DENIAL OF LOBOTOMYAS A CONTINUATIONOF THE DEFENSE

MECHANISM OF DENIAL IN SCHIZOPHRENICS

BY A. E. PAGANINI, M.D., AND M. ZL(~TLOW, 1Vf.D.

Although the fact th~at many lobetomized lmtients deny the

operation has been mentioned by ~a.riou.s oh,servers, n~o ,system-
atized study of the phenomenon of the denial of lobotomy ~and its
relationship to ~he use of the p,syahologictal mechanism o~ denial
ha,s ever been made.
The corffusiorra~ ,state which e~:~s~tsimmediately postoperatively
co.ns.ists not..on,ly ,of a de,algal o.f the Ol~.e,ratio~a, .but also o,f many
sen.,so~rial defeots ~such .a,s memory i~r~pairment, vari,ou~s degrees of
diso.rientation, red~pli,cation, eon~i~abu]~ati:on, paraph, asic lan~guage
and .confusion. Blot, many years after the immediate po.sto~pera-
tire .confu,sionM state clears, there reanains the denim .of 1,obo.tomy
in a number of l~obotomized patien, ts.
Some observers have fe~t. that this .denial o,f operation, that
remains even 'after signs of anatom,ieal brain .damage di,sa.ppear,
is but a continuing manife,s~tation o,f the neurological damage
nee:essarfly involved .in the operative p,roee.dare. Perhaps, thi,s
fee,ling h,as been influerrced by a particu~,ar f~rm o~f denial ,a.ss~oc~i-
ated with b,rain damage and called anosogno,s.~a.
This te,rm, introduced by Bah in,ski~ in 1914, originally pertained
to the derrial o~ the paralysis vchic~h occurs in ,some hemiplegics;
but the con cep* has been ealarged to include the denial of blind-
nes,s, the denial o,f other illnes,ses, and the denial of the exis:tence
of a pal~t (~f the body as well.
Nathan, son, Be rganan and Gordon ~ refer to this pheno,menon
simply as denial otf illae,s,s. Its etiol,o,gy has been vai'io~usly de-
,s~cribed ,as ,due to "fron~tal lesior~s," "parietal lesions," "th,a~amic
lesion,s," inte~rrupfion o,f frontottra~mnie pat~way,s o,r "~istur~bance
in the body ,scheme,." E,arly ,studie,s ,at:tribut:ed this den~al to, organic
defects. Later, ho~vever, the dynamic ,aspect of the phenomenon
came in ~or more eon,siderat~on. Thu.s Sehilder sugge,sted the
tervn "o,rganic repression," signifying an exclu,sion of unpleasant
bodily defects or funetion,s froln con,scio~s:ne,s,s. Goldstein, on the
other hand, ,s~howed ~ano,sogno,sia to be a type of ~ad,aptation to a
defect and not a pheno,menon created by brain damage.
 A. E. I~AC~A:NINI~ M.D.~ AND IVf. ZLOTLO%Vt M.D. 261

