Welcome to Jaslok Hospital, the leading center for Obsessive-Compulsive Disorder treatment in Mumbai. At Jaslok, we understand the challenges individuals face when dealing with OCD and are committed to providing compassionate care and effective solutions. With its state-of-the-art facilities, compassionate staff, and a novel approach to treatment, we have earned a reputation as the best center of OCD specialists in Mumbai.
Obsessive compulsive disorder (OCD) is a psychiatric disease that is associated with anxiety provoking thoughts (Obsessions) leading to compulsive and repetitive behavior (compulsions) that may or may not provide a temporary relief. It is a debilitating disease that can significantly affect almost all aspects of patient’s life and in some cases lead to suicide.
OCD has an approximate prevalence rate of 2–3% in the general population and 0.6% in the Indian population. OCD, particularly in its severest form, causes a high degree of mental suffering and psychosocial impairment, sometimes comparable to that of schizophrenia.
The therapeutic response to the usual treatments is still limited. Currently 60% to 70% of patients respond to pharmacotherapy with serotonin reuptake inhibitors (SRI), while 60% to 80% of them improve with behavioral therapy. Therefore, nearly 40% of OCD patients do not respond well to adequate therapeutic measures. Different treatment approaches are proposed for resistant cases. Cognitive and behavioral therapy is an important adjunct in treating difficult cases. Neurosurgery is a therapeutic alternative when all conventional approaches fail.
OCD is a debilitating disorder that affects people of all ages and backgrounds. The obsessions are distressing and intrusive thoughts; and compulsions are the repetitive behaviors which can consume a significant amount of time and energy, making it challenging for individuals to function normally.
OCD can present itself in different forms, and its severity varies from person to person. Some common subtypes of OCD include:
An overwhelming fear of contamination, leading to excessive washing and cleaning.
Persistent doubts that compel individuals to check things repeatedly, such as locked doors or turned-off appliances.
A strong desire for symmetry and order, resulting in repetitive arranging and organizing of objects.
Unwanted and distressing thoughts or mental images that may be violent, sexual, or taboo in nature.
Recognizing the signs of OCD is crucial for timely intervention and support. Common symptoms include:
The exact cause of OCD is not fully understood, but these are some of the factors that are believed to contribute to its development:
Wounds from the past lead to distressing obsessions that seem impossible to escape.
In the solemn thread of family history, a sorrowful inheritance may pass, predisposing individuals to carry the burden of OCD through their genes.
The delicate symphony of neurotransmitters in the brain can falter, plunging one into an emotional abyss, where compulsions become the futile refuge from inner turmoil.
The weight of societal expectations, broken relationships and personal disappointments can shatter the spirit, triggering a desperate need for control through compulsive rituals.
Innocence tainted by harsh experiences can plant the seeds of doubt and fear, sprouting into the obsessions that entangle one’s soul.
Unhealthy coping strategies may unwittingly pave the path to OCD, as efforts to manage anxiety and uncertainty turn into uncontrollable compulsions.
Distorted thought patterns, like a tangled web, perpetuate the cycle of obsessions and compulsions, imprisoning the mind in a labyrinth of doubt.
To help diagnose obsessive-compulsive disorder (OCD), the following steps are taken:
During this crucial step, you open up about your innermost thoughts, feelings, symptoms, and behavior patterns. The goal is to understand if obsessions or compulsive behavior are hindering your quality of life. With your consent, your doctor may even reach out to your loved ones to gain a broader perspective.
A comprehensive physical examination is carried out to rule out any other potential causes for your symptoms. Ensuring there are no underlying health issues or complications is an essential step in the evaluation.
There are various treatment options available to manage and overcome OCD, and Jaslok Hospital stands out as the leading center for treatment of Obsessive-Compulsive Disorder. Based on the results of the diagnosis, our specialists in OCD may provide the appropriate treatment including:
CBT challenges maladaptive cognitions. It targets avoidance with behavior techniques like relaxation, exposure, behaviour modifications etc. CBT helps individuals identify negative thought patterns and develop healthier coping strategies, gradually reducing the impact of OCD on the patients’ lives.
In some cases, psychiatric medications, such as selective serotonin reuptake inhibitors (SSRIs), can be prescribed to alleviate symptoms.
ERP involves gradually exposing individuals to their obsessive triggers and preventing them from engaging in their usual compulsions. This helps to reduce anxiety over time.
