Review
Neurosurgery for obsessive-compulsive disorder: Contemporary approaches

https://doi.org/10.1016/j.jocn.2009.02.043Get rights and content

Abstract

Surgery for psychiatric disorders has a controversial history. Traditionally, procedures were undertaken to physically disconnect or destroy certain areas of the brain thought to constitute critical components of the limbic pathways. The relatively recent advent of the much safer and non-destructive technique known as deep brain stimulation has coincided with a resurgence in interest in psychosurgery. Contemporary approaches to the surgical management of obsessive-compulsive disorder are discussed, together with our current understanding of its pathophysiology.

Section snippets

Introduction and background

Obsessive-compulsive disorder (OCD) is the most common anxiety disorder worldwide, with a lifetime prevalence of 1% to 3%.[1], [2] It is a heterogeneous condition characterised by recurrent obsessions and/or compulsions. These are recognised by the sufferer as unreasonable or excessive, and cause marked distress, anxiety or significant functional impairment.3 Obsessions are anxiety-provoking and unrelenting thoughts, images or impulses. Compulsions are recurrent mental acts or behaviours,

Neural circuitry in obsessive-compulsive disorder

The exact pathophysiology of OCD is yet to be fully elucidated. Positron emission tomography (PET) has demonstrated increased regional blood flow and metabolic activity within the orbitofrontal cortex, anterior cingulate gyrus, and caudate nucleus,[24], [25] and decreased activity in the dorsolateral prefrontal cortex.26 A correlation between decreased metabolism in the orbitofrontal cortex and caudate nucleus and symptomatic improvement following various forms of treatment has also been shown.

Surgical strategies for OCD

The surgical approaches to the treatment of intractable OCD can be broadly divided into lesioning (destructive procedures) and neuromodulation (inactivation of deep brain structures by high-frequency electrical stimulation [DBS]). A variety of anatomical targets have been utilised with either approach, and there are strong arguments in favour of the exploration of several structures in an attempt to treat this condition.[34], [35]

DBS has several advantages over lesioning, and has largely

Summary

DBS benefits about 50% of patients with refractory OCD. It should be seen as an adjunct to, rather than a replacement of, pharmacological and psychological strategies. It has minimal associated risks and is reversible, and is therefore gradually replacing lesional surgery. At present, the optimal target is unknown; however, evidence is accumulating to suggest that nucleus accumbens will be the most effective therapeutic anatomical substrate. It represents a treatment option in OCD patients who

References (49)

  • K. van Kuyck et al.

    Effects of electrical stimulation or lesion in nucleus accumbens on the behaviour of rats in a T-maze after administration of 8-OH-DPAT or vehicle

    Behav Brain Res

    (2003)
  • V. Sturm et al.

    The nucleus accumbens: a target for deep brain stimulation in obsessive-compulsive and anxiety-disorders

    J Chem Neuroanat

    (2003)
  • M. Karno et al.

    The epidemiology of obsessive-compulsive disorder in five US communities

    Arch Gen Psychiatry

    (1988)
  • L.N. Robins et al.

    Lifetime prevalence of specific psychiatric disorders in three sites

    Arch Gen Psychiatry

    (1984)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (2000)
  • M.E. Franklin et al.

    Cognitive behavioral treatments for obsessive compulsive disorder

  • D. Mataix-Cols et al.

    Use of factor-analyzed symptom subtypes to predict outcome with serotonin reuptake inhibitors and placebo in obsessive-compulsive disorder

    Am J Psychiatry

    (1999)
  • G.S. Steketee et al.

    Obsessive compulsive disorder

  • T. Perse

    Obsessive-compulsive disorder: a treatment review

    J Clin Psychiatry

    (1988)
  • M.A. Jenike et al.

    Managing the patient with treatment-resistant obsessive compulsive disorder: current strategies

    J Clin Psychiatry

    (1994)
  • M.A. Frye et al.

