Medication and psychotherapy are the two most commonly used treatments for Obsessive Compulsive Disorder. However, neurosurgical procedures including cingulotomy, capsulotomy and limbic leucotomy and more importantly, deep brain stimulation, have also shown to be affective in treating OCD.
SRIs (serotonin reuptake inhibitors) are medications that increase the concentration of serotonin in the brain. SSRIs (selective serotonin reuptake inhibitors) are usually tried first (before non-selective SRIs) because SSRIs only act on serotonin. The SSRIs currently available for prescription include:
Citalopram (Celexa)
Fluoxetine (Prozac)
Fluvaxamine (Luvox)
Paroxetine (Paxil)
Sertaline (Zoloft)
If these medications fail to work, a non-selective SRI may be prescribed. However, because it affects neurotransmitters in the brain other than just serotonin, there are more side effects and, thus, is usually not tried first (4). The non-selective SRI most commonly used is:
Clomipramine (Anafranil)
Effectiveness
Fewer than 20% of those treated with medication alone end up with no OCD symptoms. Thus, medication should be combined with psychotherapy to obtain the best results. However, even with the combination, about 20% of patients don't experience any improvement and, thus, have to try a different SRI (4).
Cognitive behavioral psychotherapy is another option for individuals suffering with OCD. The purpose of Exposure and Response Prevention is that anxiety usually goes down after long enough contact with something feared. Thus, if someone is obsessed with washing their hands after touching something ‘germy', the person would have to touch something they believe to be contaminated repeatedly and then not wash their hands. The purpose of this therapy is to help individuals learn how to change their thoughts and feelings by first changing behavior. Exposure helps decrease anxiety and response prevention helps decrease compulsive behavior (4).
Effectiveness
Usually 25% of patients will refuse to undergo cognitive behavioral psychotherapy. Those who complete it report a 50-80% reduction in OCD symptoms (4).
Psychosurgery is a last result, and is only used to treatment patients with refractory obsessive-compulsive disorder (meaning there was little to no improvement with the above mentioned therapies). Today, not counting Deep Brain Stimulation, there are three types of neurosurgical procedures that are currently used to treat OCD: cingulotomy, capsulotomy and limbic leucotomy. The procedures use lesions as the method of neuromodulation and because the procedures are coupled with developments in computer science, functional imaging and physiologic recording technology, they allow very accurate results. However, since these therapies result in permanent lesions in the brain, they are irreversible.
Cingulotomy:
This form of therapy began in the 1940s, when it was found that severing fibers from the cingulated gyrus led to an improvement in anxiety type states. The modern stereotactic procedure was introduced in 1967 and is performed by making a lesion 2 to 2.5 cm from the tip of the frontal horns, 7 mm lateral from the midline and 1 mm above the roof of the ventricles bilaterally. This is the most reported neurosurgical procedure for psychiatric diseases in the US .Effectiveness
In a controlled study involving 44 patients diagnosed with OCD 32% met the criteria for having responded to the therapy, 14% did partially. Only about 1,000 procedures have been preformed for OCD patients, but none resulting in death. However, the hemorrhage rate is 0.3%, and other adverse effects include seizures and hydrocephalus, but no significant behavioral or cognitive changes have been reported (5).
Capsulotomy:
This procedure was developed by Lars Leksell and Jean Talairach. It has been used to treat refractory psychiatric illnesses since 1949. There are two forms of this operation: The first uses radio frequency and the other uses gamma radiation. Both target the area between the anterior and middle third of the anterior limb of the internal capsule. Recently, gamma radiation has been updated to be more precise, and, thus, it is used more often. Most procedures result in two lesions of approximately 15 to 18 mm in length and 4 to 5 mm in width. The procedures effectiveness is probably due to cutting the ventral fibers in the anterior internal capsule from the orbitofrontal cortex (OFC) and subgenual anterior cingulate cortex (ACC) to medial, dorsomedial, and anterior thalamic nuclei, thus, disrupting the cortico-striatal circuit.Effectiveness
Historically, response rates range between 48% and 78%. However, a recent study using gamma capsulotomy indicates a 27% response rate for patients receiving a single bilateral lesion, and a 62% response rate in patients receiving two pairs of bilateral lesions. Currently, no deaths have been reported, but adverse effects include headaches, confusion, urinary incontinence, weight gain, lethargy, and cerebral edema. Only, one patient has reported cognitive/personality effects, which manifested in apathy and amotivation (5).
Subcaudate Tractotomy: (not a frequently used procedure)
It was developed in 1965 by Knight. This procedure also is geared toward interrupting fibers from the orbitofrontal cortex to the thalamus. The lesion is created by multiple 1 x 7 mm rods (with a half life of 68 hours after which they become inert) that release lethal radiation to tissue within 2 mm. The rods are placed in bilateral burr holes made by the surgeon.Effectiveness
The technique is most often used for depression, but response rates for patients diagnosed with OCD are about 50%. Adverse side effects include transient headache, confusion, and lethargy. The procedure has resulted in one death (5).
Limbic Leucotomy
This is designed to interrupt fibers in two separate areas, one involving the fronto-thalamic loop and the other involving an area of the Papez circuit. It was developed by Desmond Kelly and Alan Richardson in the 1970s. The operation consists of three 6 mm cryogenic lesions in the lower medial quadrant of each frontal lobe and two 6 mm lesions in each cingulum. In essence, it is a combination of a subcaudate tractotomy and a cingulotomy. It disrupts multiple cortico-striato-thalamocortical interactions.Effectiveness
Patients with OCD showed a response rate of about 50%. To date, there have been no reports of deaths or seizures. Adverse effects include transient headaches, lethargy, apathy, and incontinence. One patient experienced significant memory loss due to misplacement of the lesions (5).