Aside from conventional treatments, Jaslok Hospital also offers non-invasive therapies to complement OCD management:
TMS involves stimulation of a particular group of neurons by magnetic induction. It provides treatment by the principle of neuroplasticity and has shown significant benefits in various trials. This treatment is delivered in Jaslok hospital by Restorative and Regenerative Medicine, first of its kind in India, which includes dedicated staff who have expertise in this procedure.
DBS involves implanting electrodes in the brain to modulate abnormal brain activity, effectively reducing OCD symptoms.
At Jaslok, we understand that treating OCD is a journey that requires ongoing support. Our team of compassionate professionals is dedicated to providing continuous care and guidance throughout the treatment process. We believe in building lasting relationships with our patients and their families to ensure their well-being.
Our approach to OCD treatment sets us apart as the leading clinic treating Obsessive Compulsive Disorder in Mumbai. The hospital’s dedicated team of psychiatrists, psychologists, and counselors work collaboratively to create personalized treatment plans for each patient. The serene and supportive environment at Jaslok Hospital fosters healing and recovery, making it the ideal choice for OCD treatment in Mumbai, India.
Not only does Jaslok Hospital excel in OCD treatment, but it also offers top-notch care for schizophrenia. With a multidisciplinary team and cutting-edge treatments, the hospital stands out as a reliable destination for comprehensive mental health care.
The success of any treatment depends on the expertise of the medical professionals. At Jaslok Hospital, a highly skilled and experienced team of OCD specialists led by the best neurosurgeon in India, Dr. Paresh K Doshi, provides compassionate care, guiding patients toward a brighter future.
The Obsessive Compulsive Disorder (OCD) symptoms vary from person to person. We all have some symptoms of OCD, e.g. we are used to checking the locks of the car or the house couple of times before we leave, or we are very particular in our work and want it be finished to perfection, for which, if require, and we do the same tasks again. All successful people have some form of OCD in them! However, when the thoughts or acts become very intrusive and affects the daily living of a person, it is called a disease. The common themes are checking, washing and cleaning, excessive need for order and symmetry, unwanted aggressive thoughts, unwanted sexual thoughts, counting, the need to ask or confess and hoarding.
The most common symptom like frequent washing of hands, checking and washing symptoms respond well to surgical line of treatment. The obsessions and compulsions are accompanied by overwhelming anxiety and are distressing and time-consuming. They lead to serious impairment in occupational, scholastic and/or social functioning. Patients go to great lengths to avoid objects or situations that provoke obsessions or compulsions and severely restrict general functioning. We had patient who had not taken bath for 90 days in order to avoid the compulsions. The patient is aware of the obsessive thoughts, but is unable to control it. The compulsions are very disturbing and are not associated with any pleasure but have to be completed in order to be at peace.
OCD symptoms are also associated with depression and anxiety. Anxiety is very high amongst the patients suffering from OCD. According to one study, up to 67% of patients of OCD would suffer from major depression during their lifetime. All the patients of obsessive compulsive disorder that we have operated had comorbid depression. There are associated psychiatric disorders that can be found in patients of OCD and this can be seen in up to 60-90% of OCD patients. Research suggests that when OCD improves longitudinally with effective treatment, depressive symptoms disappear as well.
The quality of life (QoL) of patients of OCD is affected considerably, due to frequent absences from the work. lack of focus and difficulty in maintaining relationships with colleagues. This is compounded by a sense of guilt and shame which these patients suffer. According to a study this is found to affect more than 30% of the patients. The family of the OCD patient also suffer considerable disturbance. We had a patient who insisted that her parents would have to wash their hands to her satisfaction if they went out with her and touched any object that she thought was contaminated. Due to this kind of behavior she had to be taken out of the school. About 75–90% of patients report a decrease in self-esteem and 50% reported having frequent thoughts about suicide.
Recently there have been a lot of advances in understanding Obsessive Compulsive Disorder (OCD) with the help of investigations like Magnetic Resonance Image (MRI) and Positron Emission Tomography PET scans.
