Efficacy, management of adverse effects and relapse forms after obsessive-compulsive disorder surgery: The first Egyptian and Arab cohort

Abstract

Background:

The aim of this study was to investigate the outcome of neurosurgery for mental illness in a cohort of Egyptian/Arab patients with treatment-resistant obsessive-compulsive disorder (OCD).

Methods:

Sixteen patients were recruited from various psychiatric clinics. All participants met DSM-5 criteria for OCD and had failed extensive trials of psychiatric medications and psychotherapies. Eligibility criteria focused on significant distress and functional impairment, as well as a Yale-Brown Obsessive Compulsive Scale (YBOCS) score greater than 30. Patients underwent either cingulotomy or capsulotomy and were followed monthly beginning immediately after surgery. Follow-up assessment evaluated OCD symptom severity, depression, anxiety, functional status, and both immediate and delayed postoperative adverse effects.

Results:

At the most recent follow-up (median: 19, range: 6 months – 25 months), 56.25% (9/16) of patients achieved at least a partial response, including 8 responders and 1 partial responder. Significant reductions in YBOCS, Beck Depression Inventory (BDI), and Hamilton Anxiety Rating Scale scores were recorded, suggesting that psychosurgery may be associated with improvement in OCD symptoms. However, because this was a noncontrolled study, causality between surgery and clinical improvement cannot be established. Immediate adverse effects were mild, transient, and observed in 37.5% (6/16) of patients. Delayed adverse effects were reported by 68.75% (11/16) of the total cohort and were predominantly characterized by recurrence of the initial OCD symptoms (9/16), often accompanied by depressive symptoms. Notably, two-thirds of patients who experienced symptom relapse were subsequently managed successfully with pharmacotherapy and behavioral therapy.

Conclusion:

Both cingulotomy and capsulotomy may be associated with significant reductions in OCD symptom severity, as well as improvements in depression and anxiety among patients with treatment-resistant OCD. Although relapse of OCD symptoms during follow-up was common, close monthly monitoring immediately after surgery and ongoing management were effective in restoring clinical improvement in many patients. As the first study of its kind conducted in Egypt and the Arab world, these findings also highlight the unique cultural challenges encountered in introducing psychiatric surgery within this setting.

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a chronic, debilitating psychiatric disorder with a lifetime prevalence of 2–3%. Despite the availability of multiple nonsurgical treatment modalities, a substantial proportion of OCD patients is treatment resistant, resulting in profound functional impairment and markedly reduced quality of life. For these individuals, neurosurgical intervention has been an established option since the mid-twentieth century, evolving from ventriculography, stereotactic radiofrequency lesioning to modern magnetic resonance imaging (MRI)-guided procedures.[21,25] Numerous studies, although predominantly noncontrolled, have demonstrated that both cingulotomy[2,9,18] as well as capsulotomy[21,25] may provide meaningful clinical benefit for patients with severe, treatment-refractory OCD.

Psychiatric neurosurgery was introduced in Egypt only recently, with the first procedures performed in 2023 by our team.[14] We report herein the results of our prospective longitudinal follow-up of all patients who underwent psychosurgery for OCD in Egypt. While most published studies have evaluated outcomes in 6-month intervals, we hypothesized that close postoperative monitoring through monthly “zoomed-in” follow-up – particularly during the early postoperative period – would improve the detection and management of symptom recurrence and postoperative adverse effects, thereby optimizing long-term outcomes.

Previous studies have generally provided limited discussion of postoperative adverse effects, particularly from a psychiatric perspective. Likewise, “relapse” following response has received relatively little attention. Although some authors have distinguished between “objective” and “subjective” relapse, comprehensive descriptions of relapse patterns and their management remain scarce. For example, Baer et al. (1995) described a patient who underwent cingulotomy, maintained a favorable clinical response for 60 months, and subsequently experienced recurrence of OCD and depressive symptoms. Despite continuing to meet the study’s criteria for treatment response, the patient ultimately underwent a second cingulotomy procedure.[2]

