Treatment Options for Obsessive-Compulsive Disorder

The Role of Neurosurgery in Obsessive-Compulsive Disorder

Currently, neurosurgery is a treatment of last resort for obsessive-compulsive disorder (OCD) and is considered as an option for patients with severe, debilitating OCD who have failed to respond to other cognitive-behavioral therapy and drug therapy. The rationale for using neurosurgery as a treatment for OCD is based upon observations from brain imaging studies that have found an association between obsessions and compulsions and dysfunction of circuits or pathways in certain areas of the brain. The goal of neurosurgery is to alter the activity of these dysfunctional brain circuits and, thereby, reduce or eliminate the obsessions and compulsions.

In general, there are two types of neurosurgical procedures that are being investigated at medical centers around the world for the treatment of severe, intractable OCD:

• Destructive procedures
• Non-destructive procedures

Destructive Procedures

This approach involves surgically severing (cutting) and destroying connections between dysfunctional brain circuits or pathways at specific areas of the brain in hopes of establishing new connections that "by-pass" the dysfunctional brain circuits that are thought to be responsible for obsessions and compulsions. Examples of destructive neurosurgical procedures that are being investigated for the treatment of OCD include:

• Subcaudate tractotomy
• Limbic leucotomy
• Anterior cingulotomy
• Anterior capsulotomy

Nondestructive Neurosurgical Procedures

This approach involves the use of either electrical stimulation or magnetic stimulation to alter the electrical activity at specific regions of the brain in an attempt to better control the symptoms of OCD. Examples of nondestructive neurosurgical procedures that are being investigated for the treatment of OCD include:

• Deep brain stimulation
• Transcranial magnetic stimulation

Limitations of Neurosurgical Procedures

It should be noted that the various neurosurgical procedures that are being used at various medical centers worldwide for the treatment of severe, refractory OCD are still in the early stages of development and are, therefore, considered as experimental. Patients with OCD who are considering neurosurgery as a treatment option should be aware of the following limitations of these procedures:

• Only a small number of patients with OCD worldwide have undergone one or more of these neurosurgical procedures and, therefore, strong evidence supporting the effectiveness of these procedures is currently lacking.

• Currently, neurosurgeons do not have an accurate way to identify subsets of OCD patients who may benefit from neurosurgery and those who will not benefit from this type of surgery.

• Currently, there is a lack of randomized, controlled clinical trials showing that these neurosurgical procedures are effective for the treatment of OCD and, therefore, these treatments are still considered as being experimental.

• Because neurosurgery for OCD is still in its infancy stages of development and is still evolving, few neurosurgeons worldwide have gained a significant amount of experience with these neurosurgical procedures.

Despite these limitations, however, studies involving small numbers of patients appear to be promising with about 50% of patients with severe, debilitating OCD experiencing an improvement in symptoms. Patients who are considering neurosurgery as a treatment option for OCD should carefully question their neurosurgeon about the risks and benefits of this treatment modality so that they will be in a better position to make an informed decision regarding the management of their OCD.