MRI studies comparing volumes of specific brain regions in patients with OCD have often yielded conflicting and inconsistent results. Brain regions of interest have included the head of the Caudate Nucleus (CN) the orbitofrontal cortex and the anterior cingulate gyrus. With respect to the caudate nucleus (CN) especially, studies have found increases, decreases and no change in volume between OCD patients and healthy controls on (MRI) scans. The source of this apparent discrepancy in the volumetric literature may be methodological in nature. Furthermore it has been suggested that the heterogeneity of OCD a disease with several unique classifications and subtypes can be responsible for the inconsistent volume differences among various structures as reported in the literature.
PET examines cerebral metabolism using flurodeoxyglucose. PET studies on patients with OCD confirm that elevated glucose metabolism occurs in the bilateral thalamus, caudate and OFC regions. In an another study of the patients who check, hypermetabolism was found in the putamen/globus pallidus, the thalamus and the right inferior frontal cortex; in those who wash, the greatest activation was identified in the OFC the Cingulate Gyrus and the ventrolateral prefrontal cortex.
In 1947 stereotactic neurosurgery was developed, reducing considerably many post-operative adverse effects and complications. Since then, different centers have started to employ several stereotactic techniques, such as anterior cingulotomy (US), capsulotomy (Sweden), subcaudate tractotomy and limbic leucotomy (England and Australia).
Afterwards, Leksell simulated capsulotomy lesions focusing gamma rays beams emitted by Cobalt-60 radioactive isotope on the internal capsule. Large number of surgeries was performed during this time i.e. during 1940-1960s as there was no medical treatment for these disorders. However, with the availability of newer drugs the number of surgeries decreased. Recently, due to the better understanding of the disease and improved safety of surgical procedures, the interest in surgical treatment has reappeared.
Overview of surgical targets and technique
Appropriate selection of patients for surgery remains a major issue and the responsibility of the psychiatrist, guided by the informed and expert opinions of the other members of the psychosurgical team. Ethical objections of psychiatric neurosurgery are addressed in all centers by ensuring an informed consent from the patient and family.
Patient Selection
The selection criteria that we adopt are derived from distillation of various randomized study around the world. These have been further reaffirmed by the “National Advisory Committee for Psychosurgery in India” committee that met on 8th March 2009. The following guidelines have been adopted for selection of patients:
Treatment resistance
Exclusion criteria
Although many psychosurgeries have been done in the past, the following four procedures have evolved as the safest and most effective. They are all performed using modern stereotactic conditions to allow for the precise identification and accurate lesioning of the target structures. The contemporary procedures are anterior cingulotomy, sub caudate tractotomy, limbic leucotomy, amygdalotomy and anterior capsulotomy (and its neighboring structures). All these procedures involve lesions of limbic or paralimbic areas or interruptions of their connections with deeper brain structures.
The pre surgery evaluation must be performed by committed multi-disciplinary teams with expertise and experience in the surgical treatment of psychiatric illness. Diagnosis based upon a formal classification scheme is essential. All centers with experience emphasize the importance of rehabilitation post-operatively and the need for ongoing psychiatric follow-up. It appears that many patients are greatly improved after surgery and the complications or side effects are few.
Two methods of surgery are employed for altering these targets. One involves performing lesion and the other involves stimulation of these targets using deep brain stimulation (DBS). In a lesion, a radio-frequency unit is used to produce (destroy) a thermal lesion of calculated volume. This is permanent and irreversible. In DBS, an electrode is implanted at the site of the target and current is delivered through a pacemaker to alter the signals emanating from the target.
The pacemaker is implanted in the infraclavicular region over anterior chest wall and is connected by extension wire that are tunneled subcutaneously to the electrodes that are implanted in the brain. The amount of current and thereby the stimulation or the inhibition of the target site is controlled by an external programmer. DBS offers an exceptional benefit of reversibility and titrability. Both these procedures are performed using stereotactic techniques, which offer a high degree of accuracy (within 1–2 mm). Recently, US Food and Drug Administration (FDA) under humanitarian device exemption category approved the use of DBS for OCD.
Ablative surgery to treat mental illnesses is one of the therapies that has expanded more rapidly and widely as a non-pharmacological therapy. Throughout decades many targets approaches and techniques have been tried with diverse and sometimes contradictory outcomes. Although the effects on mood gained the attention of medical community, due to the growing prevalence and socioeconomic burden, often no objective measurement of the effects was performed and probably misdiagnosed patients were included into the studies.