Similarly, Rasmussen et al. reported that approximately one-quarter of patients experienced transient postoperative improvement that resolved within 3 months,[27] while Hay et al. described two patients who demonstrated marked initial improvement followed by relapse at 12 and 24 months, respectively. Other investigators have suggested that symptom recurrence may reflect neuroplastic repair following psychosurgical lesioning, particularly after nucleus accumbens lesioning,[16] although detailed descriptions of relapse management remain lacking. To our knowledge, this is the first study to characterize relapse and recurrence patterns of OCD symptoms following cingulotomy and capsulotomy as delayed postoperative adverse effects and to examine their psychiatric management in detail. Our primary objectives were to evaluate surgical efficacy, characterize both immediate and delayed adverse effects through close month-by-month follow-up, and develop an effective postoperative management strategy. Particular emphasis was placed on understanding the clinical patterns of relapse and recurrence.

In addition, we sought to investigate patients’ responsiveness to conventional pharmacological and behavioral therapies after surgery and compare these responses with their treatment outcomes before surgery, thereby assessing whether psychosurgery enhances the effectiveness of subsequent standard therapeutic interventions.

MATERIALS AND METHODS

Study design

This is a prospective analysis of patients suffering from treatment-resistant OCD, diagnosed according to the DSM-5 criteria of the American Psychiatric Association (2013).[4,17] Subjects were recruited from the outpatient clinic of our psychiatry and neurology center. The diagnosis for each subject was confirmed by at least two certified psychiatrists experienced in the diagnosis and management of OCD. Surgical procedures were performed at tertiary hospitals. The study was approved by the institutional ethics committee, and written informed consent was obtained from each patient and one first-degree relative after detailed discussion of the procedure, expected benefits, potential risks, and possible complications.

The study was carried out at a specialized center offering comprehensive resources for managing OCD, including clinics, medications, cognitive behavioral therapy (CBT), repetitive transcranial magnetic stimulation (rTMS), electroconvulsive therapy (ECT), and experienced psychiatrists and psychologists. Surgery was integrated as one component of a comprehensive treatment pathway rather than a standalone intervention, allowing all postoperative psychiatric management and follow-up to be provided by the same multidisciplinary team. This treatment model was explained to all patients and their families before surgery.

Inclusion criteria

Eligibility for surgery was determined according to four principal criteria: severity, disability, chronicity, and treatment refractoriness. “Severity” was defined as a Yale-Brown Obsessive-Compulsive Scale (YBOCS) score >30.[12] “Disability” is determined by substantial distress and functional impairments as assessed by a Global Assessment of Functioning (GAF) score of <50 (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [DSM-IV-TR], American Psychiatric Association, 2000).[7] “Chronicity” required persistence of symptoms for at least 2 years without sustained remission.

“Treatment refractoriness” was defined as failure to respond to all standard evidence-based nonsurgical treatments. Clinical response is defined as a reduction of at least 35% in the Y-BOCS score. Treatment refractoriness is defined as failure to respond to all the following treatment trials: (1) at least three adequate trials of different selective serotonin reuptake inhibitors (SSRIs), each administered at the highest tolerated dose for a minimum of three months, together with standard augmentation using at least two atypical antipsychotics at adequate doses and durations.[17,30] (2) OCD-specific CBT consisting primarily of exposure and response prevention for at least 30 h without adequate clinical response. Shorter treatment duration was accepted only when continuation was prevented by symptom severity rather than noncompliance. (3) Any previous improvement achieved with medication or psychotherapy had not been sustained over time. (4) Full adherence to all prescribed treatments.

Exclusion criteria

Patients were excluded if they had any of the following: frank psychosis, current substance use disorder, severe personality disorder, noncompliance with treatment, uncertainty regarding surgery, pregnancy, or participation in other studies.

