Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Monday, September 12, 2011
Howard Dully's Lobotomy
If you're looking for a reason to hate psychiatry, I found it for you. I just finished reading My Lobotomy by Howard Dully. It's his memoir, focused around the event of a transorbital "ice pick" lobotomy which he underwent at the age of 12. Twelve. Oy.
Dully talks about his devastating childhood--- his mother died of cancer when he was five, and his father remarried to his evil step-mother. He spends a lot of time making the case that she was the problem and he was a normal kid. At the time of the lobotomy, he was going to school and had a paper route. He does describe himself as a kid who might have had behavior issues (for any one of many reasons). His step-mother seeks the advise of psychiatrists, and Dully says she was unhappy with the suggestions she got-- namely that she was the one with issues. Until she met Dr. Walter Freeman.
Dr. Freeman is credited with performing over 3,000 lobotomies. He traveled around the country in his own vehicle, which he dubbed the "lobotomobile" and performed transorbital lobotomies by inserting a sharp object through the eye sockets. No open surgery required. No anesthesia required (he used electroshock to render his patients unconscious).
In 1960, Howard Dully had a lobotomy. He had seen Dr. Freeman for 4 visits. He was diagnosed with schizophrenia and was offered no other form of treatment. No therapy, no medication, no hospitalization. He was told he would be undergoing testing and was not told about the lobotomy until after it was done.
It's a chilling read, one that still lingers with me days later, and the book was written after NPR did a story on Howard Dully. You can listen to that here:
Not one of psychiatry's finer moments.
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I'm not anti-psychiatry (as you know!), but I will say that psychiatry DEFINITELY has some questionable history. We read part of this book as part of my Narrative Ethics class in the spring, and it made me cry - I almost had to leave the room at one point as our teacher was reading from it aloud. I have since bought the book, but I haven't had time to read the entire thing. It's very, VERY moving - but warning, parts are quite upsetting. I'm glad to read his story - stories like this (and so many others) need to be told.
So do we think we've come all that far in 50 years? Before you answer, think how advanced we thought we were in 1960.
wv = devod; infelicitous name for child s/p transorbital frontal leucotomy
I am not anti psychiatry either, but I we still have enough children on drugs that alter their brain chemistry and have other physical side effects. Many of them do not need the drugs. Perhaps some do but as Rob points out, we probably have not come as far in 50 years as people would imagine.
Thanks for sharing this book... it sounds interesting but disturbing at the same time.
My new psychiatrist wants me to take clozapine, and I have to wonder if this is just lobotomy light. Destroy who the patient is in order to "save" her?
After reading about Nancy Andreasen's work showing that antipsychotics appear to shrink brain tissue, I don't think I could ever agree to yet another antipsychotic trial unless I was dangerous to other people.
Antipsychotics do their damage over many years, instead of in an instant, like a lobotomy.
My new doctor didn't trivialize the risks, though, which is a NEW thing for me as a patient. Other doctors played down the side effects and risks.
I do not want to be turned into a 400 lb. drooling freak who does nothing but watch TV (and go to the clinic for a weekly blood draw). I was already a TV watcher on Risperdal. However, I think that is preferable to a lobotomy.
I do think that someday, antipsychotics will be held as an example of evil psychiatry.
Rob, I was not here (or anywhere else for that matter) in 1960 to think about how far anyone had come. As the individual shrink, I'm just trying to the best I can given the constraints of what we've got. Plenty of room for improvement. Probably true in pediatrics as well.
The book was interesting but disturbing, as is the NPR audio.
Catlover...what can I say? The medicines are supposed to make things better....(and sometimes they do).
I'm glad I'm not a child psychiatrist.
The history of medical/obstetric/psychiatric and veterinary medicine, for that matter, are replete with stories that would twist your stomach. As the rigor and dissacociation of profit and results in scientific trials have decreased, medications and surgical procedures have increased in efficacy. Psychiatry and obstetrics have had obviously gruesome histories of blatant experimentation.
The cardiologist I took care of 12 years ago, dying of lung cancer, who had founded the cardiac catherization lab at Long Island Hospital, trusted me, trusted us to treat him for the lung cancer which I am certain he contracted while doing procedures to save patients' lives.
