For some patients, removing brain tissue can help treat OCD and other disorders. But ethical concerns remain

Frieda Klotz, UndarkApril 25, 2025

Up until a couple years ago, an attorney in his late 30s used to repeatedly check his vehicle for signs that he might have injured a pedestrian. The man had no reason to think he had actually hit someone, but his obsessive-compulsive disorder made him fearful. “I spent hours examining the car,” he said. He’d feel the body for dents, take photos and was never quite done. At its worst, the condition consumed up to 17 hours of his day.

“My mind was hijacked for 25 years by a devil that was OCD,” said the man, who asked that his name not be used due to the stigma surrounding mental health disorders and the treatment he’s undergone.

He was first diagnosed with the disorder, which is characterized by obsessive preoccupations that interfere with daily life, when he was 15, shortly after his mother died. In the intervening years, he tried numerous forms of therapy, medication, brain stimulation and residential treatments—all of which, he estimated, cost him hundreds of thousands of dollars. None of them helped long-term.

In 2022, his father heard about a brain surgery intended to relieve OCD symptoms and found it was offered by two hospitals affiliated with Brown University. In December 2023, a neurosurgeon created a small hole in the man’s skull and deployed heat to burn away brain tissue. The resulting lesion is thought to disrupt the interaction between parts of the brain associated with OCD symptoms.

“I didn’t think it would work at all, because nothing had worked on me,” he told Undark on a Zoom call with his neuropsychologist at Brown, Nicole McLaughlin, and a communications officer from the health system where the attorney had his surgery. “It was a complete miracle.” He added that he was still aware of his repeating thoughts after the surgery, but they no longer bothered him: “It was unbelievable.”

Originally known as psychosurgery, this uncommon approach to mental health care involves operating on the brain to alter its function. After lobotomies left many vulnerable patients disabled in the mid-20th century, the practice lost momentum and acquired a stigma. But surgeons in the field continued to refine their techniques. Now, psychiatric neurosurgery, a nimbler descendent, has seen an uptick in the treatment of conditions like severe OCD, and—more rarely—treatment-resistant depression and anxiety. Researchers say it may also prove beneficial in other hard-to-treat conditions, like anorexia nervosa. In other words: Some now believe that for a small group of patients who have exhausted standard therapies, the removal of brain tissue is a valid treatment path.

Many more patients could benefit from these treatments than currently receive them, at least in theory. Some 2.8 million Americans have treatment-resistant depression. An estimated 1 to 3 percent of the world’s population experiencessome form of OCD. In about 20 percent of cases, McLaughlin said, the condition is estimated to be resistant to treatment.

Still, ethical concerns remain: In a recent survey of practicing and resident psychiatrists in Quebec, about a third said the practice, along with another treatment called deep brain stimulation, was dangerous. And practitioners themselves acknowledge that risks, while generally rare, may include loss of energy and motivation (usually temporary, McLaughlin said), brain bleeds, memory impairment, and weight gain. Meanwhile, given the small number of operations performed each year, the field lacks large-scale trial data on its effectiveness.

But based on smaller studies and anecdotal evidence, experts say that sophisticated imaging techniques now enable surgeons to focus on areas of the brain much more precisely than in the 1950s, reducing the risks involved. And because of new technologies that are more targeted and less invasive, these procedures are no longer seen as a last resort, said Nir Lipsman, a neurosurgeon at the University of Toronto, who added that they have gained currency compared with other novel approaches like deep-brain stimulation. “We’re seeing sort of pendulum swing in the field of neurosurgery,” he said.

The numbers of patients who receive such treatments is still tiny. Lipsman’s clinic in Toronto, for example, performs about two psychiatric neurosurgeries a month, though he said it has the capacity to do more. And the Brown-affiliated program has only seen about 110 patients since 1993, when psychiatric neurosurgery procedures were first offered there. Meanwhile, just a handful of centers in the U.S. offer neurosurgery for psychiatric conditions; McLaughlin said patients come to the program from all over the world. To be eligible, patients typically must be diagnosed with severe OCD and have tried several other treatments to no effect. A Belgian psychiatrist, Chris Bervoets, who leads the University Center for Obsessive Compulsive Disorders at KU Leuven, told Undark that patients at his clinic typically endure OCD for 15 to 20 years before they consider surgery.

