Hostname: page-component-745bb68f8f-d8cs5 Total loading time: 0 Render date: 2025-01-20T17:22:32.891Z Has data issue: false hasContentIssue false
  • English
  • Français

Neurosurgical Approaches to Intractable Obsessive-Compulsive Disorder

Published online by Cambridge University Press:  07 November 2014

Steven Rasmussen ,
Benjamin Greenberg ,
Per Mindus ,
Gerhard Friehs  and
George Noren
Get access Rights & Permissions [Opens in a new window]

Abstract

Although significant progress has been made over the last decade in the treatment of obsessive-compulsive disorder (OCD), approximately 20% of OCD patients remain refractory to nonsurgical therapies, including pharmacologic and cognitive-behavioral therapy. Because a number of neural circuits involving the basal ganglia, thalamus, limbic system, and frontal lobes have been implicated in the pathophysiology of OCD, the need for an effective intervention in these patients has brought the focus on surgical approaches, including cingulotomy and capsulotomy procedures. Unlike free-hand surgical approaches used in the past, current neurosurgical interventions have been greatly enhanced by advances in technology, which allow lesioning to an accuracy of 1 mm. Today's neurosurgical approaches have shown significant benefit in as many as 60% of refractory patients, while preserving personality and cognitive functioning and limiting morbidity. A study of gamma knife capsulotomy conducted at Brown University School of Medicine showed that 40% of patients undergoing two lesioning procedures were much or very much improved 2 years postsurgery. The inherent obstacles to conducting placebo-controlled studies in these severely ill patients mean that further study is required to identify optimal candidates for surgical intervention.

Type
Feature Article
Information
CNS Spectrums , Volume 5 , Issue 11: Surgery for Psychiatric Disorders: Part Two , November 2000 , pp. 23 - 34
Copyright
Copyright © Cambridge University Press 2000

