According to a study in the January issue of Neurosurgery, patients with extremely severe obsessive-compulsive disorder (OCD) may find relief with radiosurgery procedures. Dr. Douglas Kondziolka and colleagues at the University of Pittsburgh report promising results in three patients with very severe, "medically refractory" OCD. Although further research is needed, radiosurgery could provide a new treatment alternative for the most extreme and difficult cases of OCD.

The patients were two women and one man with extremely severe OCD. Despite taking multiple medications, all patients continued to have severe and disabling OCD symptoms. For example, one woman spent hours washing every day and had not left her house for a year. After exhausting all other treatment options, the three patients underwent radiosurgery, with the an intense beam of radiation targeted precisely to the area of the brain (the anterior cingulate cortex) responsible for OCD symptoms. Radiosurgery was originally developed as an alternative to surgery in destroying brain tumors.

The experimental procedure was tried only after careful evaluation. In addition to meeting criteria for extreme OCD, the patients had to request radiosurgery, and the procedure had to be recommended by at least two psychiatrists. All radiosurgery procedures were performed without complications; the patients were followed for up to 4½ years.

"All patients noted significant functional improvements and reduction in OCD behavior," Dr. Kondizolka and co-authors write. For example, the patient obsessed with washing reduced her bathing routine from four to two hours per day and was able to leave the house for daily activities. The other two patients also improved; one had a 90 percent reduction in her OCD severity score. The improvements occurred gradually, typically peaking between two and four months. All patients had to continue taking medications—one patient's OCD symptoms began to worsen again when he stopped.

Although most patients with OCD improve with drug treatment, some continue to have severe and disabling symptoms even with extensive medications. Some patients have benefited from a surgical procedure (anterior cingulotomy) performed on the involved area of the brain. More recently, deep brain stimulation (DBS)—using electrical stimulation applied to disrupt abnormal brain activity—has been approved for use in severe OCD.

Although preliminary, the new results suggest that radiosurgery could offer a valuable new option for those most severe cases of OCD. Radiosurgery has some potential disadvantages compared to DBS: the procedure is irreversible and doesn't allow adjustment of stimulation patterns, which is possible with DBS. On the other hand, radiosurgery doesn't require implanted electrodes and generators and avoids the equipment-related complications that are possible with DBS.

Much more research will be needed before radiosurgery can be widely recommended for patients with severe OCD. Dr. Kondziolka and colleagues call for studies comparing radiosurgery with DBS, including the benefits, risks, and costs of the two treatments.