Cognitive Behavioral Therapy Versus Psychosurgery for Refractory Obsessive-Compulsive Disorder

SIR: There is debate concerning the adverse effects of psychosurgery for the treatment of anxiety disorders. Currently, the literature suggests that there may be brain deterioration, irreversible cognitive side effects, and negative changes in personality following capsulotomy and cingulotomy,^1,2 which have an efficacy rate of 50% at best.^3,4 Some neurosurgeons mandate that drug therapies and behavioral therapy trials must have been attempted prior to candidates being scheduled for surgery. This combination of psychotherapy and pharmacotherapy has proven to be the best treatment for Obsessive-Compulsive Disorder (OCD). However, some persons with severe and chronic OCD opt to undergo psychosurgery in efforts to alleviate symptoms. What seems to be missing from the literature are successful reports of less invasive techniques for refractory OCD. One such occurrence is the following case.

The patient was a 57-year-old woman, diagnosed with OCD at the age of 21. She reported a family history of depression and OCD. Specific symptoms included washing/self-cleaning, counting, and checking behaviors. Her ritualistic behaviors were so severe and debilitating that she was placed in a long-term care, state psychiatric facility at the age of 35. Baseline data, collected for 1-week, revealed a 10-hr/day hygiene routine, with ritualistic behaviors accounting for approximately 20 hours of her day. A sophisticated medication regimen using multiple medications only minimally curbed symptoms. The most effective pharmacological intervention was a combination of fluvoxamine (50 mg), fluoxetine (20 mg), and clomipramine (25 mg), which decreased maladaptive behaviors an average of 2 hours per day (10%).

The patient decided anterior cingulotomy was necessary. She was hesitant to attempt cognitive behavior therapy, but was required to do so by her neurosurgeon. Cognitive behavior therapy, prior to surgery, decreased ritualistic behavior approximately 40%, after a 6-week treatment phase. The patient found therapeutic techniques aversive, and continued with her scheduled surgery.

Immediately following surgery, and 5 months post-procedure, the targeted behaviors were back to baseline. Cognitive behavior therapy was again attempted, and drug treatment continued. Treatment included a psychoeducational phase, cognitive behavior techniques outlined by Craske,⁵ and social skills training used within the state hospital system. The psychoeducational phase was to teach the patient specific structures and neuropsychological functioning of the frontal lobe. Cognitive behavior treatment focused on cognitive restructuring and informing the patient that obsessive thoughts may continue to be present, but to “get past/work through” the thoughts by taking risks despite anxious feelings. Social skills training was rewarding for the patient, as she had not been able to participate in social activities or groups, for 2 decades, due to her preoccupation with rituals. The entire treatment phase lasted 90 days. Maladaptive behaviors continuously decreased, with total suppression of symptoms after approximately 75 days. Symptoms were also absent at 1-year follow-up (20 months postsurgery).

Cognitive behavior therapy, coupled with pharmacotherapy, psychoeducation, and social skills training, effectively treated refractory OCD following anterior cingulotomy in this case. Including psychoeducation and social skills training is a novel paradigm in terms of psychological intervention. This type of treatment may generalize to other severe and chronic cases of OCD.