While many patients have suffered for the experimentation called "medicine" without their consent, until I entered the field and worked in current NIM trials, I would never have imagined the risk and sacrifice medicine requires of doctors and nurses. (Could it be, I wondered, that other humans were, like myself, really in this tgether?) Many bloggers have posted here--some MDs,in fact, a perspective that would imply that everyone is in this for themselves. I have never agreed with this idea of humanity.
Somewhere in the process of modern medicine I know there has been misogyny, racism, "normalization" and other forces of imperialism. But the only way forward at present as an intelligent patient is with the humor of Mark Twain. Sure he is a dead white guy, but he is the wisest, oldest American dead white guy you will ever laugh at. Sure the foundations are pure bog.
Please do no not forget that thalidamide was given given for nausea to pregnant women and the birth defects it caused or preplanned and executed Tuskeegee syphillis experiments on African-Americans men over 40 years between 1932 and 1972 in Alabama. None of these things had to do with psychiatric treatment Yet there were horrifying. The list goes much further. I won't go into how OBs discovered the need for handwashing that nurses had been doing for 50 years before.
Think about it. I assert the obvious: Humans' attempts to cure each other have always had mixed results. The more empowered the "doctor", the less subject to common sense the cures have been.
Some of us were not here in 1960 or 1965. I started prescribing after the advent of the Great Prozac!
I am not sure why we have to defend the olden days (though my last post was just that....) I am not an apologist for psychiatric history practice or, God forbid, for my second choice: current or historical practical practice of obstetrics.
I wasn't around in 1960 either, but others were, and they wrote books and journal articles about their experiences. I've read them.
As for pediatrics and the way we're going to be judged by future generations: When the history of this period is written, particularly if we continue to pay attention to harms, I believe we'll find that more children were harmed by physicians, particularly by psychiatrists, than were harmed during any previous period.
Chemical lobotomy is far more prevalent than the ice-pick version ever was, and the harms are greater.
I am actually shocked at your post (although it is really a comment on me that I continue to engage you at all). Until quite recently, children were thought to not have fully developed pain receptors as infants. When topical anesthetics were used, frequently physicians would not wait the 20 minutes for the anesthetic to work. They were put through surgical procedures with no age appropriate explanations of what was going to happen to them and with little concern for their pain afterward.
Treating children with psychiatric medications is a relatively new phenomenon of approximately 10 years duration--with the exception of stimulants for ADD.
I do not think you have done a thorough search of the literature regarding the psychological impacts of historical methods of hospitalization, surgery, and treatment of children. Your feelings about psychiatry blind you, doctor.
The lobotomobile? That he could be so casual and even facile about something so serious, well, I wonder if he had a disorder or illness, geez.
Who is blinded? You've missed both my points. The first is that is a mistake to assume that future generations are going to look upon us with anything less than the slack-jawed disbelief with which we regard the early days of pediatric anesthesia! The second is that it is a mistake to overlook the epidemic of over-treatment of all people, especially children.
Anesthesia is better, but our judgment as to who requires surgery has not improved. Look no farther than the tympanic myringotomy, currently the most common surgical procedure in the U.S. Longitudinal studies by Paradise, et. al. (from Pittsburgh) demonstrate that the procedure is largely unnecessary for the overwhelming majority. The adverse consequences of unnecessary procedures are only the tip of harms iceberg.
Now asked to believe that the lifetime risk of receiving a diagnosis of a mental illness 50% (Kessler, et. al, Arch Gen Psych 2005) and that half of these illnesses begin before age 14. You needn't hate psychiatry to be extremely skeptical of these numbers.
We are treating these diagnoses whose putative mechanisms we don't understand with drugs whose mechanism of action we cannot predict. You may choose to look the other way from the harm we're doing, but in so doing you'll appear even worse in the history books.
I've read many of your comments and your hatred for psychiatry is obvious. I wonder why you continue to comment here, since you don't seem to have changed anyone's mind with any of your rants. What do you gain with these harangues?
Dinah observed that Walter Freeman is a comment on "psychiatry" and feared that this will mobilize those that have it in for our profession. It certainly will and did, but it is not so. It is no more a comment on "psychiatry" than the Aristotelian solar system is a comment on astrophysics: "not among astronomy's greatest thousand years" certain members of the physics world would say, wisely shaking theIr heads.