VCeinstein and K,mhn,3 in a review ,~f more than 50 year~s o~ study

of the problem off denial o~f illnes,s, state:
"Our findings indicate that the various forms o,f anosognosia
are not discrete entities that can be localized in different areas o,f
the b~ain .... " " U n d e r the requisite conditions of brain function,
the patient m a y deny the p aralys~s (~f a n a r m whether it results
from a h'~acture, a n i n j u r y to the brac'lfial plext~s, a brain stem o~r
c~rt~cal lesion. The effect of the brain d a m a g e is to provide the
milieu o,f ,a~tered function in which the pat4ent m a y deny anyth~ing
that he feels i,s wrong with h i m . . .
"Our problems ,are re~ated to ,s~o,meof the p ro,blems o,f p r e f r o n t a l
l(~b,otomy. This procedure when p e r f o r m e d bilaterra],ly evidentily
creates a milieu ef brain fune,tion sufficient for the, existence o~
.ano,sognosia." T,hese: authorrs state that the denial ~o~fillness .as
u,sed by these loat4e~ts i,s rela.ted, net to differently looa,ted brain
lesion~s, b~t to "features in the p,re~mo,r,bid per s,onali,ty." H o,w-
ever, F r e e m a n and W,a tts ~ devote considerable attention to the
p,henomenon of denial o.f l obotomy and c~onclude t h a t the meah,an-
is m is "prob,~bly ne~ro,]~ogiea~'."
Stengel, 3 in a ,study 'o~ 324 patienqt,s, ~ e n t i o n s the: presence o,f
denial o.f .operati~on in 51 patients, but :gives no indic,at:ion (~f the
existenc:e o.f the p.sycholo,gical mechanisnl of denial before the:
o.per,ation.
Fr,ank ~ ,als.o obse~rves the deni.al o,f .opera,tion, but .again wit~hot~t
oorre,lation with the patients' lorevious use of denial as a defense
mechanism. Legault ' ascri,bes the, symptom o~ denial in post-
1,obotomy patients to "complex processes representing psyohologi-
cal defensive o.perations .as we~l as ,an at~o~i.cal d a r m g e . "
F o r the sake o~ clarity, Lau,~hlin's ,definition s .o~ the me~h~anism
o,f den,ial i,s used here by the ,author,s :
"Denial has been defined ,as ,an unco.nsci~us inenial .meeimaism
employed to res,o.lve emo,ti,on,al conflicts and ,allay consequent anx-
iety by co nsciou, sly disowning one af the i m p o r t a n t elements o,f
the confliot. T~he presence o,f a thought, wish or deed m a y ,be
denied, or the e(mflicting standards, p,ro,hibitions or consequences
m a y be denied. Denial is one o,f ,the rsimplest and moist priufitive
kinds o,f eg~o defenses."
Th~s mevh~ani,s~ o,f denial is used by ehildren, by so-ca~]ed nor-
reals, and by neuro,t~cs and it is extensively used by c,hronic schizo-
phrenics. The ,authors are particularly concerned here with the
262 DENIAL OF LOBOTOMY IN SCXtIZOPI-IRENICS

systematized study o,f the phenomenon of the denial of l~botomy

and its relations`hip to the defense mechanism of denial, espe-
cially as used by chronic sehiz,op`hrenics.

METHODS AND MATERIAL

One hundred frg,ty u~seleeted rome postlobo,tomy patients were
studied at Pilgrim (N.Y.) State Hio,spital. All o,f these patients
had been institu~on'alized for ~a,t ,lceast 10 years and all `had diag-
noses o.f schiz,oplirenic reaction. Most of these t~tients were h,os-
pitalized at leas,t five years before iobotomy wus performed, and
most o,f thegn were lobotomized at le,ast five years ago ,at Pilgrim
State Hospital by the ,same neuro-surgeon using the same olas.sieal
teahnique. All were lobotomized because they eonstitated severe
management p~oblems, were assaultive, restless, aggressive and
destructive before .operation. With a few exceptions, none of them
had ever been considered well enough for release f r o m the ,hospital,
and those few ex,ceptions returned to the hospital within a year
after release on convalescent s:tatus.
All of the 150 p,atien~ts were ir~terviewed repeatedly by the
au~thol~s ~o determine whether ,at present they denied the lob,o,t-
omy, used other terms (rf denial, or whether their use o,f .denial
was "questi,onalble." In add~ti,on, the hospital records o~f ,all these
patients were carefully ~studied to determine if these patients had
also used the meehani~s,m of denial ,before operation. Many o~ these
eases were well kntown to. one ,o,f the authm, s before oloeration.