Capsulotomy
Jean Talairach based on the leucotomy work got the idea to disconnect frontothalamic fibers e.g. fibers running between the subgenual anterior cingulate cortex, the orbitofrontal cortex, the medial anterior and dorsomedial thalamic nuclei. The procedure represented in that way a restricted lobotomy procedure and was performed stereo tactically by electro coagulation between the anterior and mid third of the anterior limb of the internal capsule at the level of the interventricular foramen. Lars Leksell propagated this procedure in Sweden were the procedure also have been performed with the gamma knife.
During the course of years, the target got more refined. Additional information suggested that the ventral part of the internal capsule was surrounded by functionally active an important areas like red nucleus of stria terminals, nucleus accumbens, ventral striatum etc. Nuttin et. al showed that the initial Capsulotomy target can be further modified to move posteriorly and ventrally to achieve better outcomes. The current strategy is to use stereotactic techniques to make a lesion in the VC/VS area. We have also now performed lesions in nucleus accumbens which are much smaller and have lesser side effects.
Results: There is no age limit for the surgery but capsulotomy below the age of 20 has not been reported. The anterior capsulotomy has been reported to be especially effective against obsessive compulsive disorder with a long lasting improvement among 48–78%. Side effects are generally few and transient consisting of headache, confusion, urinary incontinence and weight gain. The most prevalent side effect is tiredness and lack of initiative, this lethargia, although generally transient has been reported to last for several weeks or months and at least in some case may result in a persistent mild apathy or dominant frontal lobe syndrome.
We have performed 1 classical anterior capsulotomy and 3 Capsulotomy in the region of nucleus accumbens and VC/VS with excellent results
Cingulectomy (cingulotomy)
In 1967, Ballantine described the first stereotactic anterior cingulotomy for psychiatric disorders including depression, after the publication of reports by Foltz and White who by that time had carried out stereotactic cingulotomies in patients with untreatable pain. The stereotactic neurosurgical technique was applied for the first time in patients by Spiegel and Wycis in 1947. It was a milestone in neurosurgery because specific deep targets could be reached through one burr-hole by using internal cerebral landmarks. Ballantine reported an improvement in 77% of operated patients with comorbid fear and depression. Other studies showed an improvement between 44% and 92% with personality changes, epilepsy, weight gain and urine incontinence as the most reported side effects. Cingulotomy is more commonly used for treating depression than OCD.
Subcaudate tractotomy
In 1964, Knight described the stereotactic subcaudate tractotomy using radioactive Yttrium implants in order to perform lesions anteroventral to the head of the caudate nucleus in the substantia innominate (SI). The goal was to interrupt the SI fibers that run from the frontal cortex and amygdala to the hypothalamus. From the initial 15 depressive patients whom he operated on 14 remained therapy-free after surgery. Other studies showed improvement percentages of 59– 100%. Subcaudate tractotomy is not commonly practiced in present times.
Limbic leucotomy
In 1973, Kelly and Richardson described the stereotactic limbic leucotomy which consisted of an anterior cingulotomy in combination with a subcaudate tractotomy. Previous studies involving both areas had shown good results when performed separately. Experimental results had already shown a relation between the autonomous responses and emotions at the level of the limbic system. Intraoperative stimulation was applied to patients in order to evoke physiological responses which would confirm the exact location of the electrode in the target. Of the first 40 operated patients five of whom with depression four showed mild to large improvement of depressive symptoms. Three other studies showed an improvement percentage of 30–78%. The most common reported side effects were drowsiness, weight gain and memory problems but also epilepsy, urine incontinence and personality changes were described. This surgery is practiced occasionally in much selected cases especially if they fail one of the procedures.
Amygdalotomy
Terzian and Ore confirmed that there was a taming effect in human beings following removal of temporal cortical sturctures and amygdala. Over the next decades there was increasing evidence that the amygdaloid nucleus was a dominant component of the basolateral limbic circuit and actively involved in the development of aggressive behavior. Based on these observations Narabayashi et al. described a clinical series of 60 patients who had undergone stereotactic amygdalotomy for severe aggressive behavior. Since that initial report there have been 500 reported cases of stereotactic amygdalotomy for various behavioral disturbances and epilepsy with varying results.