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1.Rasmussen, SA, Eisen, JL. The epidemiology and clinical features of OCD. Psychiatr Clin North Am. 1992;15:743–758.CrossRefGoogle Scholar
2.Rasmussen, SA, Eisen, JL. The epidemiology and clinical features of obsessive compulsive disorder. In: Jenike, MA, Baer, L, Minichiello, WE, eds. Obsessive Compulsive Disorders: Practical Management. St Louis, Mo: Mosby; 1998:12–43.Google Scholar
3.WHO Report. The Global Burden of Disease. Murray, ECJ, Lopez, AD, eds. Cambridge, Mass: Harvard University Press; 1998.Google Scholar
4.Dupont, R, Rice, D, Shiraki, S, et al.The economic burden of obsessive compulsive disorder. Pharmacoeconomics Medical Interface. 1995;8:102–109.Google Scholar
5.Rasmussen, SA, Eisen, JL. Treatment strategies for chronic and refractory OCD. J Clin Psychiatry. 1997;58(suppl 3):9–13.Google Scholar
6.Eisen, JL, Goodman, WK, Keller, MB, et al.Patterns of remission and relapse in obsessive compulsive disorder: a 2-year prospective study. J Clin Pyschiatry. 1999;60:346–351.CrossRefGoogle ScholarPubMed
7.Baer, L, Minichiello, WE. Behavior therapy for obsessive compulsive disorder. In: Jenike, MA, Baer, L, Minichiello, WE, eds. Obsessive Compulsive Disorders: Practical Management. St Louis, Mo: Mosby; 1998:337–368.Google Scholar
8.March, JS, Carpenter, D, Kahn, DA. Treatment of obsessive compulsive disorder. J Clin Psychiatry. 1997;58(suppl):1–28.Google Scholar
9.Hassler, R, Dieckman, G. Relief of obsessive compulsive disorders, phobias and tics by stereotactic coagulation of the rostral intra-laminar and medial-thalamic nuclei. In: Laitinen, LV, Livingston, KE, eds. Surgical Approaches in Psychiatry. Baltimore, Md: University Park Press; 1973:206–212.Google Scholar
10.Corsellis, J, Jack, AB. Neuropathological observations on yttrium implants and on undercutting in the orbitofrontal areas of the brain. In: Laitinen, LV, Livingston, KE, eds. Surgical Approaches in Psychiatry Baltimore, Md: University Park Press; 1973:90–95.Google Scholar
11.Stuss, DT, Benson, DF. Personality and emotion. In: Stuss, DT, Benson, DF, eds. The Frontal Lobes. New York, NY: Raven Press; 1986:121–138.Google Scholar
12.Modell, JG, Mountz, JM, Curtis, GC, et al.Neurophysiologic dysfunction in basal ganglia/limbic striatal and thalamocortical circuits as a pathogenetic mechanism of obsessive-compulsive disorder. J Neuropsychiatry Clin Neurosci. 1989;1:27–36.Google ScholarPubMed
13.Insel, TR, Winslow, JT. Neurobiology of obsessive-compulsive disorders. Psychiatr Clin North Am. 1992;15:813–824.CrossRefGoogle Scholar
14.Nauta, HJW. A simplified perspective on the basal ganglia and their relation to the limbic system. In: Doane, BK, Livingston, KA, eds. The Limbic System: Functional Organization and Clinical Disorders. New York, NY: Raven Press; 1986:67–77.Google Scholar
15.Malloy, P. Frontal lobe dysfunction in OCD. In: Perecman, E, ed. The Frontal Lobes Revisited. New York, NY: Institute for Research in Behavioral Neuroscience Press; 1987:207–223.Google Scholar
16.Baxter, LR. Neuroimaging studies of obsessive-compulsive disorder. Psychiatr Clin North Am. 1992;15:871–885.CrossRefGoogle ScholarPubMed
17.Jenike, MA, Baer, L, Ballantine, HT Jr, et al.Cingulotomy for refractory obsessive-compulsive disorder: a long term follow-up of 33 patients. Arch Gen Psychiatry. 1991;48:548–555.CrossRefGoogle ScholarPubMed
18.Kelly, D. Anxiety and Emotions: Physiological Basis and Treatment. Springfield, Ill: Charles C Thomas; 1980.Google Scholar
19.Rauch, SL, Jenike, MA. Neurobiological models of obsessive-compulsive disorder. Psychosomatics. 1993;34:20–32.CrossRefGoogle ScholarPubMed
20.Swedo, S, Pietrini, P, Leonard, HL, et al.Cerebral glucose metabolism in childhood onset obsessive-compulsive disorder: revisualization during pharmacotherapy. Arch Gen Psychiatry. 1992;40:600–604.Google Scholar
21.Mindus, P, Nyman, H, Mogard, J, et al.Frontal lobe and basal ganglia metabolism studied with PET in patients with incapacitating obsessive-compulsive disorder undergoing capsulotomy. Nordic Journal of Psychiatry. 1990;44:309–312.Google Scholar
22.Mindus, P. Capsulotomy. Anxiety disorders: a multidisciplinary study. Paper presented at: Department of Psychiatry and Psychology, Karolinska Institute; July 23, 1991; Stockholm, Sweden.Google Scholar
23.Greenberg, BD, Murphy, DL, Rasmussen SA Neuroanatomically based approaches to OCD: neuro-surgery and transcranial magnetic stimulation. Psychiatric Clin North Am. In press.Google Scholar
24.Jenike, MA, Rauch, SL, Baer, L, Rasmussen SA Neurosurgical treatment of obsessive compulsive disorder. In: Jenike, MA, Baer, L, Minichiello, WE, eds. Obsessive Compulsive Disorders: Practical Management. St Louis, Mo: Mosby; 1998:592–611.Google Scholar
