Obsessive Compulsive Disorder
Obsessive Compulsive Disorder
The birthdate of a surgical
procedure is often problematical. There is no doubt, however, as to the birth of
functional neurosurgery for psychiatric disorders. In July 1935. John Fulton of Yale
University brought two chimpanzees to an international meeting in London who had had their
frontal lobes removed. This procedure produced a dramatic change in their behavior,
rendering them much less aggressive. Other physicians attending the meeting included Egas Moniz,
a Portuguese neurosurgeon and Walter Freeman, an American psychiatrist. Moniz
prophetically questioned if "it would not be possible to alter anxiety states in man
by surgical means?" By the Fall of 1935 Moniz had answered this question by
performing the first human lobotomy. The following year, Freeman and James Watts, a
neurosurgeon, had taken up the procedure in the US. During the next ten years various
methods of frontal leukotomy were developed by Moniz, Freeman and Watts. A large
world-wide population of institutionalized, psychotic individuals facilitated this
development as there was no truly effective medical treatment available. In 1949 Egas
Moniz won the Nobel Prize for Medicine, lending frontal lobotomy a cachet of
respectability. By this time the reckless enthusiasm of Walter Freeman had produced the
transorbital (ice pick) leukotomy. This freed him from the necessity (and constraint) of
involving Dr. Watts in the performance of this procedure and brought even further abuse.
The introduction of chlorpromazine in 1952 for the treatment of psychiatric illness caused a precipitous decline in surgical procedures to alter human behavior. Functional neurosurgery on the human limbic system no longer seemed necessary or desirable.
Recent advances in neurosurgery for movement disorders have caused a renewed interest in the effects of surgery in the limbic system. Since 1952 advances in neuropharmacology and other psychiatric treatments have remained the basis for management of patients suffering from Obsessive Compulsive Disorder (OCD), major affective disorder (depression) and anxiety states. A minority of individuals remain refractory to conventional treatment. These individual remain disabled and may be considered for neurosurgical procedures.
Four surgical procedures have evolved over the past 50 years to alter limbic lobe expression of emotional disorders. These new operations arose from a need to limit the untoward effects of classical frontal leukotomy: postoperative seizures, disinhibition and other personality disturbances. These techniques are anterior cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leukotomy (combined subcaudate tractotomy, and cingulotomy. Each procedure has its advocates; each seems to produce similar results with low morbidity,
Anterior capsulotomy (AC) was introduced by Talairach in 1949 and further developed by Lars Leksell. The procedure involves the production of small, bilateral lesions in the anterior limb of the internal capsule to interrupt frontothalamic pathways as they pass beneath the head of the caudate nucleus and putamen just posterior the tip of the frontal horn of the lateral ventricle in the anterior limb of the internal capsule. Destructive lesions may be made with radiofrequency thermocoagulation or radiosurgical technique (Gamma Knife).
As in all functional surgery treatment results are difficult to quantify. Mindus and co-workers reviewed 362 cases reported in the literature and found 64% of 213 patients undergoing anterior capsulotomy had achieved a satisfactory result 1. Another study from the Karolinska Institute by Mindus and others cited 22 patients treated by thermal lesions for OCD. When measured by the obsessive compulsive sub scale of the Comprehensive Psychopathological Rating Scale, 23% were worse; 9% improved from 1 to 25%; 23% improved 26% to 50%; 13% improved 51% to 75% and 32% improved by 75% to 100% 2. A very recent paper from the Karolinska group with anatomical analysis of results in patients treated 10 to 20 years ago found a common anatomic volume ( in the right anterior limb of ther internal capsule) in all successfully treated individuals. All patients with poor reulsts had no lesion in this region.
Overall, 7/9 Gamma Knife and 9/14 thermal lesion patients had good outcomes.3 Currently a double-blind, placebo controlled study of Gamma knife capsulotomy is underway at the Karolinska Hospital, Brown and Harvard Universities. Post operative complications included weight gain in a majority of patients, transient episodes of confusion in most, lasting weeks; rare complaints of fatigue, and slovenliness. Intracranial hemorrhage, infection and seizures are quite rare and not expected from the non invasive Gamma Knife radiosurgical technique 4..Criteria to be considered for radiosurgery include:
1. Individuals who fulfill the criteria for obsessive- compulsive disorder and major affective disorder as defined by the Statistical Manual of Mental Disorders, Third Edition, Revised
2. Chronicity :patients under at least 5 years of treatment
3. Severity as may be measured by the Yale-Brown Obsessive Compulsive Scale score of > 20 for OCD or a Beck Depression Inventory score of > 30
4. Disability as measured by a Global Assessment of Function score of < 50
5. Disorder has been shown to be unresponsive to conventional psychiatric and pharmocological treatment
6. Patient can give informed consent
7. Patient and family agree to participate in pre-operative and post-operative programs of psychological evaluation, treatment and follow up 1.2. .
The radiosurgical technique consists of bilateral lesions in the anterior limb of the internal capsule using standard Gamma Knife procedures. These include the placement of a stereotactic coordinate frame under local anesthesia followed by MR imaging of the internal capsule and treatment planning with Gamma Plan software. Actual treatment will the Gamma Knife will require approximately 60 minutes. Patients should experience no immediate side effects (other than local discomfort from the frame placement) and may require an overnight stay in the hospital. Radiosurgical technique avoids surgical sequellae, such as infection, wound healing problems, seizures and hemorrhage, and is less expensive. Retreatment may be undertaken if necessary.
It is anticipated that these patients will be followed at intervals with appropriate psychological measures in an effort to document the results of surgery on a psychological, functional and anatomical basis.
References
1. Cosgrove GR, Rauch SL: Psychosurgery. Neurosurg Clin N Amer 6:167-176, 1995
2. Mindus P, Rasmussen SA, Lindquist C: Neurosurgical treatment of refractory obsessive-compulsive disorder: implications for understanding frontal lobe function J Neuropsych 6:467-477, 1994
3. Lippitz B, Mindus P, Meyerson BA, Kihlstorm L, Lindquist C. Lesion topography and outcome sfter thermocapsulotomy or Gamma Knife capsulltomy for obsessive-compulsive disorder:relevance of the right hemisphere. Neurosurg 44:452-460, 1999
4. Mindus P, Nyman H: Normalization of personality characteristics in patients with incapacitating anxiety disorders after capsulotomy. Acta Psychiatr Scand 83:283-291, 1991