Treating OCD and Depression With Bilateral Cingulotomy

Surgery considered a last resort when all other options fail

Doctor looking at brain scans
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Bilateral cingulotomy is a type of brain surgery considered a last resort for people with obsessive-compulsive disorder (OCD). It is also used to treat major depression and occasionally chronic pain for persons who haven't found relief from any other form of therapy.

This surgery targets two parts of the brain:

  • The cingulate gyrus, which helps regulate emotions and pain
  • The frontal lobes, whose functions include reasoning, impulse control, and judgment

    Surgical procedures in psychiatry are controversial, and most doctors will not perform a bilateral cingulotomy unless all other avenues of treatment have been exhausted. Many neurosurgeons, in fact, will require consent from both the patient and a close family member before proceeding with the operation.

    Bilateral cingulotomy was first proposed as an alternative to the lobotomy in 1947 by American physiologist John Farquhar Fulton.

    Rationale for Bilateral Cingulotomy

    The cingulate gyrus serves a unique purpose in the brain, connecting experiences and sensations to either pleasant or unpleasant memory. Among other things, it induces an emotional response to pain and can connect that response to one or more of our senses (sight, smell, taste, touch, sound). The cingulate gyrus also completes the circuit to another part of the brain called the caudate nucleus, whose function it is to form habits.

    It is believed that by disrupting these circuits, the connecting between painful emotion and habitual behavior will also be disrupted.

    How the Surgery Is Performed

    To perform a bilateral cingulotomy, an electrode or gamma knife (a targeted radiation device) is guided to the cingulate gyrus by means of magnetic resonance imaging (MRI).

    There, the surgeon will make a half-inch cut or burn to severe the circuit.

    Recovery from the operation takes around four days. Side effects are generally mild, with some experiencing headache, nausea, and vomiting in the days following the surgery. The surgery may also trigger seizures in some, although this typically happens in those with a previous history of seizures.

    Some people complain of apathy following surgery, while others will experience memory lapses. These are uncommon side effects but a potential risk candidates of the surgery would need to consider.

    Effectiveness of Bilateral Cingulotomy

    While bilateral cingulotomy can offer improvement to some with living with OCD, it is by no means a cure-all. A 2016 review of clinical studies concluded that 41 percent of patients who had undergone a bilateral cingulotomy had responded to the procedure with 14 percent experiencing short-term side effects and five percent experiencing serious side effects.

    Bilateral cingulotomy appears to be least effective in persons with treatment-refractory OCD. Treatment-refractory OCD is diagnosed in persons who have achieved little, if any, response to at least two different selective serotonin reuptake inhibitor (SSRI) drugs.

    It is also seen to be less useful in persons with more severe manifestations of the disorder, including OCD-related hoarding.

    Bilateral cingulotomy has also been used to treat people with chronic refractory pain (pain which cannot be treated by any known means). A systematic review of studies has shown that the procedure resulted in significant pain relief in more than 60 percent of patients for up to a year following surgery. Of these, more than half of these indicated that they no longer needed painkillers.

    While some studies have proposed bilateral cingulotomy for persons with treatment-resistant bipolar disorder, studies have thus far been inconclusive.

    As such, it is currently not endorsed as a means of bipolar treatment.

    Sources:

    Brown, L.; Mikell, C.; Youngerman, B.; et al. "Dorsal Anterior Cingulotomy and Anterior Capsulotomy for Severe, Refractory Obsessive-Compulsive Disorder: A Systematic Review of Observational Studies." Journal of Neurosurgery. 2016; 124(1):77-89.

    Shah, D.; Pesiridou, A.; Baltuch, G.; et al. "Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician." Psychiatry. 2008; 5(9):24-33.

    Gentil, A.; Lopes, A.; Dougherty, D.; et al. "Hoarding Symptoms and Prediction of Poor Response to Limbic System Surgery for Treatment-Refractory Obsessive-Compulsive Disorder." Journal of Neurosurgery. 2014; 121(1):123-30.

    Zhang, Q.; Wang, W.; and X. Wei. "Long-Term Efficacy of Stereotactic Bilateral Anterior Cingulotomy and Bilateral Anterior Capsulotomy as a Treatment for Refractory Obsessive-Compulsive Disorder." Stereotactic and Functional Neurosurgery. 2013; 91(4):258-61.

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