McLaughlin has stayed in touch with many of her patients, including the attorney, who is now participating in a study to explore his brain’s response to the surgery over time.

“It’s amazing for some patients, and this is why I do what I do and I love what I do,” she said. “But then there’s certainly still a subset of patients who it doesn’t do anything for. And so our goal is to figure out how to improve it, how to refine the surgery, so we can improve it over time.”

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Modern medicine’s first attempt to cure psychiatric illness through surgery may be traced back to the late 19th century, when Gottlieb Burckhardt, a Swiss psychiatrist, removed tissue from the cerebral cortex in a half-dozen patients. Most of those patients had schizophrenia, or what was known at the time as simply “madness.” But it wasn’t until decades later that neurosurgery gained widespread attention when, in the mid-1930s, António Egas Moniz introduced the frontal lobotomy—a surgical procedure in which nerve connections between the frontal lobe and the rest of the brain were severed. He won a Nobel Prize for his work in 1949.

Transorbital lobotomies, which used a tool inserted into the back of the eye socket, were conducted on about 60,000 people across the U.S. between 1936 and 1956 alone. Although mortality and morbidity rates were high, some patients saw significant improvements. “There’s no question that they had a beneficial effect,” said G. Rees Cosgrove, the director of functional neurosurgery at Brigham and Women’s Hospital, who has worked in the field for more than 35 years.

But poor research practices abounded. American neurologist Walter Freeman believed that his uniquely designed instrument meant that he no longer needed surgical scrubs. And even though many surgeries resulted in injury or death, reporting was unreliable, Cosgrove and colleagues pointed out in a recent review. In one paper, they noted, Moniz failed to cite “a single adverse event.”

“It was well-intentioned to help people,” said Judy Illes, a neuroethicist at the University of British Columbia. But, she added, regulation was inadequate. “It went rogue.”

Compared with the methods of the mid-20th century, today’s techniques are considerably more precise. Typical procedures include the capsulotomy—which creates a lesion, either through heat or radiation, to sever fibers in a part of the brain that connects regions associated with emotion and behavior; and the cingulotomy, which deploys similar techniques to target a larger area nearer the brain’s surface called the anterior cingulate gyrus. (The attorney who was treated at a Brown-affiliated hospital underwent a capsulotomy.)

Another practice, deep brain stimulation, or DBS, targets similar regions as the other procedures through electrodes implanted in the brain, which can subsequently be modified or fully removed. Some clinicians argue that DBS is distinct from psychosurgery because it stimulates, rather than destroys, tissue, and it is technically reversible, making it more appealing to certain patients. Some debate persists about which approach is best.

The benefits of ablative treatments—meaning those that permanently remove or destroy parts of brain tissue—align with their risks: They are one-off surgeries with permanent results. For some patients, this makes them easier to tolerate, McLaughlin said. Patients with OCD who tend to pick their skin or are bothered by implantation may be better served by a single surgery. An implanted device may also be burdensome for people with anorexia who are frail and medically compromised, she added.

While capsulotomies and cingulotomies are defined by the brain region targeted, the method surgeons use can vary. Among the oldest and less common is radiofrequency ablation, in which the surgeon inserts electrodes that have their tips heated to 70 degrees Celsius into the skull to generate a lesion. Gamma knife ablation, meanwhile, uses radiation beams to destroy tissue. Another technique, focused ultrasound, heats parts of the brain using soundwaves. And laser interstitial thermal therapy, or LITT, the technique the Brown-affiliated team used in the attorney’s procedure, deploys a laser beam to target part of the brain.

These new techniques reduce what Lipsman, who is also a neurosurgeon at Toronto’s Sunnybrook Health Sciences Center, described as collateral damage. In the past, capsulotomies were more likely to affect cognitive function or memory, but now, he said, “we’re finding that today’s lesional procedures can be done in a much safer way.”