    The increasing use of polypharmacotherapy for refractory mood disorders: 22 years of study

    J Clin Psychiatry

    (2000)
  • G.S. Steketee

    Treatment of Obsessive Compulsive Disorder

    (1993)
  • A.T. Beck

    Cognitive Therapy and the Emotional Disorders

    (1976)
  • A. Ellis

    Rational emotive behavior therapy approaches to obsessive-compulsive disorder

    J Rational-Emotive Cognitive-Behav Ther

    (1994)
  • Cited by (21)

    • Gamma Knife capsulotomy for correction of obsessive-compulsive symptoms in a patient with schizophrenia: Case report

      2022, Progress in Brain Research
      Citation Excerpt :

      Nevertheless, a large amount of evidence indicates that management of certain therapy-resistant psychiatric diseases using modern minimally invasive neurosurgical modalities is quite effective and sufficiently safe. In particular, efficacy of surgical or radiosurgical interventions for obsessive-compulsive disorder (OCD) has been widely acknowledged (Bear et al., 2010; Lopes et al., 2014; Rasmussen et al., 2018; Spatola et al., 2018), while practical experience with such treatment in the majority of clinical centers still remains limited. On the other hand, invasive interventions for correction of concomitant obsessive-compulsive symptoms in patients with schizophrenia, have been attempted only rarely (Plewnia et al., 2008) and their results are largely inconsistent.

    • Obsessive compulsive disorder (OCD): Current treatments and a framework for neurotherapeutic research

      2019, Advances in Pharmacology
      Citation Excerpt :

      A less invasive type of neurostimulation that has been explored as a possible treatment for OCD is repeated transcranial magnetic stimulation (rTMS; Lefaucheur et al., 2014) Active rTMS has been shown to be superior to sham rTMS for OCD, producing a modest reduction in Y-BOCS scores, and rTMS over the supplementary motor area (SMA) produced greater reduction in Y-BOCS scores than rTMS applied over the dorsolateral prefrontal cortex or orbitofrontal cortex. One hypothesis for the therapeutic effect of rTMS in reducing OCD symptoms is that it, like psychosurgery and DBS (Bear, Fitzgerald, Rosenfeld, & Bittar, 2010), may alter the functioning of the cortico-striato-thalamo-cortical (CSTC) circuits implicated in OCD. Similar to the foregoing considerations for DBS, “rTMS can interact with spontaneous oscillatory rhythms existing in the cortical circuits activated by the stimulation” (Lefaucheur et al., 2014, p. 2154).

    • Clinical and electrophysiological outcomes of deep TMS over the medial prefrontal and anterior cingulate cortices in OCD patients

      2018, Brain Stimulation
      Citation Excerpt :

      Up until now, most studies targeted the supplementary motor area (SMA) or components of the cortico-striato-thalamo-cortical (CSTC) circuits - the dorsolateral PFC (DLPFC) and orbitofrontal cortex (OFC). Indeed, converging evidence points towards the involvement of the CSTC circuits in the etiology of OCD [12], including structural abnormalities [13,14] and impaired function of the CSTC circuit as a whole [15–17], or of its different components [15,18–22]. For example, the anterior cingulate cortex (ACC) and the medial prefrontal cortex (mPFC) were found to be hyperactive in OCD patients while detecting cognitive conflicts [23] or making an error [24].

    • Repetitive transcranial magnetic stimulation of the supplementary motor area in treatment-resistant obsessive-compulsive disorder: An open–label pilot study

      2017, Journal of Clinical Neuroscience
      Citation Excerpt :

      In the past, severe treatment-resistant OCD was one of the most common psychiatric conditions treated with lesional neurosurgery. Deep brain stimulation (DBS), which is a reversible neuromodulatory surgical intervention, has been used as a treatment option for OCD since 1999 [11,12]. However, non-invasive brain stimulation techniques have been recently in the spotlight because they have less cost and less risk than DBS.

    • Treatment of resistant obsessive-compulsive disorder

      2011, Quaderni Italiani di Psichiatria
    View all citing articles on Scopus
    View full text