Assessment

Subjects were assessed pre and postoperatively with the following standardized tests: YBOCS for severity, Y-BOCS-I clinician-rated Symptoms Checklist,[12] Beck’s Depression Inventory (BDI),[4] Clinical Global Impression Improvement Scale (CGI-I) for OCD symptoms, depression, and anxiety,[6] Hamilton Anxiety Rating Scale (HAM-A),[29] GAF scale (DSM-IV-TR, p.34.).[1]

Surgical operation

Thin-slice imaging was utilized as preoperative magnetic resonance (MR), registered with frame-based computed tomography (CT) with contrast (1.5 T MR Vantage Titan, 320-row CT Aquilion ONE, Toshiba Medical Systems, Otawara, Japan), using a stereotactic frame (Riechert Mundinger-R) applied via a scalp block. The MR parameters included TE = 10 ms, TR = 600 ms, slice thickness = 0.5 mm, and spacing interval = 0.5 mm. During awake surgery, the team interacted with the patient. Headache intensity was consistently assessed using a 0–10 scale to ensure that there was no exacerbation of the initial mild headache from frame application and to rule out any intraoperative surgical complications, such as hematoma or mis-targeting. The surgery was planned to be terminated if any alarming neurological signs or deterioration in consciousness occurred. The radiofrequency generator used was the Inomed Neuro N50, delivering a temperature of 85°C for 90 s via a bipolar TC013 standard thermistor-equipped thermocoagulation electrode. Patients were randomly assigned to undergo either anterior cingulotomy or anterior ventral capsulotomy. It is important to note that the subjects/participants were blind to which procedure they would receive, whereas the investigators were aware; thus, our study is considered a single-blind study.

Follow-up

All patients underwent both clinical and radiological follow-up. An immediate postoperative CT scan of the brain was conducted to rule out any surgical complications, followed by an MRI 1 month later to confirm the location of the lesion. Objective scales including the Y-BOCS, CGI-I for OCD symptoms, the BDI, the HAM-A, and the GAF Scale were re-administered monthly to closely monitor postoperative changes. Clinician ratings were obtained from patients and verified through interviews with family members.

YBOCS-based outcome and relapse

The cut-off values were determined using the YBOCS during the follow-up period to categorize responses and relapses. Responders were defined as those exhibiting a reduction of 35% or more on the YBOCS scale after surgery. Partial responders demonstrated a reduction between 25% and 34% on the YBOCS scale. Patients not fitting these criteria were classified as nonresponders. Relapse was defined as clinically significant deterioration accompanied by transition from one response category to a lower category, including responder to partial responder, responder to nonresponder, or partial responder to nonresponder.

Statistics

Statistical analyses were performed using the Statistical Package for the Social Sciences version 19 (IBM Corp., Chicago, IL, USA). Continuous variables are reported as median (range) and categorical variables as frequencies and percentages. Group comparisons were performed using Mann–Whitney U tests and Fisher’s exact or Chi-square tests, as appropriate. Pre and postoperative outcomes were compared using the Wilcoxon signed-rank test. Effect sizes for paired comparisons were calculated using the rank-biserial correlation (r = Z/√N). Exact 95% confidence intervals were calculated for response, relapse, and adverse-event rates. Relapse-free survival was evaluated using Kaplan–Meier analysis, with relapse defined as deterioration from responder to partial responder/nonresponder status or from partial responder to nonresponder status. Patients without relapse were classified at their last available follow-up. Statistical significance was defined as P < 0.05.

RESULTS

Subjects and follow-up

The median follow-up duration at the time of writing this article was 19 months (range, 6–25 months). Sixteen patients (8 males and 8 females) underwent surgery. The median age at surgery was 27.5 years (range, 16–45 years), and the median duration of OCD before surgery was 12.5 years (range, 2–35 years). Patient demographics, disease duration, and follow-up data are presented in Table 1. Comorbidities and principal OCD symptom profiles are summarized in Table 2, while preoperative treatment history is presented in Table 3. Most patients were refractory not only to pharmacotherapy and OCD-specific CBT but also to rTMS, theta burst stimulation (TBS), and ECT.

Table 1:

Characteristics of patients with obsessive-compulsive disorder undergoing psychosurgery by radiofrequency.

Table 2:

Comorbidities and principal OCD symptoms.