In 1999, Nuttin et. al from Belgium showed that Deep Brain Stimulation (DBS) can also be applied for the treatment of OCD. They chose the anterior limb of internal capsule as the target. They reported results of 26 patients operated at four different centers around the world. Over a period of time they realized that patients who had more ventrally and posteriorly implanted electrodes had better outcomes. So they moved the target to VC/VS and later on nucleus accumbens and bed nucleus of stria terminals. One of the hypotheses for this is that in the posterior area the cortico-striatal-thalamo-cortical tract fibers are more condensed and the target can serve as node. The surgical procedure is very safe and similar to that offered for movement disorders.
Recently a meta-analysis of all the DBS studies for OCD was performed. The aim of this study was to measure the response to DBS in severe treatment resistant OCD patients using the meta-analysis. The data available from 116 subjects produced a global percentage of Y-BOCS score reduction of 45.1% and a global percentage of responders of 60.0%. Better response to DBS was associated with an older age at the time of OCD onset and with the presence of sexual or religious obsessions and compulsions. These results confirm that DBS appears to have an efficacy comparable to that reported for capsulotomy or cingulotomy, ablative techniques after which 64% and 56% of patients respectively are rated as significantly improved.
Nevertheless, severe adverse effects seem to be less frequent with DBS than with lesional neurosurgery. Three cases of intracranial hemorrhages were reported, representing 2.6% of the total number of patients. Five subjects presented an infection of the scalp, chest or abdominal wound, but they were controlled with antibiotic therapy and just one patient suffered a tonic-clonic seizure. Interestingly, no persistent frontal syndrome, cognitive impairment or personality changes have been described for OCD patients treated with DBS. Nevertheless, almost all studies describe these stimulation-related adverse effects as mild, transient and reversible after the adjustment of the stimulation parameters.
Most patients report a significant improvement in at least some aspects of their quality of life. Interestingly, this improvement was not directly correlated with the reduction of symptom severity and was reported even by non-responding patients. Also, QOL keeps on improving years after the initiation of DBS, and even when there was no further reduction of OCD severity was evident, suggesting than factors other than OCD intensity such as anxiety release, reward processing and motivation or affective status, influence QOL. The effects of DBS on abnormal neural connectivity in the CSTC circuit involved in the mechanism of OCD, might explain why stimulation of different brain regions, achieves similar percentages of improvement finally.
Stimulation of STN has been reported to decrease mPFC and OFC metabolism as well as ACC activity, while stimulation of the ALIC has similarly been associated with decreased OFC, subgenual ACC and right DLPFC metabolism. Interestingly, though stimulation of STN did not significantly modify comorbid depressive and anxiety symptoms but a significant and early improvement was observed in anxiety and mood levels, preceding any change in OCD severity, is commonly reported in patients receiving stimulation in the striatal areas. Future studies should address the local and distant effects responsible for mutual as well as distinct mechanisms of action of DBS depending on specific targets in order to personalize the choice of the optimal implantation area according to the individual presentation of the illness.
Our own observation about DBS in two patients of OCD, have been very encouraging. Both patients had more than 60% improvement in their YBOCS scores with significant improvement in the quality of life.
Mr. V, 62 years old Engineer from Karnataka was an anxious, determined, short tempered, reserved and dominating personality. He developed depression after the demise of his father in 1990. He was treated for the same in Mysore. One year later his symptom progressed to anxiety, dominated by obsessive and compulsive symptoms, which gradually increased in severity. He had taken voluntary retirement and had not been working since past 15 years.
He was also unable to withdraw his pension, as he could not sign for himself. His obsessive symptoms included insisting on repeated checking and verifying documents, cheques and money. His compulsions included repeated washing of the hands (about 80-100 times at the time of admission) spending long time in the toilet (about 3-4hrs) repeatedly asking the same questions and verifying the answers multiple times. There were no ideas of reference on persecution. There were no hallucinations.
Since the last two years he had been confined to home due to these symptoms. His disease had significantly affected his and his caregiver’s quality of life. He had been on SSRIs and SDAs, including Fluoxetine, Fluvoxamine, Sertraline, Clomipramine, Escitalopram and many others in maximum doses. He had also undergone behavioral therapy during these 15 years (more than 20 outpatient sessions) under the care of psychiatrist without any significant change in his symptoms. At the time of admission he was on a daily dose of Risperidone 2mg, Quetiapine 75mg, Alprzolam 5mg, Escitalopram 10 mg and Fluoxetine 100mg. The referring psychiatrist and the psychiatrist who independently assessed him for surgery both were satisfied with the duration of the treatment (medical and behavioural therapy) and had found to be adequate to establish intractability.