I~ESULTS
Of the 150 patients, 99 (66 per cent) deny their lobotomies at
present; 30 ~p,atients (20 per cent) do not deny them; ,and 21
p,atients (16 per cent) "questi~onably" deny them.
T`he 99 patient,s who deny their operati~Irs do, ,s,o ~ather em-
phati,eally. 'When the sears o~ the burr ~ol_e,s are poin~e,d oat t~
them, they offer ,M1 so,r.~s .of rati,(~nalization,s to ex.pl~in their pres-
e:~se: "I waLs in a restraint sheet o.nee ,and .someone hit me in
the head." "They are just marks; the7 don't mea.n an:fthing."
"I~'s ;a bone like that." "I have a ~onn, al head." "Tbe7 c,ame by
themselves." "I go~t bturrp,s from sleeping in the dormitory." "Sud-
denly, I ~fourrd tyro, .dents. ,I didn't ~have ,any ope.ras "They
cu~ o~t piece,s (~f my head to deaden the microbes o,f my head,
 A. E. PAGA~INI~ M.D.~ AND ~[. ZLOTLOW~ M.D. 263

but t h e y did n,ot oper~mte on my brain." "I m u s t h.ave fell on my

head."
So,he patients also use displ, acement, saying t h a t the brains ,o,f
o,ther patien~ts on the vcard were o,perated on beeause the patients
w e r e "crazy," but delay the o~)eraiion fo,r them se'l~es. ~ e t , m a n y
o,f these s,a~e patients hawing ,o,ther oper~ai~ive s oa.r~s, such :as frown
hernio,rrhaphy and ,appendec,~omy, :do not deny the presence o~
these sva~s ,o,r 'the reason~s for t h e ~ .
Some of these p,atients explicitly d e n y ,any opera~tion "on my
head o r m y brain." O ecasion,Mly, when s,oCne patients ,are speeifi-
cMly t(/ld that they have h.ad lo~bot,o,mies, that a lo.bolomy means
a a operatio,n on the .b~ain and th~a~ the svars o,r depression, s in
the, skull indicJate a lopbotonly, they apparer~tly aece,pt the sta'te-
ment o.nly t,o deny the o~pe.r}ati,on again ra few hour~s later.
All o!f th,ose 99 pa~tients ~also used o,ther for~n,s ,o.f den~,al. Some
denied :float they were sexuaJl devi,ants, ,o,r that they w e r e recently
invo,lve,d ~n ,a~tercation:s, o.r t,hat they at one time ~ada~itted having
h~Mlucinati,ons. All denied th~at they a r e o r ever w e r e mentally
in.
W h e n a p,atien~t was so regressed that .an adequate interview
wlas i~npo,ssible, o.r vchen the, denial ,co.~d po,ssibly be :attributed
to a man6festati~o.n o,f nega,tivis,m, he was pla,eed with ~.be "qnestion-
~able" gi~o,up. There was ,a Lo~al otf 21 such patier~ts.
The 30 patients wh,o a d m i t having :had lo.botomies ,seem ito under-
stmtd, ~and be fully aw,are, t h a t ,a l obo~omy ane,an~s ~an o,per:ation
o,n the brain.
Of @e 99 p~tier~t:s wh~o use the denial of loboto~ny, 81 p~tients
(82 per cent o~f ~this group) used t~e mechanism ,o,f .den~ial in t h e i r
illne~sses before the operation. T.birteen patients did not use the
mechan~sal o,f deni,al in their illnesses before operation, yet deny
their 1.o.boton~ies at present. F i v e p~atients "qaes~tior~ably" used
'the nmcha:nis~n (d denial hero.re operation, ,and deny their ~o~)era-
tions at present. Of the 30 patients who ~&nit h a v i n g had 1,obot-
o mies, 24 (80 p e r cen~t) did not use the mechanism of de ni~al in
their illnesses before the opera~tio.n.
Two pa/dents who ad~ni~t to their 1,(~botomies at present used the
mech~anism of den~al in their i~l~nesses her,ore oper~ation.
F~o~r patients v~ho ,admit to their l o,botomies at present, "ques-
tio,n~ably" used the mecl~aais~n o,f deni,al in the6r illnesses before
oper,ation.
264 D E I ~ I A L OF L O B O T O M u II~ S C H I Z O P H R E N I C S

