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Neurosurgery for Mental Disorder (NMD)

Over recent years there has been an increase in exploring the possibility of Psychosurgery, also called neurosurgery for mental disorder (NMD) for the treatment of severe treatment refractory OCD. 

The National Institute for Health and Clinical Excellence (NICE) treatment guidelines are clear, that Neurosurgery is not recommended in the treatment of OCD. 

However, there continues to be some doctors that suggest neurosurgery should be considered for the most severe treatment resistant cases, where the person’s quality of life is poor.

Although there are reports of improvement for some of the procedures, there are also sufficient reports of both transient and persistent adverse effects to cause concern.

Concerns regarding the irreversibility and possible long-term adverse effects of ablative neurosurgical procedures have led to the investigation of a number of non-destructive neuro-physiological interventions like Deep Brain Stimulation (DBS), however despite widely reported claims that DBS is a safe and reversible procedure it is still thought that brain cell damage occurs.

Although a variety of different procedures are used, all involve the ablation or disconnection, of ventral and medial prefrontal cortical areas. Four main ablative procedures have been used in OCD. 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.

  • Capsulotomy
  • Cingulotomy
  • Subcaudate tractotomy
  • Limbic leucotomy

In addition, there is one non-ablative procedure, Deep Brain Stimulation (DBS) which has been investigated with OCD. A second procedure, vagal nerve stimulation (VNS), has been discussed as a potential treatment for OCD.

The most well known example of dramatic psychosurgery is that of the prefrontal lobotomy. First used in Portugal, the prefrontal lobotomy, particularly for violent patients in mental hospitals, was rendered upon thousands of patients between 1935 and 1955. As is often the case neurosurgery techniques, initial reports of results tended to be enthusiastic, downplaying complications, (including a 1 in 4 death rate) and undesirable side effects.

There are now only two remaining NMD centres in the UK, Dundee and Cardiff. The University Hospital of Wales in Cardiff and in Dundee the service is based at Ninewells Hospital which has adopted the title of an Advanced Interventions Service (AIS) to emphasise that neurosurgical treatments are only one component of a comprehensive service delivery that also includes medication and specialist psychological therapies.

Summary
Whilst long term improvements are still not known, and with adverse effects widely reported neurosurgery continues to remain a treatment that OCD-UK would not recommend, not even as a last resort when alternative, safer treatments with evidence to support their effectiveness like Cognitive Behaviour Therapy remain available.

One important factor in the effectiveness of CBT is reliant on the ability of the treatment provider, however even poor quality CBT remains far safer than neurosurgery.

In some cases, a course of CBT will not always be effective the first or even second time and if this happens you should consider seeking a request to an OCD specialist, or another specialist.  CBT should perhaps be considered like learning to drive, not everyone passes their test first time and sometimes you need several courses of lessons with different instructors (therapists) who will teach you the same basics or pressing the pedals (CBT) but in slightly different ways.

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