It’s a Brain Thing: Surgery & OCD

Obsessive-compulsive disorder (OCD) is an anxiety condition that affects approximately 2-3% of Americans. The most common hallmarks of OCD are recurrent, intrusive thoughts, images, or urges (obsessions) and involuntary behaviors, rituals, and routines (compulsions).

OCD behaviors may involve repeated hand-washing, checking doors and windows multiple times, turning the lights on and off a set number of times, etc. These behaviors can disrupt your life and negatively affect your mental, social, and physical health.

Understand that people with OCD can’t control or “shut-off” the disturbing and annoying thoughts or stop the ritualistic behaviors. The good news is there are a variety of treatments available for OCD, such as psychotropics (medication), psychotherapy, and brain surgery or brain stimulation. However, keep in mind that some people may not respond to these treatments.

In fact, according to a 2019 study, only 50% of people with OCD got better with treatment, and just 10% fully recovered from it. These efficacy results stem, in part, from a lack of understanding of the true relationship between the brain and OCD. According to researchers, the participants with OCD exhibited a higher level of brain activity in the area responsible for detecting errors. However, these individuals had a lower level of brain activity in the region responsible for stopping certain actions or behaviors – as compared to those without the condition.

Still, for those, who have been grappling with OCD, brain surgery may be a viable option when the more conventional treatments like psychotropics and psychotherapy have failed.

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What is Neurosurgery?

Neurosurgery, also referred to as “brain surgery,” is a surgical procedure used to treat brain and nervous system problems. Neurosurgery is used to diagnose and treat people who have injured or damaged parts of the brain, spinal column, spinal cord, and peripheral nerves. It is also used to treat a variety of brain, spinal cord, and nerve health conditions. Neurosurgery is used with children, teens, and adults. And, in some cases, and depending on the extent of the damage or injury, a neurosurgeon may recommend both neurosurgical and non-surgical interventions.

Can OCD Be Treated with Neurosurgery (Brain Surgery)?

Yes, it can.

Approximately 20-30% of OCD-sufferers are not helped by medication or psychotherapies (i.e. cognitive-behavioral therapy and/or exposure therapy). In these cases, neurosurgery (brain surgery) may be an alternative. Psychosurgery is the “official name” for brain surgeries performed for mental health conditions.

This form of brain surgery has been used since the 1930s, however, it has always been somewhat taboo in the mental health field. This is primarily because during the early days of psychology (1940s and 1950s), lobotomies (a type of brain surgery) were unregulated and performed poorly, leading to a host of life-altering complications.

Lobotomies also caused significant changes in personality and cognitive function (reduced brain activity) in a large number of mentally ill patients. As a result of more effective treatments like psychotropics and psychotherapy, the practice of psychosurgery has steadily declined.

But even today, some psychiatrists still perform surgical procedures on mentally ill individuals. The good news is psychosurgeries are more regulated and monitored now. And, brain surgery for OCD is now only suggested after a neurosurgeon, neurologist, and/or psychiatrist has determined that an individual is a good candidate for the treatment.

No, it is not recommended for all OCD-sufferers.

Surgical interventions are only reserved for OCD-sufferers, who have not responded well to psychotherapy or traditional OCD medications.

How Does Brain Surgery Work for People with OCD?

Brain surgery for OCD involves destroying minute amounts of brain tissue and performing deep brain stimulation (DBS) on the parts of the brain responsible for thought processes and behaviors.

Is Brain Surgery Effective for OCD?

The jury is still out.

Brain surgery appears to be a moderately effective treatment for people struggling with severe OCD, who have not responded well to more conventional treatments like psychotropics and psychotherapy.

According to some researchers, some OCD-sufferers may experience a reduction in symptoms or even a full recovery within 7 years following brain surgery. But, this success rate is largely dependent on the individual’s symptoms, age, and health status. It is important to understand, however, that brain surgery for any condition has significant risks.

In fact, some OCD-sufferers have reported permanent complications (i.e. partial paralysis and cognitive deterioration) following certain types of brain surgery. Because of the possible complications, researchers suggest that this procedure only be used as a last resort treatment for OCD. Conversely, other experts believe that while older brain surgeries were dangerous and unregulated, newer surgical interventions like deep brain stimulation (DBS) show tremendous promise as an effective treatment for severe OCD.

Keep in mind that study results on the effectiveness of brain surgeries for OCD have been largely mixed. Although this procedure has been successful for some OCD-sufferers (i.e. easing unwanted thoughts and quieting urges to engage in certain behaviors), thus, improving their quality of life, for most, it has only led them to the point in which they can engage in psychotherapy.

Moreover, some individuals have reported relapses years after their surgeries, while others reported little-to-no improvement in OCD symptoms following the surgery. Due to these concerns over safety and efficacy, brain surgery for OCD is not recommended.

Are There Different Types of Brain Surgeries for OCD?

Yes, there are different types of brain surgeries for OCD.

Listed below are the most common types of brain surgeries used to treat OCD symptoms:

  • Anterior cingulotomyAnterior cingulotomy involves piercing your skull and applying a heated probe to a part of your brain (anterior cingulate cortex) to remove the parts that are damaged. Approximately 50% of people, who have not benefited from medication and/or psychotherapy, may receive some relief from this procedure.
  • Anterior capsulotomy – Although similar to anterior cingulotomy, anterior capsulotomy surgery is performed on a different part of the brain (the anterior limb of the internal capsule). Approximately 50-60% of OCD-sufferers, who have not responded well to traditional treatments (like medication and/or psychotherapy) may benefit from this procedure.
  • Gamma Knife – Unlike the other two brain surgeries for OCD, the gamma knife surgery does not require penetrating your skull. During this procedure, multiple gamma rays enter your skull. One gamma ray does not appear to harm brain tissue. However, when multiple gamma rays meet or connect, it heightens the energy allowing it to destroy the targeted brain tissue.
  • Gamma Ventral Capsulotomy is the newest version of the gamma knife. This surgical procedure specifically concentrates on the ventral or lower-half of your brain (anterior capsule). Approximately, 60% of those, who continue to have OCD symptoms after using medications or participating in psychotherapy, may benefit from this procedure.

