The New York Times today carries a story about a resurgence of interest in psychosurgery for severe obsessive-compulsive disorder. The article notes that while some patients benefit, there is considerable risk and less than stellar success in these operations.
There are several important points to note, which the Times does not cover and which I do in my book OBSESSION: A HISTORY (just published in paperback by the U. of Chicago Press). First is that OCD, while a real disorder, has major cultural and social elements that cannot be addressed by brain surgery. For example, one of the patients in the newspaper article, who is called "Leonard" to protect his identity, is described as "not unhappy" with his life. We have to recall that some of the behaviors in OCD are culturally dependent and while inappropriate in one culture or historical period might well be accepted in another. There are also people with obsessive and compulsive behaviors who are contented with their own behaviors but whose partners, parents, or friends find the behavior problematic. And many others with the disorder puzzled by their own behaviors and worry that they are "going crazy." Both those concerns are very much dependent on the cultural milleu and the judgment of people around. While ethics panels are in place to determine whether a person should have psychosurgery or not, these panels don't take into account the larger issues surrounding the establishment of this illness.
The second important point is to question whether OCD is actually a disorder. While it is clearly one in our culture at this time, it wasn't in other times and places. In my book I show the relatively complex way that OCD was formed as an illness, and I point out that it was extremely rare in the 1960's and is now the fourth most common mental disorder. How did it get that meteoric rise if the argument is that it is simply a brain disorder? If it is a cultural-brain interaction, then we might be able to explain its unbelievable increase in prevalence. And we of course cannot discount the effect of big pharma in pushing Prozac like drugs as miracle cures for a disorder that was always described as extremely hard to treat. Actually the initial euphoria over SSRI's has waned, and psychosurgery seems to be the next great hope.
A third point is that the brain is a fantastically complex organ with trillions of synaptic connections and uncountable neural networks. Applying a knife or proton beam to a chunk of the brain is like using a sledgehammer on a computer. You may get a result and you may not, but you are operating on a topographic model when the way the brain works is far more like the Internet than it is like a broken carburator. But currently surgery is the only method we have, and doctors, faced with patient frustration and suffering, are reaching for it. But let us remember that the great psychosurgery debacle of the past--the Columbia-Greystone Project of the late 1940's and early 1950's looked promising at first.
We have to worry when psychiatrists are reaching into their slim bag of cures and coming up with electro-shock and psychosurgery, assuring us that the mistakes of the past are distant errors. More complex mapping of the brain now is useful, but the blunt instrument of psychosurgery is not the happiest match to our current advanced imaging technologies. And just because the psycho surgeons tell us that 60 per cent of their patients show significant improvement, we need to question how accurate these numbers are, and what "significant improvement" means. There is always an initial optimism and euphoria by those who initiate new (or seemingly new) "cures" in psychiatry.
