Contemporary psychosurgery

Psychosurgery is a safe and relatively effective treatment which should be offered to patients with intractable obsessive compulsive disorder (OCD), m ajor 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 develo ping from advances in functional brain imaging. The optimal site and size o f the lesions remains to be established. The standard technique uses stereo tactic radiofrequency thermolesions but stereotactic radiosurgery is an alt ernative. 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. Unfortunat ely, there are as yet no reliable clinical or investigational predictive in dicators for the good outcome group. Restricted accurate lesion placement m inimizes personality change, epilepsy and cognitive decline. Careful safegu ards, including approval by an independent multidisciplinary legally consti tuted review board are mandatory in selecting and following the patients, b ut unfortunately there are individuals who are never referred or reside in a society which proscribes the operation, whose lives could be made more to lerable. Psychosurgery is probably underutilized due to negative perception s based on historical factors, and strict regulations and legislation limit ing its application. It is possible that with advances in psychiatric pharm acotherapy, the psychosurgery procedures will be made redundant, but we bel ieve that until this eventuates there is still a small place for these oper ations. 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 b est results.