What is Deep Brain Stimulation for OCD?

A common procedure used to treat OCD symptoms is deep brain stimulation (DBS). This surgical intervention involves placing a device inside of your brain and using it to transmit electrical pulses within it. Unlike other brain surgeries for OCD, DBS is reversible. In other words, it does not permanently damage or destroy your brain or brain tissue. And, because it is considered relatively safe, the FDA has approved its use for OCD.

But, although DBS has been touted as a “universal alternative treatment” for a variety of mental health conditions, including OCD, the long-term success has been fairly limited. And, even though it is considered generally safe, it can still result in temporary complications that are uncomfortable, serious, and, in some cases life-altering.

Lastly, some DBS and OCD studies have been met with poor results, especially when evaluating the effectiveness of using DBS to treat the comorbidity of OCD and depression. So, it is important to exercise caution when weighing your treatment options.

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How Does Deep Brain Stimulation Work?

DBS involves placing electrodes in specific areas of your brain. Once inside, the electrodes are attached to wires that have been positioned under your skin. The goal of these electrodes is to transmit or send pulses (using pulse generators) to targeted areas of your brain. These pulse generators work like pacemakers, except instead of being focused on the heart, they are focused on your brain.

As mentioned above, DBS does require opening your skull, however, it does not injure or destroy your brain or brain tissue while removing the damaged parts of it. Moreover, as compared to other brain surgeries, DBS allow surgeons to have more control over the electrical charge, so they can provide the proper treatment to their patients.

What is Image Guided Laser Surgery for OCD?

Another surgical intervention for OCD that is gaining popularity is guided laser surgery. This procedure involves creating “lesions” that “disrupt” or “calm” overactive circuits in your brain. The most popular laser surgeries for OCD are stereotactic radiosurgery, radiofrequency thermal lesioning, and image-guided laser surgery. Image-guided laser surgery, also referred to as laser ablation, is the newest type of laser surgery used to “quiet” an overactive brain circuit. It was originally developed to treat epilepsy, but practitioners have increasingly begun to use it to treat mental health conditions like OCD.

During the procedure, a neurosurgeon uses 3D images of your brain to target specific areas of it. Next, he or she places a tiny laser fiber (through a small incision) next to the targeted brain tissue (which in the case of OCD is an overactive brain circuit). The surgeon then uses laser beams from an MRI machine to heat up the laser fiber and burn away the damaged parts of your brain through “lesions.” The good news is if you opt for this procedure, you should see noticeable improvements in your OCD symptoms within 14 days following the procedure.

Is Brain Surgery Safe for OCD?

Brain surgery appears to be safe for many OCD-sufferers, however this treatment is usually reserved for more severe cases of OCD.

Recently, there has been an emerging interest in brain surgery for the treatment of severe refractory OCD. According to the NICE guidelines for the treatment of OCD, “neurosurgery is not recommended at this time.” However, some practitioners assert that brain surgery should still be considered in the more extreme OCD-treatment resistant cases, especially when the individual’s quality of life and future outcome is poor.

But there remains some hesitancy in the psychology field, primarily because of the seriousness associated with any brain surgery. Also, currently, there is not a clear definition on what constitutes “treatment resistant.” In other words, just because an individual has gone through a variety of psychotropics and psychotherapies without success does not necessarily mean that brain surgery will be safe for him or her – even when the OCD is severe. So, it is extremely important that you discuss the pros and cons of having this treatment with your doctor and family. It should not be a decision taken lightly.

So, to sum it up, more information is needed to determine if brain surgeries are completely safe for OCD-sufferers, and, if so who they are safe for.

What is the Future Outcome for OCD-Sufferers Who Opt for Brain Surgery?

The future outcome for OCD-sufferers who opt for brain surgery is mixed, and largely dependent on the individual person and situation.

Approximately 50-60% of people with OCD experience a reduction in symptoms following brain surgery. According to a study, approximately 37% of the participants, who underwent bilateral capsulotomy (a procedure that destroys brain tissue by creating “lesions” in a specific part of your brain), experienced a 35% (moderate-to-significant) improvement in their OCD symptoms following the surgery, while 10% of the participants experienced a 25% (mild) improvement in OCD symptoms following the surgery.

After seven years, 15% of the participants were either completely recovered or had mild symptoms of OCD. Researchers found that those, who did not respond to the neurosurgery, typically had been struggling with the condition for a longer amount of time (i.e. 20 years) as those, who were recently developed the condition (i.e. less than 12 years).

Summary

Approximately 60% of people with OCD respond well to psychotropics (medication), while another 60-65% respond well to psychotherapy or a combo of psychotropics and psychotherapy. However, a small percentage of people do not respond to either treatment protocol (medication or therapy). For these individuals, brain surgery is an option.

The truth is neither doctors or researchers fully know the “ins-and-outs” of OCD, however, the general consensus is that your brain plays a significant role in its development and progression. It can also play a role in how well you respond to various treatments.

For some, brain surgery eases OCD symptoms and restores their quality of life, especially for those, who have been grappling treatment-resistant OCD for a while. Thus, for severe cases of OCD, brain surgery appears promising. However, most mental health practitioners caution that surgery should always be the last resort and that it should only be used in cases where nothing else has worked.

Still, for those, who feel hopeless, the prospect of relief, even through surgical means, can feel like a blessing.

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