On examination He was intelligent, anxious, well oriented and had normal memory. He had preserved insight, co-operative and repetitive. His thought process had occasional tangentially, but can be brought back to rational thinking. He had no other focal neurological deficits.
He was evaluated by two psychiatrists independently, who established the diagnosis of OCD as per DSM IV criteria. The neurosurgeon (author) also concurred with them and decided to offer surgical option. He underwent neuro-psychological testing that included Minnesota multiphasic personality inventory and RORSCHACH. The MMPI revealed “Fake Bad” protocol/psychoses. The F% was 66.67% implying weakening ties with realty. It was reported as obsessive compulsive personality disorder and psychoses. However, it was also noted that the patient was very defensive in taking the tests (and was also tired). His YBOCS was 38/40 and Hamilton depression score was 24. His Beck’s anxiety inventory reflected a score of 26 revealing moderate degree of anxiety. The Mini-Mental State Examination score was 30, revealing a normal cognitive profile. Based on the clinical history, patient interview and results of various assessments, the team of psychiatrists concluded that this was a case of intractable OCD and qualified for surgical intervention. There were two options available for surgery: DBS or ablative surgery(Lesion).
Patient and his wife came from a city that was four hours’ drive from Bangalore (the closest town to have flight connections with Mumbai). They had not travelled independently in many years and felt that it would be difficult for them to make frequent visits to Mumbai for postoperative programing. Hence, they decided to opt for lesion. The case was than referred to the psychiatric surgery review board, which comprised of a neurosurgeon, neurologist and psychiatrist not involved in surgery or patient care. They found that the surgical treatment was a logical option for improving patients’ condition.
As the patient could not sign (because of OCD) an informed consent was obtained from his sister and wife. Patient consent for surgery was recorded on video. A preoperative planning MRI was performed one day prior to surgery. IR and T2 weighted coronal images were used to identify the internal capsule. A surgical target 3 mm anterior to the posterior border of anterior commissure and 2 mm inferior to the AC-PC plane was selected. This was the bottom of the target. On the day of surgery, a stereotactic CT scan was performed and fused with the preoperative MRI. The target was approached through a precoronal burr hole under local anesthesia. Neuro physiological response was noted starting from 20mm above the target to 3mm below the target on right side and 15mm above till 3mm below the target on left side. The response in the form of decrease in anxiety, more calmness and pseudo smile were noted nearer the targets. Radiofrequency lesioning was done bilaterally at 75 degree Celsius for 60seconds.
Post op CT scan confirmed appropriate target. He had good improvement in his OCD symptoms but had severe confusion and disorientation in the initial three postoperative days. He was also having high-grade fever and hypernatremia, for which no identifiable apparent cause. Reduction in the dosage of psychotropic medications was done on consultation with the Psychiatrist. At the time of discharge he had very good relief of his OCD symptoms. The YBOCS at the time of discharge (1 week postoperatively) was 9 and the depression score was 6. He had no anxiety. After three months of follow up the family reported that his obsession were as well controlled as after surgery, he had lesser anxiety and depression. The apathy has reduced. His progress and medical management is being done by the referring psychiatrist who has been keenly interested in the surgical option.
Anterior capsulotomy surgery for intractable OCD
Rodney King, a 51 years old gentleman, travelled from Australia to get his OCD and Depression treated at Jaslok Hospital by Dr. Paresh K. Doshi. Though Rod had started experiencing minor symptoms of OCD right from his teen age, his brother’s death in a car accident when he was 13 years old triggered the disease. He experienced intrusive images of people who were close to him being either injured or dead. He had concerns regarding cleanliness. He had unwanted thoughts of items being contaminated by germs. He washed his hands excessively and spent large amounts of time wiping down tables, door handles, stove knobs and other every-day items. He might wash the contents of his wallet because of concern that they were contaminated. He had difficulty going out in public. He repeated his movements and retraced his steps.