The fact is that there is no perfect science, perfectly arrived at as if born like Athena out of Zeus's head, and there are certainly no practitioners of science who are not swayed by multitudinous factors both conscious and unconscious. It has been observed that if we want to know what will be found to be untrue among our beliefs we need only look at that which we think is most certain.
This is obvious to all of us; one, however, is certain that he perceives the truth and continuously reminds us of that. Enough already, please.
I do think Rob is right in that this time period will be judged quite harshly in years to come because so many people are medicated these days. But, I think there's plenty of blame to go around. Patients demand drugs and want the quick fix. Most doctors don't have the time to be a therapist, unless they are a psychiatrist and want to do psychotherapy. So lots of people who probably just needed a good therapist end up drugged. It is not all psychiatry's fault, but they'll get the blame for it. Some of the blame is warranted but not all.
Sara - the reason he writes with such frankness is actually *because* of the lobotomy. Shoving knitting needles into the brain and scrambling things up some has an entirely unpredictable effect on what areas will be hit or not. Dully appears not to have emotion at all - but yet you can find it if you analyze his words very closely.
If physicians, nurses, researchers and so on did not choose to step outside the bounds of established practices, a lot of us would have quality of lives that are significantly worse than where we are. I actually have a belief that, instead of only pushing people endlessly through therapy who will never stop living with chronic pain and illness - sometimes it's compassionate to give an antidepressant. I saw this with a patient with cancer that I was the student NP for - the mother kept explaining the antidepressant - there was no need - I would never judge that. It's really not my place to say they shouldn't take it in this and other circumstances - and in fact, I think there are times when people certainly should consider it.
While there are good arguments on both (or all) sides, I don't think it's healthy to be so extreme in either direction. It's easy to end up dismissing patients that way, and sometimes the harm of not treating can be just as big as the harm of treating. Just sayin'...
I agree, in psychiatry, we do worry about the harm of not treating.
I think it's unfair to look at medicines as "a quick fix" -- it sounds pejorative. It a patient is suffering from mental anguish and a medication relieves that anguish, I believe the patient should have the right to take the medicine, with the awareness that there may be side effects or that we may later discover that the medication has problems. It's not just psychiatry: look at Hormone Replacement Therapy and breast cancer, Vioxx and cardiac disease, Fosamax and osteonecrosis.
Rob, you've never given a child an antibiotic who maybe didn't have a bacterial infection? And what if that antibiotic (which might have been for an ear infection or a cough before a culture came back, or for a "presumed bacterial" infection, causes GI side effects, or a severe allergic reaction? I know, somehow psychiatry is different.
I have no doubt that we will look back one day and say "can you believe they did that back then.... lobotomies, insulin shock, leeches, surgery without anesthesia, thalidamide.
I continue to glad I'm not a child psychiatrist.
I guess I was under the mistaken impression that the performer of the lobotomies named his car that.
Hmmm,not sure who called it the lobotomobile. Per wikipedia (take it for what it's worth):
"Following his development of the icepick lobotomy, Freeman began traveling across the country visiting mental institutions in his personal van, which he called the "lobotomobile."[8"
Sorry Sara - I misunderstood!
Dinah - I agree about the potential harm of not treating in psychiatry - there are obvious reasons but many less obvious that impact quality of life, functioning, etc in more subtle ways. Outside of psychiatry, I cannot tell you how many CHILDREN have been dismissed with severe headaches because their mother must be nuts or they drink too many energy drinks. Sure, family situations and energy drinks and a whole host of other lifestyle issues can lead to a worsening of headaches and it is important to tackle these things, but to blow off seriously treating because of some of the reasons I've heard is absolutely absurd. If children get severe migraines, they can morph into chronic migraines by adulthood. If children are impaired in school because of severe headaches, they may decide against going to college. If they had aggressive treatment (even though the vast majority is off label and much of it has not yet been studied), then perhaps they'd have a shot at not ending up with lifelong severe headache issues.