Represdentative C;ase Reports

J. O. This 48-year-(~ld, whi~e, single man was ad~nitted to Pil-
grim State Ho,spital, May 25, 1938, with a hi,storF of ooml~lain~s
o.f p~a~n in his pelvis and "some trouble" with his p eni~s because
he had developed the "clap/' ~ h e n he had had ~sexua] relations
with a female. After admis,sio,n, file p~atient beca~ne i.mpul~sively
~ssaultive, re,s,tles~s, distu1~bed, had to be in a lmo~st ~oon~stant re-
straint, and w,as .a ~severe management problem. The p~atient als~o
p articip,ated in mastarbatory prac~tices and in active and pafssive
feltatio, tIowever, the pat~ient denied any deviant rsex~al practices,
den~ed theft .he ~a,s ass~aul,tive and denied that he vc~s men,tally
ill. Despite symptomatic ECtT, he oon,tinued ~o be asJs,aultive, de-
structive arid dep,ressed.
He was ]obotomized on October 3, 1949. Following" ~ i s , hiLs be-
havior in~pr~oved so,me,hat. He ooc~sionally beoame ~mpul~sively
assaultive b~t ~ot to the e~tent that ,he was before t.he ~o~eration.
However, he remained cLo~r~pletely hallucinated ~a.nd continued to
regres~s, despfte his ~continued participation in o.coupational ther-
apy a~ativities. In Jantm.ry 1956, the patien, t was started ~o~ c~lor-
p~romazine and ha,s rem,ained on this drug until the preset.t, with
oontirmed behavioral impr.ovement.
At presen,t, J:. O. particip,ates actiwely in interview situations.
He states that he was origin,ally b ro~g~l~t to the ho~spit~l because
he h,ad s~ome tro.~ble with hSs penis and th,a,t he felt he needed ~n
operation oll his peni,s to rid him of a disease v~h~ah he h~d
acquired in ~sexua] rel.ations with a worn,an. The p~tient r,ather
vividly goes into detail describing the events whiah ~occarred im-
mediately be~.ore his prefrontal to~botomy but denied h~s well-
documented sexually deviant ~behavior bef,ore ,o,per~a~ion. W h e n
ques,tioned .specifioally ~bout his lo~boto~ny, the patient state.s, "No,
I didn't h~ave ,any operation. I w~as ju~s~t,sent to Building 25 to get
a shave and haircut and to. have my pi~ct~re taken. They kept me
there for ~b,out five days ,and then they ~sent .me back." W~en asked
to p~alp~ate the bony defeots ,of the operation, the p,atieat states,
"I don't know what this ~s."
The patient a~so denies .his t m m o - a n d auto-erotic ,activity, whioh
is still g:o~ng on at present.
Obviously, ~ i s patien~t used the me~han~ism o~ denial before
o,peration and s,till uses this meohan~sm today.
 A. E. l~AGANINIt M.D.~ AND 1VL ZLOTLOW~ M.D. 265

