* Capsulotomy. Surgeons insert probes through the top of the skull and down into the internal capsule, a region near the thalamus and part of the circuit connecting to the cortex. They then heat the tips of the probes, burning away raisin-sized portions of tissue. The operation can also be done with external radiation, by shooting beams into the capsule, where they converge to burn away tissue.
* Cingulotomy. In this operation, surgeons thread probes through the top of the head down into the cingulum, a bundle of connective tissue near the capsule that appears to regulate the circuit that's hyperactive in OCD patients. They then burn away tissue by heating the probes' tips. The procedure can be done with external radiation.
* Deep brain stimulation. In this operation, surgeons thread wires through the skull and into the capsule. No tissue is destroyed. The wires, which remain embedded in the brain, are connected to a battery pack implanted in the chest. The batteries produce an adjustable, high-frequency current that interrupts the circuitry implicated in OCD. Doctors have been using the procedure for years to settle the tremors of Parkinson's disease. It's reversible -- if the stimulation doesn't work or causes problems, the current can be turned off.
Early studies encouraging
Over the past decade and a half, several pioneering doctors have quietly built a track record for capsulotomy and cingulotomy. In one 1996 study, published in the journal Neurosurgery, doctors at Massachusetts General Hospital, a Harvard-affiliated institution, followed 34 men and women who had cingulotomies for OCD or other major mood disorders. The doctors found that 13 (or 38%) of the patients improved substantially in the months and years after surgery. In a 2002 study in the American Journal of Psychiatry, the same team reported that 20 of 44 OCD patients (45%) who had cingulotomies improved significantly -- meaning that they could manage their symptoms well enough to make a significant change in their lives, such as resuming work.
At Butler Hospital in Providence, R.I., which is affiliated with Brown University, doctors report similar response rates for capsulotomies using radiation.
Some patients who were almost completely disabled by OCD before surgery are now leading fuller, more normal lives, said Dr. Benjamin Greenberg, chief of outpatient services at Butler and an associate professor of psychiatry at Brown. One formerly severely ill man has gone on to graduate school. Greenberg is now working with doctors at the Cleveland Clinic , the University of Florida and Massachusetts General to test the effectiveness of deep brain stimulation for both OCD and depression.
Several doctors involved in these programs were either hesitant to discuss the issue or asked not to be quoted by name. Some explained that they are wary because the shadow of lobotomy still haunts public perceptions of the field, despite all the advances. "There is history to deal with, and it's not a good history," Greenberg said. "We don't like to call it psychosurgery anymore, so much has changed. It's neurosurgery for severe psychiatric illness."
Patients' interest growing
Word of the advances is reaching patients. Last month, Greenberg discussed the Butler program at the annual meeting of the OCD Foundation, a group that includes doctors, researchers and patients. "There's a whole lot of interest in surgery now among patients," said Patty Perkins, the foundation's director. "I think there are many who at least would consider it."
Ann M. Lenkewicz was one of them. Lenkewicz, 47, a nurse living in Providence, considered having brain surgery several years ago to treat her OCD. Her compulsions were religious: She believed she had to repeat a variety of prayers, painstakingly and exhaustively throughout the day, to avoid an unnamed disaster. "It plagued every part of my life for almost 30 years: my job, my family, my relationships," she said. She was spared the decision on surgery after finding an antipsychotic drug that, in combination with psychotherapy, kept her anxieties in check. "It was a big relief; brain surgery is a very serious thing."
The family of Mary Lou Zimmerman would agree. In 1998, Zimmerman, a former bookkeeper who was then 58, visited the Cleveland Clinic to have surgery to relieve severe OCD. Zimmerman suffered from one of the most common compulsions, a fear of contamination. She spent hours every day showering and washing her hands, and neither drugs nor counseling could break the cycle.