Psychosurgery for OCD: Some Respond in the Long Run

Some patients with obsessive-compulsive disorder improve significantly with psychosurgery, but it may have permanent and significant risks.

Many patients with obsessive-compulsive disorder (OCD) continue to experience severe symptoms even with medication or behavioral therapy. Various psychosurgical approaches have been used, but published studies on outcomes are few. In this single-center, longitudinal case series, researchers reported on 19 treatment-refractory OCD patients (12 women; mean age, 41) who had an anterior capsulotomy between 1997 and 2009.

The patients had undergone multiple trials of medications and therapy; symptoms lasted a mean of 16 years. The mean baseline severity score on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was 34.9, in the extreme range; patients showed some impairment in global functioning. Most patients had a coexisting psychiatric condition (mood disorder, 58%).The mean improvement in Y-BOCS score was 23% at 3 months and 31% at 24 months and long-term follow-up (mean, 7 years). At 7 years, seven patients met the criteria for “full response” (35% decrease in symptoms) — three “recovered” (Y-BOCS score <8), and three had mild symptoms. Responders had a shorter duration of symptoms than nonresponders, but similar comorbidities. The most common adverse consequence was “frontal syndrome” (5 patients). One patient had a permanent hemiplegia; another became cognitively impaired.

Comment

This report usefully depicts the potential benefits and significant risks of anterior capsulotomy. Without detailed neuropsychological testing, we cannot know the surgery's cognitive effects, and we cannot gauge the nature or severity of the “frontal syndrome.” In long-term follow-up, almost one third of patients appear either to have recovered or to have mild symptoms. It would be useful to have similar data on deep brain stimulation, which has few published results in OCD patients. Psychosurgery may be an option for patients with severe, debilitating OCD, but the full benefits and permanent, disabling risks remain indistinct.

Reviewing Author

Jonathan Silver, MD

Disclosures

RoyaltiesTextbook of Traumatic Brain Injury, 2nd and 3rd editions

Editorial BoardsUpToDate; Journal of Neuropsychiatry and Clinical Neuroscience

Leadership Positions in Professional SocietiesNorth American Brain Injury Association (Board Member); National Institute on Disability, Independent Living, and Rehabilitation Research (Chair of Data Monitoring Safety Board for study of donepezil on cognition after traumatic brain injury)