If he experienced an intrusive thought whilst performing an action, he would make himself repeat the action. He exhibited checking behaviors, e.g. when driving he constantly checked in the rear vision mirror to make sure that he had not hit anyone. After throwing out rubbish, he had to re-check to make sure he had not thrown out anything valuable. When shopping, he spent large periods of time deciding what to buy, even when considering mundane items. He exhibited counting phenomena, e.g. He counted letters in people’s names or the number of windows in buildings. His excessive hand washing had resulted in him causing scars to his hands because of the methylated spirits he had used. These symptoms took up the majority of his day and interfered with his everyday life. They had interfered severely in his ability to form relationships. As the disease progressed he started becoming more depressed. During the course of his illness he had tried virtually all the possible treatments available to control his disease. All drugs used to help him little (except Clomipramine) but they brought in intolerable side effects like gastric upset. Some of the drugs made him put on excessive weight because of which he is >150 Kg. today. He also tried around 40 ECTs (Electro-convulsive therapies) > 20 cognitive and behavioural therapy, transcranial magnetic stimulation and rTMS, with little and transient improvement.
During this time he found out about the surgical option and went to Melbourne for getting operated. He was refused surgery and this shattered him. He bought a nail gun to perform lobotomy on himself. He also tried to commit suicide (six times) to get rid of his illness. He got married, and had one son, but the marriage did not last long enough and ended up in a bitter divorce. Presently he is unemployed and lives with his mother. He found out about the surgery being offered by Dr. Paresh K. Doshi and approached him. After due deliberation with Rod’s psychiatrist and the local multidisciplinary team, Rod was offered surgery on the 18th December. He underwent anterior capsulotomy. During the surgery itself Rod found that his anxiety decreased, he felt bright, happier and his obtrusive thoughts became insignificant. He is now back with his mother and preparing to go back to Australia.
Surgery for psychiatric disorders has been always marred with controversies. In order to avoid the mistakes of the past psychiatrists from all across India. From academic and private practice all functional neurosurgeons met in May 2009.
Around 30 experts brain stormed and debated over the published literature and evidence. Guidelines for this were subsequently laid down and recommended for any center desirous to follow surgical program. In 2011, World society of stereotactic and functional neurosurgery, set up a “Psychiatric surgery task force” to evaluate the evidence and draw guidelines for the psychiatric disorders surgery.
After two years of debate and data analysis, the guidelines were formed taking several aspects into consideration and published in 2013. This is an open source publication and can be reviewed by anyone. Some key parts of guidelines are reproduced below:
The treatment for psychiatric disorders, ranges from those that are used frequently in specialist centers for several decades (e.g, anterior cingulotomy for MDD, anterior capsulotomy for OCD) to those that remain highly on experimental basis and have only been tested in very small number of patients (e.g: DBS for anorexia nervosa). However, despite the lengthy history and the weight of publications, associated with lesion procedures in particular, the accumulated evidence supporting the application of all neurosurgical treatments for psychiatric disorders requires to be strengthened.
While certain procedures are considered to represent ‘established’ practice for severe, treatment-refractory psychiatric disorders in some countries (eg: radiofrequency anterior capsulotomy for severe, treatment-refractory OCD in Belgium, thermal anterior cingulotomy for MDD and OCD in the USA, Scotland, South Korea and elsewhere) the nature of these and many other procedures in neurosurgery, including DBS for psychiatric disorders, remains at a ‘proof-of-principle’ investigational stage of development. Current practiced stereotactic ablative procedures do not have level I evidence with randomized controlled trials, but their safety and efficacy are supported by level II evidence in treatment-refractory MDD and OCD. However, this degree of evidence is not yet available for ‘new’ lesioning methods such as gamma knife and stereotactic-focused ultrasound.”
The paper goes on to suggest that besides careful patient selection, till the therapies get fully established, they should be overseen by ethics committee or Institutional review board. The guidelines were endorsed by several world organizations, including, European Society for Stereotactic and Functional Neurosurgery (ESSFN), partnering with the Working Group ‘Deep Brain Stimulation in Psychiatry: Guidance for Responsible Research and Application’, along with the Psychiatric Neurosurgery Committee of the American Society for Stereotactic and Functional Neurosurgery (ASSFN), the Latin American Society for Stereotactic and Functional Neurosurgery (SLANFE), the Asian-Australasian Society for Stereotactic and Functional Neurosurgery (AASSFN) and the World Psychiatric Association (WPA).
At the Jaslok Hospital and Research Centre strict adherence is followed. Even before this paper all surgeries were scrutinized and overseen by the Ethics committee and scientific committee of the Jaslok Hospital to ensure patient’s safety.