H. H. This 39-year-o}d, white, single nmle was admitted to Pil-

grim State HospitM on October 29, 1947 on transfer from a private
psychiatric hospital ~to which he had been admitted in 1944 and
from vr he had never been released. On ~admiss.ion to Pil.grim,
he vcas extremely restless, a.gdt~ted, ,actively hallucinated and ~a~s-
s anttive. H e ,admitted i nce,ss,ant vr and feelings :o~firldtability
and stated, "I'm ~s:ick. I'm avcfuJly sick- ~getting too mt~eh o,f ~that.
I'm eonfu~sed--~ma~stu~bation h~d done it." He a~n~t~ted h~av~ng
h~al,lucin.ations b~ut could nolt ~adequately describe t:hem. H e w,as
treated with E C T and insulin shock with n~o c~ange in his con-
dition. H e remained impul~sive]y as,saul~tive and mastm'~bated open-
l y on the ward. He was lobotamized ,on J u l y 13, 1948; but his
cond~t~o~ remained es,sentiMly the s~me. He was over,active,
noisy, confu:sed, i,m,pulsively .assaultive, and halh]cinated; and h e
continued ,to .mastu~r,bate open']y. Nevertheless, the patient admi,t-
ted th~at he was operated on ~or a "lobotomy :and they to,ok five-
s ixt~h,s af my br,aln a ~ a y because I was mentally sick." He was
p~taced on cMorpr,omazine in J a n u a r y 1956 and h~as been con-
r on the d r a g since that time. At present, the patient freely
and frankly admits that he ha:s h~d ,an ,operation on his br~ain,
thas he mastu~b.~tes, tlmt he has had, and is having, a "nervou,s
breal~do,wn" ~and that ~ e operation was p e r f o r m e d on his brain
in o~rder to, ,cure hi,s mental illness. Ho,wever, the patient rem,ain:s
actively hMl,ucirm~ted and .severely regre~ssed. Obvio.u.sly, t,his pa-
tient never used the mechanism o~f denim before operation and
does not uFse iJt today.
Co~EN~
F r o m the data p,resented, it is :evident that the deni,al of lobot-
.pray is fairly c o ~ m o n - - 6 6 per kent o,f the: patier~ts in thins study
show r phen,o.menon. In thi,s group .of patients .the denial i.s .com-
plete a~d emphatic. Also. tlmse patients not only ,deny ~he,ir lo-
bo.tomie,s b~s ,al,so ,deny ,o~.er h4g~hlye~o.ti.onally da~arged :or ".afflect-
laden" ma~tte.rs.
When, during int.ervie~v:s, these p~atients .are asked to. touch their
scar~s, or to I)alpate their skull depressions with their o~r hands,
and coneom~nitantaly and repeatedly are tom that Ni~s indica.tes
an ope,ra~tion on tlmir brain:s, they emphatically ~and po.sitively
deny thi.s. Repetitive eff~orts to convince .a patient o.f his o,per,a-
tion are met with persistent denial.s; .s,ome patients even accuse
the e.)mminex :o~ lying. At the same time, these very .same patients
266 D E N I A L OF LOBOT01V[Y I N S C t t I Z O P I - I R E N I C S

also deny that they were reeentib- involved in well-do.emnented

altereations o.r wel]-do,cu~mented sexual deviations. They also eate-
go rieally deny th.at they ,axe ment,ally ill or were ever m.entally
ill. These pratients al,s'o de~lonstr;ate ~a "belle indifference" which
can als,o be described a,s .euphoria. In the presence of this super-
fi~ial e~phorba., the p,atients show a tendency to avoid talking ~bout
the operation, bat if ~the examiner persists and "boxes in" the
patient, the obvio~Ls physie,al and emotional aspeets o.f anxiety
develop--such as sweating, flushing, irritability, distractibility,
qu~ave,ring o,f the voi~e, ~a.nd, finally in some, even tourism. T~h.is
manifes.tation o.f anxiety and 'the obvious use o,f the meehanis,m
o,f denial to cope with tlfis anxiety constitute the .corner,stones of
these p~atients' defense ,mechanisms.
In ~a re c~ent study, the authors have al,so found that ~obotomy
does not ~hange t~he pattern o.f sexual loehavior ~h~eh existed prior
to oper,ation in the majo.rity o,f eases. The present study .seems
to show that lob,otomy does not change the use of the b.asie de,lense
Ineehanism ,o~ denial which existed prior to operation.
Thins 5~s borne out by the finding that 80 per cent o,f the patient,s
who deny lohot~my, used the mechanism o.f denial before oper~a-
tio,n. Thi,s meehani.sm ,o,f denial hero.re operation took tIhe form
o,f the denial o,f many highly emotionally-charged t'h~oughts, wishes,
desires, events or snbjeets; ,and in the denial o,f illness per se.
Thi,s "sin~plest and amst primitive kind o~f ego defen:se" is also
u.sed to. a gr.eat degree in ma.ny ehr~oni.e nonlob.o.tomized s,ohiz~o-
phrenies.
It, therefo,re, appears unten:~ble that the denial of lo~bo,to,my
is merely ~a aenroto,g~.eal phenomenon, due to the 4aalaged brain
o~f the patient. The findings ,of this study seem t,o explain, then,
the existence ,o~fthe denial of operation in postlobo4:omy palient~s
as an extension, continuation or further n~anifest~ation o~ t~he basic
mee~m.ni,s.m o~ denial used by the patient in his severe mental ill-
ness. It ,seems thM denial, having proved useful to these patients
in their need to tolerate signs and symptoms of illn:ess, may
ene:ourag~e ~he further nmintenanee of such an attitude in the form
o~f a mee.hanism of denial.
Although ttfis s,tudy deals with hospit, alized patients, t~hi~sdenial
,of lobbotomy a,nd the use o,f t3m mechanism ,o,f denial pre-~aa,d post-
,opera,tively has been ,observed in p,atient,s who haxe been released
 A, Eo PAGAIqI~I~ M.Do~ AND ~r ZLOTLOW~ •oD. 267