Lipsman and other specialists who carry out these procedures say that the changes in their patients are visible and significant, although they may need to continue medication and treatment. Lipsman said that following a capsulotomy at one year, 50 to 60 percent of patients see improvement in their OCD: “It’s some of the most rewarding and incredible transformations that we’ve seen in some of our patients.”

Other clinicians agree. Martina Mustroph, a surgical fellow at Emory School of Medicine who has collaborated with Cosgrove, said that treatments for severe, treatment-resistant OCD are effective but should be discussed carefully with patients and their families, and a multidisciplinary team. Mustroph said that she doesn’t see the surgeries as experimental: She pointed to a 2019 review of anterior capsulotomy studies, which analyzed data from 512 patients over 57 years and concluded that the procedure is a “safe, well-tolerated, and efficacious therapy. Its underuse is likely a result of historical prejudice rather than lack of clinical effectiveness.”

That does not mean there are no risks. In a long-term follow-up study of 25 patients (four of whom had a unilateral and 21 of whom had a bilateral capsulotomy), which was published by researchers in Sweden and Scotland in 2008, one patient became hypersexual and was convicted of rape five months after surgery. Some patients had memory problems, and a woman lost her job because of sexual disinhibition. The group noted that although capsulotomy was effective in treating OCD, the likelihood of adverse events was high, affecting ten of the patients who had undergone the procedure.

Christian Rück, the psychiatrist who led the study at the Karolinska Institute in Sweden, wrote by email that he is no longer directly involved in this sort of research but that he assumed the techniques had improved since his 2008 paper was published. (Mustroph, who was not involved in the study, confirmed that clinicians’ ability to target the treatment was not as refined then as it is today.)

“Of course, even a small lesion in the wrong place can be detrimental,” wrote Rück.

About ten years ago, the Brown team observed the potential harms of treatment firsthand when a handful of patients developed brain cysts after ablative treatment using gamma knife radiation. They did not know why the cysts occurred, so they put the procedures on hold. But one patient who underwent surgery to remove a cyst ended up in a vegetative state. He later died, an event that Michael Schulder, a neurosurgeon who had treated that patient after his cyst formation, described as distressing for all involved.

After starting back up with smaller lesion capsulotomies using the gamma knife radiation, the group at Brown began using LITT in December of 2016. “There’s technically risk of death with any kind of neurosurgery you do” said McLaughlin, adding that their team aims to be “as cautious as possible with our patients.”

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Even the slightest likelihood of such an outcome, coupled with the long shadow of lobotomy, has deterred many psychiatrists from referring patients for such surgeries. “Many of them still think that they’re not safe,” said McLaughlin, who recently conducted a survey of 93 psychiatrists and psychologists that has not yet been published. In Japan, for example, the country’s Society of Psychiatry and Neurology passed a resolution against psychiatric neurosurgery in 1975.

McLaughlin argues that stigma and misinformation have colored many clinicians’ perspectives. But other experts say they’re wary because of a dearth of safety data, and because the results are permanent.

Rebecca Park, a psychiatrist at the University of Oxford who specializes in eating disorder research, said she couldn’t comment on using ablative neurosurgery for disorders such as OCD or depression, but she has cautioned against using it for anorexia. “The problem with ablative techniques is that they’re irreversible,” she said. Others raised concerns about side effects: “Moreover, whilst the numbers are small, we should acknowledge that some patients who have undergone ablative procedures do unfortunately report serious and long-term adverse events,” wrote Jonathan Pugh, an ethicist at Oxford, in written comments to Undark.

Schulder, who is the former president of the American Society for Stereotactic and Functional Neurosurgery, said that ablative therapies could suit some patients but cautioned against a generalized recommendation since their effects cannot be undone: “You burn a hole in the brain, you’re sending a horse out of a barn.”

