Obsessive-Compulsive Disorder is characterized by intrusive and recurrent thoughts or images. Often, they are distressing. These thoughts are associated with repetitive actions, or rituals, that are performed to relieve the anxiety caused by the thoughts or images. OCD can become so severe that patients are unable to function. It is estimated that OCD affects 2-3% of the general population. The first-line treatments for OCD are medications (especially serotonin reuptake inhibitors, or SRIs), and behavioral therapy (especially exposure and response prevention, or ERP). Unfortunately, 20-30% of patients do not respond sufficiently to these conventional treatments. For these patients with treatment-resistant OCD, there are neurosurgical procedures available that may provide benefit.
At Columbia/NYP, we have a multi-disciplinary team of expert psychiatrists, psychologists, and neurosurgeons to help patients determine whether they are eligible for these procedures.
Two types of neurosurgical procedures are available for the treatment of patients with severe, refractory OCD who have failed conventional therapies: stereotactic lesions and deep brain stimulation. The decision regarding the optimal procedure for each patient is reached on an individual basis, based on patient preference and our team’s recommendations. A brief description of each follows.
Stereotactic lesions have been utilized since the 1960s to treat psychiatric and neurological conditions. These procedures consist of creating a precisely targeted lesion within the neural circuit that is dysfunctional in OCD. The two most effective target regions are the anterior internal capsule (capsulotomy) and the cingulate cortex (cingulotomy).
Capsulotomy. This procedure is performed using highly focused radiation, known as Gamma Knife. Using a high resolution MRI scan, we precisely target the desired region within the anterior internal capsule. During the actual treatment, radiation energy is accurately focused on this chosen target. The patient is comfortably lying down during the treatment and does not feel anything while it occurs. This therapy does not involve any surgical incisions, and is performed on an outpatient basis.
Cingulotomy. This procedure is performed using a precisely controlled laser. In the operating room, we place a laser fiber in the exact desired brain region. We use a specialized robotic system to perform this procedure in a minimally invasive way. The ablation is then performed using precise, real-time MRI guidance. This technique allows us to accurately control the placement and size of the lesion. Because the procedure is minimally invasive, the recovery time is quick, with usually a single overnight stay in the hospital.
Long-term outcomes following stereotactic lesion procedures have demonstrated a response rate (≥35% reduction in Y-BOCS score) of 50-65% (Patel et al. World Neurosurgery 2012; Sheth et al. Journal of Neurosurgery 2013).
Deep brain stimulation (DBS) is a neurosurgical procedure during which thin electrodes are precisely placed within a specified region of the brain. These electrodes are connected to a pacemaker-like battery that delivers stimulation to the targeted brain regions. DBS has been used since the 1990s to treat disorders such as Parkinson’s disease and Essential Tremor, with approximately 100,000 patients implanted to date for those indications. DBS for OCD was approved by the U.S. Food and Drug Administration (FDA) in 2009 under a Humanitarian Device Exemption.
DBS involves the implantation of a device that delivers electrical stimulation to the targeted brain region. The settings on the device can be adjusted to try and achieve the most benefit. Therefore unlike lesion procedures, this therapy is adjustable and reversible, but the device does require ongoing adjustments and maintenance. Results for DBS are similar to those for lesions, with response rates in the same 50-65% range (Greenberg et al. Molecular Psychiatry 2010).
The choice of which of these therapies may be best for each patient is made on an individual basis, taking into account the patient’s wishes and our team’s recommendations.
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