PHYSICAL CONTROL OF THE MIND Toward a Psychocivilized Society Jose M. R. Delgado, M.D. © 1969 Human Pleasure Evoked by ESB (Electrical Stimulation of the Brain)   On the basis of many studies during cerebral surgery, Penfield has said of anger, joy, pleasure, and sexual excitement in the human brain that "so far as our experience goes, neither localized epileptic discharge nor electrical stimulation is capable of awaking any such emotion. One is tempted to believe that there are no specific cortical mechanisms associated with these emotions." This statement still holds true for the cerebral cortex, but studies in human subjects with implanted electrodes have demonstrated that electrical stimulation of the depth of the brain can induce pleasurable manifestations, as evidenced by the spontaneous verbal reports of patients, their facial expression and general behavior, and their desire to repeat the experience. In a group of twenty-three patients suffering from schizophrenia, electrical stimulation of the septal region, located deep in the frontal lobes, produced an enhancement of alertness sometimes accompanied by an increase in verbal output, euphoria, or pleasure. In a more systematic study in another group of patients, further evidence was presented of the rewarding effects of septal stimulation. One man suffering from narclolepsia was provided with a small stimulator and a built-in counter which recorded the number of times that he voluntarily stimulated each of several selected points in his brain during a period of seventeen weeks. The highest score was recorded from one point in the septal region, and the patient that pushing this particular button made him feel "good" as if he were building up to a sexual orgasm, although he was not able to reach the end point and often felt impatient and anxious. His narcolepsia was greatly relieved by pressing this "septal button." Another patient, with psychomotor epilepsy also enjoyed septal self-stimulation, which again had the highest rate of button pressing and often induced sexual thoughts. Activation of the septal region by direct injection of acetylcholine produced local electrical changes in two epileptic patients and a shift in mood from disphoria to contentment and euphoria, usually with concomitant sexual motivation and some "orgastic sensations."   Further information was provided by another group of sixty-five patients suffering from schizophrenia or Parkinson's disease, in whom a total of 643 contacts were implanted, mainly in the anterior part of the brain. Results of ESB were grouped as follows: 360 points were "Positive I," and with stimulation "the patients became relaxed, at ease, had a feeling of well-being, and/or were a little sleepy." Another 31 points were "Positive II," and "the patients were definitely changed...in a good mood, felt good. They were relaxed, at ease, and enjoyed themselves, frequently smiling. There was a slight euphoria, but the behavior was adequate." They sometimes wanted more stimulations. Excitation of another eight points evoked behavior classified as "Positive III," when "euphoria was definitely beyond normal limits. The patients laughed out loud, enjoyed themselves, and positively liked the stimulation, and wanted more." ESB of another 38 points gave ambivalent results, and the patients expressed occassional pleasure or displeasure following excitation of the same area. From three other points, responses were termed "orgasm" because the patients initially expressed enjoyment and then were completely satisfied and did not want any more stimulation for a variable period of time. Finally, from about two hundred points, ESB produced unpleasant reactions including anxiety, sadness, depression, fear, and emotional outbursts. One of the moving pictures taken in this study was very demonstrative, showing a patient with a sad expression and slightly depressed mood who smiled when a brief stimulation was applied to the rostral part of the brain, returning quickly to his usual depressed state, to smile again as soon as stimulation was reapplied. Then a ten-second stimulation completely changed his behavior and facial expression into a lasting pleasant and happy mood. Some mental patients have been provided with portable stimulators which they have used in self-treatment of depressive states with apparent clinical success.   These results indicate the need for careful functional exploration during brain surgery in order to avoid excessive euphoria or depression when positive or negative reinforcing areas are damaged. Emotional instability, in which the subject bursts suddenly into tears or laughter without apparent reason, has been observed following some neurosurgical interventions. These major behavior problems might have been avoided by sparing the region involved in emotional regulation.   In our own experience, pleasurable sensations were observed in three patients with psychomotor epilepsy. The first case was V.P., a 36-year-old female with a long history of epileptic attacks which could not be controlled by medication. Electrodes were implanted in her right temporal lobe and upon stimulation of a contact located in the superior part about thirty millimeters below the surface, the patient reported a pleasant tingling sensation in the left side of her body "from my face down to the bottom of my legs." She started giggling and making funny comments, stating that she enjoyed the sensation "very much." Repetition of these stimulations made the patient more communicative and flirtatious, and she ended by openly expressing her desire to marry the therapist. Stimulation of other cerebral points failed to modify her mood and indicated the specificity of the evoked effect. During control interviews before and after ESB, her behavior was quite proper, without familiarity or excessive friendliness.   The second patient was J.M., an attractive, cooperative, and intelligent 30-year-old female who had suffered for eleven years from psychomotor and grand mal attacks which resisted medical therapy. Electrodes were implanted in her right temporal lobe, and stimulation of one of the points in the amygdala induced a pleasant sensation of relaxation and considerably increased her verbal output, which took on a more intimate character. This patient openly expressed her fondness for the therapist (who was new to her), kissed his hands, and talked about her immense gratitude for what was being done for her. A similar increase in verbal and emotional expression was repeated when the same point was stimulated on a different day, but it did not appear when other areas of the brain were explored. During the control situations the patient was rather reserved and poised.   The third case was A.F., an 11-year-old boy with severe psychomotor epilepsy. Six days after electrode implantation in both temporal lobes, his fourth tape-recorded interview was carried out while electrical activity of the brain was continuously recorded and 5-second stimulations were applied in a prearranged sequence at intervals of about four minutes. The interviewer maintained an air of friendly interest throughout, usually without intiating conversation. After six other excitations, point LP located on the surface of the left temporal lobe was stimulated for the first time, and there was an open and precipitous declaration of pleasure. The patient had been silent for the previous five-minute interval, but immediately after this stimulation he exclaimed, "Hey! You can keep me here longer when you give me these; I like those." He went on to insist that the ongoing brain tests made him feel good. Similar statements with an emphatic expression of "feeling good" followed eight of a total sixteen stimulations of this point during the ninety-minute interview. Several of these manifestations were accompanied by a statement of fondness for the male interviewer, and the last one was accompanied by a voluptuous stretch. None of these manifestations appeared during the twenty-two minutes when other points were excited. Statistical analysis of the difference between the frequency of pleasurable expressions before and after onset of stimulations proved that results were highly significant (P<0.001).   The open expressions of pleasure in this interview and the general passivity of behavior could be linked, more or less intuitively, to feminine strivings. It was therefore remarkable that in the next interview, performed in a similar manner, the patient's expressions of confusion about his own sexual identity again appeared following stimulation of point LP. He suddenly began to discuss the desire to get married, but when asked, "To whom?" he did not immediately reply. Following stimulation of another point and a one-minute, twenty-second silence, thepatient said, "I was thinking - there's - I was saying this to you. How to spell 'yes' - y-e-s . I mean y-o-s. No! 'You' ain't y-e-o . It's this. Y-o-u." The topic was then completely dropped. The monitor who was listening from the next room interpreted this as a thinly veiled wish to marry the interviewer, and it was decided to stimulate the same site again after the prearranged schedulehad been completed. During the following forty minutes, seven other points were stimulated, and the patient spoke about several topics of a completely different and unrelated content. Then LP was stimulated again, and the patient started making references to the facial hair of the interviewer and continued by mentioning pubic hair and his having been the object of genital sex play in the past. He then expressed doubt about his sexual identity, saying, "I was thinkin' if I was a boy or a girl -- which one I'd like to be." Following another excitation he remarked with evident pleasure: "You're doin' it now," and then he said, "I'd like to be a girl."