Another reason for skepticism within the psychiatric community is the almost total absence of randomized controlled trials proving efficacy. Such trials are hard to finance at a large scale, Cosgrove said. His team has received FDA approval for a randomized trial of one type of capsulotomy, but it has not yet obtained funding.

And such trials raise their own ethical worries because patients are so vulnerable.

Researchers from Brown and the University of São Paulo conducted a randomized trial on 16 patients with severe OCD just over a decade ago—the first of its kind in the field. (The paper was later corrected because of a statistical error.) Eight patients underwent a sham procedure—meaning that they experienced the rituals of the procedure and were sedated, but not the medical intervention—and eight had a capsulotomy. Two out of the eight patients in the treatment group experienced improvement in their OCD symptoms, compared with none out of eight in the control. Four and a half years later, three other patients in the treatment group were also doing better. Despite these improvements, one year out from treatment, there was no statistical difference between the groups in depression and anxiety. One patient had brain swelling and developed a cyst caused by radiation. The researchers had to conclude that the surgery’s benefits were not statistically significant.

Such trials are hard to design and carry out. In order to do a blind study—meaning that the patient doesn’t know which treatment they receive—“we would ultimately have to take a patient and put them through six hours of general anesthesia, a full neurosurgical procedure, and not actually lesion anything,” McLaughlin said. The previous randomized clinical trial used gamma knife, which is non-invasive. But studying laser ablation, McLaughlin said, would mean drilling holes in the skill of someone not getting treatment. She added that eligible patients are already mentally fragile, and “also then you’re withholding care, too.”

Sabine Müller, a neuroethicist at the university hospital Charité—Berlin University of Medicine and an author of a 2022 paper exploring why many experts have reservations about psychiatric neurosurgery, told Undark in a written statement that concerns about the lack of evidence underpinning these treatments are justified. Many studies are not double-blinded or placebo-controlled, and few have adequate statistical power, she said: “Most of the studies in psychiatric neurosurgery do not meet the basic scientific criteria that are standard in pharmaceutical research.”

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To help build a bank of evidence, some experts have called for an international registry of patient trajectories. Indeed, a national registry was first proposed in 1978, McLaughlin said, adding that she has applied for funding to collect data across several hospital sites and is currently waiting on a recent resubmission.

Müller has also called for such registries. “Important to note is that [randomized controlled trials] are not the only study designs that can produce valuable scientific evidence,” she wrote via email. Comparing patient outcomes before and after different treatment techniques “can also prove the efficacy and safety of a method.”

Still, even the most established experts in this field believe that progress will be slow, and that because of the stigma and risks, these techniques will not be widely available to patients in the near term. Such delays in making innovative treatment available are unfortunate to Illes, the neuroethicist, although she emphasized that regulations and safety are a prerequisite. “If we’re going to be innovating new interventions for treatments, for conditions that are not responsive to other treatments, and they work, well, of course they ought to be available,” she said.

Withholding psychiatric neurosurgery is not the right path, Schulder agreed. “To turn away from either actual or potential surgical options that are so vastly safer than their predecessors of 50-plus years ago is stupid,” he said. “To say that no one should ever get psychiatric surgery is ridiculous.” Still, in the absence of randomized controlled trials, Schulder argued, surgeon testimonies are inadequate even when the results of the procedures seem genuinely promising.

“The neurosurgeons don’t have credibility on this issue,” he said, adding that the lobotomy scandal still haunts the field of neurosurgery. As a result, for surgeons, “If you’re already stepping into the minefield of psychiatric surgery, you know, [you have] already got a big weight around your ankle.” Instead, he said, psychiatrists must take the lead in promoting these procedures.

The attorney who kept checking his car for dents, out of fear of hitting a pedestrian, said he has encountered doubts about the surgery among therapists and even within the OCD community. But he had the treatment when he was feeling particularly low, and he said it has essentially saved his life.

At the time, his young son was 5 months old. And he said he’s hopeful his son won’t remember his symptoms back then. “I just was, you know, not able to probably be with him as much as I wanted to,” he said. “I was really struggling.”

This article was originally published on Undark. Read the original article.