Wednesday, March 13, 2013
Simplistic thinking may be attractive if you happen to be in one specific discipline, but I think that it rarely provides either the results that are sought or the research breakthroughs that are touted about in professional journals. Although the heyday of psychosurgery was probably sometime during the 50s and 60s, when it was alleged several extremely wealthy and prominent individuals had lobotomies, it seems to be having somewhat of a resurgence. Invasive procedures to the rescue!Lobotomies, as you may know, were crude attempts at surgical assaults on the frontal lobes of the brain to change behavior quickly and permanently. The man who was the maven of lobotomy was a Dr. Freeman who apparently frantically traveled around the country wielding a golden ice pick in a velvet case; this was his sole surgical instrument. Freeman was incredibly busy and, from what I have read, did not bother himself with extensive workups of patients, instead just going on from procedure to procedure to procedure. In my professional career I have only come across one patient in a hospital who had had a lobotomy to put an end to her rather violent and aggressive behavior. Did it do that? No, because she continued to threaten people and could not be placed in even the simplest job in the community. She spent the remainder of her life as a person with a severe seizure disorder in a supervised setting.Surgery was seen as the answer to much of mental illness even from the time when Freud nearly destroyed a woman's nose in the belief that the nerve found there was causing her to be hypersexual in activity related to herself. Yes, I am being a bit delicate here. Other surgeons removed people's, or should I say women's, uteruses and pulled all of their teeth in the belief that both of these were causing mental illness.It sounds quite barbaric, but it was a bit better than what they had been doing previously which was to lock people up in containers until they "came to their senses." Read some of the books by Dr. Thomas Szasz who did a great job on the history of psychiatric treatment.I've seen some of this in one now-closed psychiatric hospital where people were put into "quiet rooms" until they calmed down. Some of these people had food withheld from them to facilitate this calming. Others, who became more worked up, tried to kill themselves by leaping from the small windowsill and aiming their heads at the ceramic floors. They did not succeed but did have quite serious injuries as a result. The practice went on.Patients with psychiatric disorders were chained to the walls, pounded with something that looks like a fire department hose (I believe these are similar to the Scotch shower used in some spas) or were placed in tubs filled with ice water that would then be tightly covered on top with a canvas so that only their heads poked out. Think "Snake Pit" here. There's quite an interesting correlation here between this treatment and why people die in the snow in the woods when they get lost. The freezing cold causes them to become sleepy and tired and they sit or lie down and die. So, placing patients in a freezing tub of ice cube-filled water may have a calming effect for a brief period of time, but it certainly is a punishment more than a treatment.Several psychiatric disorders currently classified in the manual known as the DSM (Diagnostic and Statistical Manual) are particularly resistant to a number of therapies. When I use the word resistent what I mean is that the treatments are really not effective or insufficiently effective because simplistic reasoning seems to be in use here. One pill or three pills together probably do not address the disorder because it is much more complex than anyone knows right now.Just as we know that cancer may have a number of not only different forms, but be caused by a number of different viruses including who knows how many numbers of genes all acting in concert, it doesn't work. Patients who suffer greatly from these disorders will try desperately for any relief and anyone who offers a glimmer of hope will be to whom they will go. It's the same as it is with the cancer patients.Now we are hearing about a number of intrusive measures aimed at alleviating the symptoms of these disorders by either putting electrodes into the brain (of people with anorexia) or something like a pacemaker. It would seem that electricity is regaining a prominent role in this area. We know that ECT (electroconvulsive shock therapy) is being used on an outpatient basis and, for some, it seems to work. But it is not a cure all. The body and in particular the brain is still highly mysterious and it will not give up its secrets easily.A few years ago there was a belief, and it may still be active in the medical community, that the vagal nerve that runs down the center of the body in the area of the abdomen, was actively involved in producing treatment resistant depression. If, somehow, this nerve would be brought under control, then perhaps depression could be lifted in patients who were receiving no benefits from antidepressant medications. The FDA approved the device in 1997 for epilepsy and then researchers tried it for depression.A specially designed nerve stimulator was placed in the abdomen of patients and it was believed that this was a breakthrough in depression treatment. Still used in some of the most famous psychiatric clinics in the United States, the VNS (Vagal Nerve Stimulator) has had somewhat mixed results on at least one (and possibly more) trial where some patients had their stimulators turned on and others didn't. Reports indicate that half of the patients, whether or not they had their stimulator turned on, improved. Sounds like the placebo effect to me.The technology, which I understand would be extremely difficult to remove, is going to be tried on patients with anxiety, Alzheimer's, tinnitus, migraines and fibromyalgia. It's almost as though they are hoping it will work well for something if not more than one thing. I remain a bit skeptical.Technology can be a lifesaver and there is no doubt about that. But my concern is that, without a true understanding of the sum total of the underlying mechanics, and I use that word advisedly, of a disorder, it's as though they are persons walking in the dark and hoping to find the light switch.Psychiatric disorders are dreadful and cause people enormous pain and it is this pain which will lead them to try almost anything. Again, comparing it to cancer, I remember the case of the famous actor Steve McQueen who, after he developed cancer, went to Mexico for an experimental treatment with Laetrile. Reports of his condition revealed that he, as many others, had been duped and he died in Mexico refusing to allow anyone to see him in his debilitated state. Desperation is the parent that provides hope where no hope exists. Once again, I remind people of that famous phrase we use whenever you are going to go shopping for something; caveat emptor, let the buyer beware. It doesn't matter if someone or someplace tells you that they have had remarkable success and that their success rate is two or three times that of others. We've seen too many times that people cherry pick their statistics for their patients so that they can use these types of promotional techniques to get new patients. Unfortunately, medicine is a business and, like any business, it needs to always look at the bottom line.
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