from tile ho~spital beeau.se o,f imp~ro.vement in mental +tatu,s. An

.analy~sis of th:i's gr:ol~p o,f patien.ts awaits further study.
In ,a vol~ateral an,alysis .o,f 150 lo.ng-hospita~ized, nonl~bo.to~mized
~c,hr~nic schiz,olo~hrenicbsit was ,a]s~o. f~und that o.ver 70 per cent
.o~f these patients u:sed t~le mechanism o~ ,denial in .one f o r ~ v.r
.another. This finding seems to lend weight to the .con.c:ept thlat
the meehanism o,f denial i.s peeu.liar t,o the complex proces.s .of
.s~hizo.phrenia r~ather ~ a n to s.o.me an,at,omi=cal dam~age o.f the b,rain.
Finally, the .a.ss~ump.tion o,ften made, that the "per~sona]ity
.eha~ges" in brain-injured people +are .due to. un,atom~ea~ deficit or
attempts to. compe.ns~ate fo.r it, is (~pen to grave d~oubt.. A thorough
kn.o~wledge o.f the pre~o.sbi.d perso~ality is .a prerequ~bsite to the
con61~sio.n tsha,t ~a per,sona~lity chan~ge is the re..sult o,f a dmn,aged
brain.
CO~CL~JSiO~S
1. T'he irLcidence .o~ deni~a] o.f 1,o,bo.tomy in 150 male institution-
alized p,o,stlobotomy patients is 66 per cent.
2. Of these patients who deny their l(~bo4o.mies, 82 per cent used
the psyc~h.olo,gical mechanism o,f denial hero.re opesa.tio.n.
3. Of the patients who. do not deny their to,boto~nies at present,
80 per cent did n.ot ~se t~he meehqanism .of .denial in their' illnes,ses
before operation.
4. The deni.al o~f .operation in p.o~stloboto.my p,atients a.p~.e~ars to
be a .cor~tin.uat~,on o.f i~h.eb,asic p,sy~h,ol(~gJ~al ,nle~hanism o.f den~,al
used by the se~ ~same pa.tients before, .o.peratio,n. I t would ,see~q~th,at,
s~inee .deni~al proved usefu~ to. these patients in enabling them to.
tolerate sign,s and sympto+ms of illnes.s, they may have been en-
coar~aged to. ~ain.tain their .attitude further by ,settin,g ~p ~a ~nec.'h-
an~sm of .denial.
This. meeh~anism .o.f denial ~s we~l kn(~wn to be extensively used
by p s y ~ o t i e s .

Pilgrim State Ho=spital

West Brentwood, N. Y.
,and
Middletown State Hos,pital
Monhagen Avenue
Middletown, N. Y.
268 DENIAL OF LOBOTOM_Y I N SCHIZOPI:IREI~ICS

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