In terms of adults - I've heard countless personal tales of people saying that Women Don't Get Cluster Headaches - this has been said by physicians so many times that on the cluster headache websites, we just abbreviate it to WDGCH... ;) When I first got them, I had already been suffering from New Daily Persistent Headache for almost 3 years. I was getting clusters every day at 5pm, 7pm, 9pm, 2am, 4am and they lasted 45-90 minutes. It was so awful to wake up in the throes of one that I'd stay up until the 4am one ended and then sleep for an hour or two before class. This was going on for at least a month or two when I saw my neurologist. I wasn't great at differentiating it from my regular NDPH in my description of it, but he blew me off, saying there was no reason to treat or abort these headaches. I was floored - absolutely devastated. I had gone so long on so little sleep - and these things are the most painful thing I've ever experienced. So I went back to school and kept up the pattern.
When I landed in the hospital over a month later, I described it again - he finally realized it might be cluster headache and had me try 15LPM of oxygen for about 15-20 min to abort - and voila - it helped! Then ramping up verapamil, frequently used for clusters, to high doses resulted in busting up the clockwork schedule. My story is more complicated than that, BUT - the point is, many people are harmed by not treating - plain and simple. Yes, there is overtreatment, but in some of these less common areas, undertreatment is much more of a problem.
I dunno, I think with things like depression the bigger problem is not lack of treatment. I think more often the problem is meds handed out too readily, but that's true of a lot of areas of medicine. I can have a bad day walk into a physician's office and come out with an antidepressant just by saying "I feel depressed." Not sure that's such a good thing.
Some of this is people looking for a quick fix to life stuff. I was not arguing that this is a universal truth. Of course sometimes meds are needed, but at this rate? I doubt it.
What we should probably focus on is the question of what, in our lifestyle and society, has made people so miserable? Because I think it's gotten worse and worse over time. People are overextended, exhausted, and the expectations keep getting higher.
I would venture a guess to say that people don't see psychiatrists (on their own - forget about the involuntary stuff for a minute) without feeling that something is wrong in the first place. I'm not even a fan of primary care docs treating migraines that require more than a monthly imitrex - and I also don't like the idea of them writing a script for an antidepressant unless they have a plan for how they are going to follow up, manage, etc or it's a specific circumstance, such as a divorce where the person hasn't been able to function, and then they can refer to a therapist.
People have choices - in the vast majority of cases, this is not forced upon them. Psychiatrists aren't just pushers - the more I listen, the more I hear of many of them that do therapy or treat in other ways besides just prescribing meds - and many of the ones I know well also believe that med use should be minimized and/or avoided if at all possible - and some of these are just finishing up training or recently did so.
All treatments have risks to some degree - I got avascular necrosis from repeated steroid doses to treat severe headaches. That sucks and resulted in another surgery (that has really pretty much fixed the problem!), but at the time, if somebody had told me there was a small risk of AVN, I would have taken the steroids anyway. Hindsight is always 20/20 when adverse events happen in those types of situations.
As one who obviously has been critical of psychiatry on this and other similar type blogs, the Walter Dully story has had nothing to do with my outrage. There are enough things going on currently in psychiatry to spark my anger.
By the way, during my time on withdrawal boards and other blogs that would be perceived as anti-psychiatry, I can't recall his story ever being mentioned. Again, people are too concerned with the present and how their lives are being effected.
I do agree with the previous commentators who feel that in many ways, things have not changed. Of course, lobotomies are no longer being performed.
But ECT is being done against people's will. Additionally, people continue to be treated with psych meds for life issues like grief and unemployment.
Someone I know who was the victim of spousal abuse was incredulously diagnosed with bipolar disorder. She was about as much BP as I am a millionaire.
At the same time, I do agree that psychiatry shouldn't be the only medical specialty singled out. Primary care doctors also wrongly prescribe alot of psych meds.
Additionally, many other drugs are way overprescribed that have dangerous side effects. Statins and the osteoporosis drugs are prime examples.
I do thank Dinah for posting this story. I was cringing big time when I even read snippets of this story so I won't be buying the book. But it is obviously a very important one.
"Rob, you've never given a child an antibiotic who maybe didn't have a bacterial infection? And what if that antibiotic (which might have been for an ear infection or a cough before a culture came back, or for a "presumed bacterial" infection, causes GI side effects, or a severe allergic reaction?"
