Contemporary psychosurgery

Psychosurgery is a safe and relatively effective treatment which should be offered to patients with intractable obsessive compulsive disorder (OCD), major affective disorders, and chronic anxiety states after a minimal period of 2 to 5 years and after all other reasonable treatments have been tried. A greater understanding of the biological basis of psychosurgery is developing from advances in functional brain imaging. The optimal site and size of the lesions remains to be established. The standard technique uses stereotactic radiofrequency thermolesions but stereotactic radiosurgery is an alternative. A good outcome following psychosurgery can be expected in 50-60% of cases, and some of the failures may respond to reoperation. This leaves about 40% who have not benefited or in a few cases may be worse. Unfortunately, there are as yet no reliable clinical or investigational predictive indicators for the good outcome group. Restricted accurate lesion placement minimizes personality change, epilepsy and cognitive decline. Careful safeguards, including approval by an independent multidisciplinary legally constituted review board are mandatory in selecting and following the patients, but unfortunately, there are individuals who are never referred or reside in a society which proscribes the operation, whose lives could be made more tolerable. Psychosurgery is probably underutilized due to negative perceptions based on historical factors, and strict regulations and legislation limiting its application. It is possible that with advances in psychiatric pharmacotherapy, the psychosurgery procedures will be made redundant, but we believe that until this eventuates there is still a small place for these operations. Psychosurgery should only be carried out in a national centre by a multidisciplinary team with experience in these disorders, and an intensive ongoing postoperative rehabilitation program is essential to achieve the best results.