25.Mindus, P, Rasmussen, SA, Lindquist, C. Neurosurgical treatment for refractory obsessive compulsive disorder: implications for understanding frontal lobe function. J Neuropsychiatry Clin Neurosci. 1994;6:467–477.Google ScholarPubMed
26.Rylander, G. Personality analysis before and after frontal lobotomy: the frontal lobes. Association of Researchers Into Nervous and Mental Diseases. 1947;27:691–705.Google Scholar
27.Meyer, A, Beck, E, McLardy, T. Prefrontal leucotomy: a neuroanatomical report. Brain. 1947;70:18–49.CrossRefGoogle ScholarPubMed
28.Freeman, W, Watts, JW. Obsessive Compulsive and Obsessive Ruminative Tension States in Psychosurgery. Springfield, Ill: Charles Thomas; 1950.Google Scholar
29.Malmo, RB, Shagass, C. Behavioral and physiologic changes under stress after operations on the frontal lobes. Archives of Neurologic Pyschiatry. 1950;33:113–124.CrossRefGoogle Scholar
30.McIntyre, MD, Mayfield, FH, McIntyre, AP. Ventromedial quadrant coagulation in the treatment of the psychoses and neuroses. Am J Psychiatry. 1954;3:112–120.CrossRefGoogle Scholar
31.Meyer, A, Beck, E. Prefrontal leucotomy and related operations: anatomical aspects of success or failure [monograph]. Henderson Trust Lecture 17. Edinburgh and London: Oliver and Boyd; 1954.Google Scholar
32.Spiegel, EA, Wyeis, HT, Freed, MD, Orchinik, MA. The central mechanism of the emotions. Am J Psychiatry. 1951;121:426–432.CrossRefGoogle Scholar
33.Talairach, J, Hecaen, H, David, M, et al.Recherches sur la coagulation thérapeutique des structures sous-corticales chez l'homme. Rev Neurol (Paris). 1949;81:4–24.Google Scholar
34.Leksell, L. A stereotaxic apparatus for intracerebral surgery. Acta Chir Scand. 1949;99:229–233.Google Scholar
35.Herner, T. Treatment of mental disorders with frontal stereotactic thermo-lesions: a follow-up of 116 cases. Acta Psychiatr Scand. 1961;suppl 36:941–967.Google Scholar
36.Mindus, P, Meyerson, BA. Capsulotomy for intractable anxiety disorders. In: Schmidek, H, Sweet, W, eds. Operative Surgical Techniques. Philadelphia, Pa: W.B. Saunders; in press.Google Scholar
37.Bingley, T, Leksell, L, Meyerson, BA, et al.Long term results of stereotactic anterior capsulotomy in chronic obsessive-compulsive neurosis. In: Sweet, WH, Obrador, S, Martín-Rodríguez, JG, eds. Neurosurgical Treatment in Psychiatry, Pain and Epilepsy. Baltimore, Md: University Park Press; 1977:287–299.Google Scholar
38.Lopez-Ibor, JJ, Lopez-Ibor Alino, JJ. Selection criteria for patients who should undergo psychiatric surgery. In: Sweet, WH, Obrador, S, Martín-Rodríguez, J, eds. Neurosurgical Treatment in Psychiatry, Pain and Epilepsy. Baltimore, Md: University Park Press; 1977:151–162.Google Scholar
39.Burzaco, J. Stereotactic surgery in the treatment of obsessive-compulsive neurosis. In: Perris, C, Struwe, G, Jansson, B, eds. Proceedings of the 3rd World Congress of Biological Psychiatry. Amsterdam, The Netherlands: Elsevier North-Holland; 1981:1103–1109.Google Scholar
40.Mindus, P, Rauch, SL, Nyman, H, et al.Capsulotomy and cingulotomy as treatments for malignant obsessive-compulsive disorder: an update. In: Hollander, E, Zohar, J, Marazziti, M, et al, eds. Current Concepts in Obsessive-Compulsive Disorder. Chichester, UK: Wiley; in press.Google Scholar
41.Leksell, L. Stereotactic radiosurgery. J Neurol Neurosurg Psychiatry. 1983;46:797–803.CrossRefGoogle ScholarPubMed
42.Leksell, L, Backlund, E-O. Stereotactic gamma capsulotomy. In: Hitchcock, ER, Ballantine, HT Jr, Meyerson, BA, eds. Modern Concepts in Psychiatric Surgery. Amsterdam, The Netherlands: Elsevier North-Holland; 1979:213–216.Google Scholar
43.Lindquist, C, Hindmarsh, T, Kihlstrîm, L, et al.MRI and CT studies of radionecrosis development in the normal human brain. In: Steiner, L, Lindquist, C, Forster, D, et al, eds. Radiosurgery: Baseline and Trends. New York, NY: Raven; 1992:245–253.Google Scholar
44.Guo, WY, Lindquist, C, Kihlstrîm, P, et al.Radionecrosis Created in the Internal Capsule for Psychosurgery With the Gamma Knife [doctoral dissertation]. Stockholm, Sweden: Department of Neuroradiology, Karolinska Institut; 1993.Google Scholar
45.Mindus, P, Bergstrîm, K, Levander, SE, et al.Magnetic resonance images related to clinical outcome after psychosurgical intervention in severe anxiety disorder. J Neurol Neurosurg Psychiatry. 1987;50:1288–1293.CrossRefGoogle ScholarPubMed
46.Schalling, DS, esberg, M, Edman, G, et al.Markers for vulnerability to psychopathology: temperament traits associated with platelet MAO activity. Acta Psychiatr Scand. 1987;76:172–182.CrossRefGoogle ScholarPubMed
