Obsessive compulsive disorder (ocd) as a severe mental health disorder: A concise review of management with radiosurgery for intractable disease

Obsessive Compulsive Disorder (OCD) is among the most important psychiatric disorders signifi cantly deteriorating the mental health of affected patients along with severe consequences such as unemployment, marriage failure, and maladjustment in familial relationships. Patients suffer from substantial impairment in their quality of life. Available fi rst-line therapeutic strategies including exposure and response prevention, cognitive-bahavioural-therapy, and pharmacological agents such as selective serotonin reuptake inhibitors and tricyclic antidepressants may result in clinical improvement in majority of patients, however, approximately 20% of patients have refractory OCD unresponsive to fi rst-line management, and a subgroup of patients unresponsive to fi rstline therapies suffer from severe debilitating symptoms referred to as intractable OCD. No consensus exists for management of patients with intractable OCD and treatment decisions Abstract


Abstract
Obsessive Compulsive Disorder (OCD) is a mental health disorder with characteristic features including uncontrollable, reoccurring thoughts referred to as obsessions, and excessive urges to perform repeated certain routines referred to as compulsions. Affected patients may suffer from tics, anxiety, negative social behaviours and self mutilation. Symptoms of patients may be intrusive, anxiety-provoking, and rather distressing which may signifi cantly compromise both social and occupational functioning. Deterioration in quality of life may occur as a consequence of unemployment, marriage failure, and maladjustment in familial relationships. Initial management of OCD may include exposure and response prevention, cognitive-bahavioural-therapy, and pharmacological agents such as selective serotonin reuptake inhibitors and tricyclic antidepressants. These management strategies may be effective for the majority of patients suffering from OCD. However, approximately 20% of patients have refractory OCD unresponsive to fi rst-line therapies and a subgroup of patients unresponsive to fi rst-line therapies suffer from severe debilitating symptoms referred to as intractable OCD. Radiosurgery has a long history as an excellent radiotherapeutic modality for management of several intracranial disorders. Radiosurgical or gamma capsulotomy technique involving discrete, circumscribed lesions in white matter of the anterior limb of the internal capsule has been introduced by the Swedish neurosurgeon Lars Leksell. Gammaknife Radiosurgery (GKRS) system has been used as a viable alternative to open surgical anterior capsulotomy procedures and gained popularity and widespread acceptance with accumulating evidence from several centers worldwide. Herein, we provide a concise review including the defi nition, epidemiology and symptomotology of OCD, patient selection criteria, and management options with focus on radiosurgery.
are typically based on retrospective data and institutional experiences. As a viable alternative to open surgical anterior capsulotomy procedures, radiosurgery has been introduced with the pertinent goal of generating relatively smaller and probably safer lesions without the need for craniotomy, and has gained popularity and widespread acceptance around the globe. Herein, we provide a concise review including the defi nition, epidemiology and symptomotology of OCD, patient selection criteria, and management options with focus on radiosurgery. This article has been intended to provide an overview of OCD, and eminent articles on radiosurgery for OCD have been reviewed.

Defi nition of OCD, epidemiology, and symptomatology
OCD is a mental health disorder with characteristic features including uncontrollable, reoccurring thoughts referred to as obsessions, and excessive urges to perform repeated certain routines referred to as compulsions. Affected patients may suffer from tics, anxiety, negative social behaviours and self mutilation. Worlwide prevalance for OCD ranges between 1.2% and 3.9% [1-6]. While symptoms of OCD may be manifested at any age, typical symptomatology is generally exhibited about the age of 30 years [6]. Symptoms of patients may be intrusive, anxiety-provoking, and rather distressing which may signifi cantly compromise both social and occupational functioning. Hospitalization may be required for some affl icted patients. Deterioration in quality of life may occur as a consequence of unemployment, marriage failure, and maladjustment in familial relationships [7,8].

Initial management of OCD
Initial management of OCD may include exposure and response prevention, cognitive-bahavioural-therapy, and pharmacological agents such as selective serotonin reuptake inhibitors and tricyclic antidepressants [9-17]. These management strategies may be effective for the majority of patients suffering from OCD [17]. However, approximately 20% of patients have refractory OCD unresponsive to fi rst-line therapies [16-21] and a subgroup of patients unresponsive to fi rst-line therapies suffer from severe debilitating symptoms referred to as intractable OCD [20][21][22][23]. There is no standard management for intractable OCD. In this context, psychosurgery may be considered for this selected subgroup of patients.

Management of intractable OCD with radiosurgery
Radiosurgery has a long history as an excellent radiotherapeutic modality for management of several intracranial disorders [68,71]. Gammaknife Radiosurgery futher supporting evidence with data on long-term safety and effi cacy. An international, multicenter, retrospective cohort study on gamma ventral capsulotomy (GVC) for severe, medically refractory OCD reported that GVC may serve as a reasonable therapeutic approach for management of selected patients with OCD [75]. Another study assessing GVC for intractable OCD revealed that 31 out of the total 55 patients had improvement, and the authors concluded that GVC could be utilized as an effective radiosurgical procedure for many treatment refractory OCD patients [76]. Kondziolka, et al. evaluated the treatment results of bilateral radiosurgical anterior capsulotomy for severe medically refractory OCD [82].
There was no morbidity after GKRS with all patients returning immediately to baseline function, and the authors concluded that GKRS provided improvement of OCD behavior with no adverse effects [82]. A pilot study by Taub, et al. revealed that GVC did not result in profound cognitive defi cits, and improvements have been observed in some cognitive domains [83]. Vigilance is required in meticulous selection of eligible patients for this highly sophisticated treatment procedure given several aspects of management including ethical issues and untowards adverse effects [99,100].

Conclusion and future perspectives
There is growing body of evidence suggesting the utility of radiosurgery for OCD management. Critical aspects of treatment include meticulous selection of eligible patients for this highly sophisticated therapy procedure, ethical considerations, and incorporation of relevant long-term safety and effi cacy data to justify radiosurgical management. Decision to treat patients with OCD using radiosurgery should be made after thorough multidisciplinary collaboration and consensus of experts from several disciplines including psychiatry, neuropsychology and neuropsychiatry, radiation oncology, neurology, and neurosurgery. Future studies may be required for refi ning and optimization of the radiosurgical technique in terms of delivered doses and precise targeting for an improved therapeutic ratio.