Yes, yes, yes, and yes. All of these actions represented a violation of my oath to do no harm. What's your point?
I agree with you. I think that lobotomies are a straw man in the grand picture of what is at stake in contemporary psychiatric practice and ethics. However, I will say that Shrink Rap is truly unusual in medical "social media" in being willing to post articles that welcome open discussion of their own medical field's grim history on their blog.
It's not just psychiatry where we don't perfectly capture who should receive medication.
"Do no harm" may be a tough standard given the pressures and options we have today. If you send a kid out saying "it's likely a virus, and antibiotics have risks," and the child dies from their raging bacterial infection, then choosing not to treat was harmful. It's not that much different from choosing not to offer medications or therapy to someone who is suicidal and who then commits suicide.
The problem is that the Do No Harm dictate assumes that physicians have crystal balls.
Do no harm, is supposed to be a tough standard. Why should it be otherwise? Frankly, I'm astonished, Dinah, that you seem to suggest we abandon the standard. I sincerely hope that's not what you mean. And if if it's not, what do you mean?
wv = queen, in honor of Freddie Mercury (RIP) who would have been 65 last week
Sideways, thank you.
Rob, no I'm not suggesting abandoning the standard, I'm just saying that the issues are different then when it appeared in the Hippocratic Oath. We now offer many prophylactic treatments, and we're not that clear for any individual that they are helpful---- how many men do you think have been rendered surgically impotent based on diagnoses of prostate cancer that never would have turned into a virulent illness? How many people get chemotherapy that makes them horribly ill who would have felt better and lived longer without treatment? It's a great goal, but medicine is not living up to it, and given that we study treatments on populations, I'm not sure it's attainable. The autism discussion aside, even immunizations will cause troublesome reactions in some children, and how could you have known that you would cause harm? Maybe a standard of Do No Purposeful Harm? Oh, that sounds ridiculous. I have no answers, just to spur the conversation.
"First, do no harm."
Let's take a look at that again. On the surface, it seems like a black or white paradigm. Either you harm (v.) or you help (v.). However, we overlook the beginning: "first". In essence, there is an implicit triage command there.
Second, there are degrees of risk and benefit to every action and decision, even when that is to "do nothing" - e.g. watchful waiting, whatever the heck that means. (Who's doing the watching? Who is doing the waiting? How do we know when the period is completed?)
Rather than an absolutist, do zero harm, edict, I perceive that the triage, then act to produce the least harm with the most benefit might be closer to the optimal. For it's certain that we don't live in the ideal.
I'm appreciative of the historical look back of this point, because reflection of our hindsight, our persistent inability to see beyond our own timeline horizon, and our disgust and horror when we realize what harms were inflicted, are all important. They cause learning to take place, they allow for a collective conscience to place boundaries around ethics and actions, and they move the science and practice forward.
We can spin wheels in condemnation, or we can use the knowledge, insight, emotional reactions and wisdom gained to improve out lot.
A little like I'd envision helpful therapy to be... (grin)
PS: For more shudders, catch some of the coverage of the physicians and scientists who participated in the STI experiments on the Guatemalans and US prisoners using prostitutes as vehicles of delivery in some cases. The researcher who uncovered this, Susan Reverby, is a nursing researcher now ensconced at Wellesley. I've been enamored of her work since my long ago undergraduate nursing school days.
Beautifully said, aek. Rather than plead guilty to spinning the wheels of condemnation, I prefer to plead guilty to standing still athwart history yelling "STOP!"
wv = dendmine; archaic noun, contraction of "dead-end mine", as in the history of the search for biological substrates of mental illness.
Not to split hairs, and frankly it really doesn't matter, but "First, Do no harm" did not actually come from the Hippocratic Oath... There is a translation of another work by Hippocrates that most likely alludes to it, but it does not have the word "first" - it is translated as "to do good or to do no harm". :)
I think it should be in the minds of all who practice in health care (ALL - though many times things that nurses view as harms are very VERY different than what physicians believe) - but it doesn't come from the original translation of the Hippocratic Oath. ;)
Bioethics trivia...I know these days most physicians seem to hate bioethicists as well, for whatever reason. That is, except for those physicians who actually become bioethicists.
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