst walls consisted of glial fibrous tissues, and severe demyelination with axonal destruction was diffusely observed in the white matter of the frontal lobe. In the thinner frontal cortex without arcuate fibers (U fibers) close to the cavities, cytoarchitectural abnormalities were observed. In the thalamic nuclei marked retrograde degeneration and astrocytic gliosis were observed. The detailed neuropathological findings of a lobotomized schizophrenic brain are reported here. It is proposed that one should be reminded of a lobotomized brain if bilateral cysts are found.

The role of psychosurgery in the treatment of selected cases of refractory schizophrenia: a reappraisal

Prefrontal lobotomy (i.e. leukotomy) was widely performed for the treatment of schizophrenia during the late 1930s and 1940s but met with growing disrepute after the introduction of effective antipsychotic agents in the early 1950s. While non-invasive methods of treatment are undeniably preferable to somatic interventions for the management of psychiatric illnesses, there nevertheless continues to be a valid role for leukotomy in the treatment of patients with severe, chronic, refractory schizophrenia, particularly when the patient poses a risk to himself and/or to society. The present article traces the history of leukotomy in the treatment of schizophrenia, and reviews the author's experience with this surgical procedure in 16 patients who fulfilled the above criteria and underwent leukotomy during the years spanning 1985 1996. This operation reduced aggression and/or produced marked to slight improvement in all patients, and in no case led to adverse consequences. Thus, leukotomy is recommended as a legitimate treatment modality in selected patients with schizophrenia.