47.Mindus, P, Nyman, H. Normalization of personality characteristics in patients with incapacitating anxiety disorders after capsulotomy. Acta Psychiatr Scand. 1991;83:283–291.CrossRefGoogle ScholarPubMed
48.Mindus, P, Nyman, H, Rosenquist, A, et al.Aspects of personality in patients with anxiety disorders undergoing capsulotomy. Acta Neurochir (Wien). 1988;44(suppl):138–144.Google ScholarPubMed
49.Vasko, T, Kullberg, G. Results of psychological testing of cognitive functions in patients undergoing stereotactic psychiatric surgery. In: Hitchcock, ER, Ballantine, HT Jr, Meyerson, BA, eds. Modern Concepts in Psychiatric Surgery. Amsterdam, The Netherlands: Elsevier North-Holland; 1979:303–310.Google Scholar
50.Nyman, H, Midus, P. Neuropsychological correlates of intractable anxiety disorder before and after capsulotomy. Acta Psychiatr Scand. 1995;91:23–31.CrossRefGoogle ScholarPubMed
51.Heaton, RK, Chelune, GJ, Talley, JL, et al.Wisconsin Card Sorting Test Manual, Revised and Expanded. Odessa, Fla: Psychological Assessment Resources; 1993.Google Scholar
52.Hay, P, Sachdev, P, Cumming, S, et al.Treatment of obsessive-compulsive disorder by psychosurgery. Acta Psychiatr Scand. 1993;87:197–207.CrossRefGoogle ScholarPubMed
53.Kartsounis, LD, Poynton, A, Bridges, PK, et al.Neuropsychological correlates of stereotactic subcaudate tractotomy: a prospective study. Brain. 1991;114:2657–2673.CrossRefGoogle ScholarPubMed
54.Whitty, CM, Duffield, JE, Tow, PMet al.Anterior cingulotomy in the treatment of mental disease. Lancet. 1952;1:475–481.CrossRefGoogle Scholar
55.Kullberg, G. Differences in effects of capsulotomy and cingulotomy. In: Sweet, WH, Obrador, WS, Martín-Rodríguez, JG, eds. Neurosurgical Treatment in Psychiatry, Pain and Epilepsy. Baltimore, Md: University Park Press; 1977:301–208.Google Scholar
56.Ballentine, HT Jr, Levy, BS, Dagi, TF, et al.Cingulatomy for psychiatric illness: report of 13 years' experience. In: Sweet, W, Obrador, S, Martín-Rodríguez, JG, eds. Neurosurgical Treatment in Psychiatry, Pain and Epilepsy. Baltimore, Md: University Park Press; 1977:333.Google Scholar
57.Baer, I, Rauch, SL, Ballantine, HT, et al.Cingulotomy for intreactable obsessive compulsive disorder: prospective long term follow up of 18 patients. Arch Gen Psychiatry. 1995;52:384–392.CrossRefGoogle ScholarPubMed
58.Knight, GC. Bifrontal stereotaxic tractotomy in the substantia innominata: an experience of 450 cases. In: Hitchcock, E, Laitinen, L, Vaernet, K, eds. Psychosurgery. Springfield, Ill: Charles C Thomas; 1972:267–277.Google ScholarPubMed
59.Strom-Olsen, R, Carlisle, S. Bi-frontal sterotactic trachtotomy: a follow-up study of its effects on 210 patients. Br J Psychiatry. 1971;118:141–154.CrossRefGoogle Scholar
60.Goktepe, EO, Young, LB, Bridges, PK. A further review of the results of stereotactic subcaudate tractotomy. Br J Psychiatry. 1975;126:270.CrossRefGoogle Scholar
61.Richardson, A. Stereotactic limbic leucotomy. Surgical technique. Postgrad Med J. 1973;49:860.CrossRefGoogle ScholarPubMed
62.Mitchell-Heggs, N, Kelly, D, Richardson, A. Stereotactic limbic leucotomy—a follow-up at 16 months. Br J Psychiatry. 1976;128:226–240.CrossRefGoogle Scholar
63.Bartlett, JR, Bridges, PK. The extended subcaudate tractotomy lesion. In: Sweet, WH, Obrador, S, Martín-Rodríguez, JG, eds. Neurosurgical Treatment in Psychiatry, Pain and Epilepsy. Baltimore, Md: University Park Press; 1977:387.Google Scholar
64.Kelly, D. Anxiety and Emotions. Physiological Basis and Treatment. Springfield, Ill: Charles C. Thomas; 1980.Google Scholar
65.Ballantine, HT Jr, Bouckoms, AJ, Thomas, EK, et al.Treatment of psychiatric illness by stereotactic cingulotomy. Biol Psychiatry. 1987;22:807–819.CrossRefGoogle ScholarPubMed
66.Mathew, SJ, Yudofsky, SC, McCullough, LB, Teasdale, TA, Jankovic, J. Attitudes toward neurosurgical procedures for Parkinson's disease and obsessive-compulsive disorder. J Neuropsychiatry Clin Neurosci. 1999;11:259–267.CrossRefGoogle ScholarPubMed
67.Livingston, RE. Psychiatric Treatment. Baltimore, Md: Williams and Wilkins; 1953.Google Scholar
68.Earp, JD. Position paper: psychosurgery: the position of the Canadian Psychiatric Association. Can J Psychiatry. 1979;24:353–365.CrossRefGoogle Scholar
69.Lippitz, B, Mindus, P, Meyerson, BA, et al.Lesion topography and outcome after thermocapsulotomy or gamma knife capsulotomy for obsessive compulsive disorder: relevance of the right hemisphere. Neurosurgery. 1999;44:452–458.CrossRefGoogle ScholarPubMed
70.Freeman, W, Watts, JW. Psychosurgery in the Treatment of Mental Disorders and Intractable Pain. Springfield, Ill: Charles C. Thomas; 1950.Google Scholar