Table 3:

Preoperative management of resistant OCD.

Surgical procedures

A total of 13 patients underwent anterior cingulotomy and 3 underwent anterior capsulotomy [Figures 1 and 2]. Among the cingulotomies, five consisted of triple bilateral lesions and eight of quadruple bilateral lesions. Five procedures targeted white matter alone, whereas eight involved combined white and gray matter lesioning. Patient 4 initially underwent anterior cingulotomy but reported no clinical benefit after 6 months and subsequently underwent anterior capsulotomy.

Figure 1:

Magnetic resonance imaging images show the cingulotomy lesions; a: coronal section and b: Axial section.

Figure 2:

Magnetic resonance imaging shows the capsulotomy lesions.

YBOCS-based outcome

During the initial postoperative follow-up, 12 of 16 patients (75%) met the criteria for response. At the most recent follow-up, outcomes among these 12 initial responders varied. Three patients (6, 9, 12) remained stable responders throughout follow-up. Five patients (2, 4, 5, 7, 13) experienced relapse but regained responder status following successful postoperative management. One patient (11) partially relapsed 1 month after surgery, transitioning from responder to partial responder, and remained a partial responder at the latest follow-up. The remaining three patients (1, 14, 15) experienced complete relapse and remained nonresponders despite attempts at relapse management.

Thus, among the initial responders, 25% (3/12) maintained a sustained response, 41.7% (5/12) regained responder status after relapse management, 8.3% (1/12) remained partial responders, and 25% (3/12) ultimately became nonresponders despite additional treatment.

Overall, at the last available follow-up, 9 of 16 patients (56.3%) demonstrated a favorable outcome, including 8 responders (50%) and 1 partial responder (6.3%). Four patients (3, 8, 10, 16) never reported a response to surgery all throughout follow-up. Eventually, the number of nonresponders increased to seven (43.7%) at the latest follow-up due to the three patients who relapsed and failed to regain clinical improvement.

Among the responders, Patient 5 discontinued all psychiatric medications immediately after surgery, while Patients 4, 7, and 12 achieved substantial reductions in their medication requirements during follow-up.

Table 4, “Outcome of Resistant OCD Surgery,” presents the individual preoperative and postoperative total scores for the Y-BOCS, BDI, HAM-A, and GAF for all 16 patients. In addition, Supplementary Tables 1-3 provide the individual preoperative and postoperative scores for each item of the Y-BOCS, BDI, and HAM-A scales, respectively. Table 5 summarizes the evolution of treatment response over time and reconciles the difference between the initial response rate (12/16) and the final outcome at the latest follow-up (9/16).

Table 4:

Outcome of resistant OCD surgery.

Table 5:

Patient-by-patient timeline progress; initial responders and final responders.

Assessment scales after surgery

Group-wise analysis and treatment effect statistical study using the Wilcoxon signed-rank test demonstrated significant improvement in all preoperative assessment scales mentioned above. Details, descriptive statistics, median, minimum, maximum, probability value, and raw data are mentioned in Table 4.

Surgery-specific outcome

At the last available follow-up, we found 5 responders and 1 partial responder among the 13 patients who underwent anterior cingulotomies. This means that 46% (6/13) of cingulotomy procedures had a favorable outcome. Furthermore, there were two responders among the three patients who underwent anterior capsulotomy, i.e., 66.7% (2/3) of capsulotomy procedures had a positive effect after surgery. Patient 4, who underwent staged anterior capsulotomy following an unsuccessful anterior cingulotomy, was classified as a responder at the most recent follow-up.

Social and occupational functioning, satisfaction and dissociated response

According to the GAF Scale (From DSM-IV-TR, p.34), five responders (patients 2, 5, 6, 12, 13), all of whom underwent cingulotomy, demonstrated marked improvement in social and occupational functioning. Patients no. 9 and 11 reported only moderate improvement in social and occupational functioning despite their classification as responder and partial responder, respectively, at the most recent follow-up. Patient 4 demonstrated marked social improvement but no improvement in occupational functioning. On the other hand, one of the responders, No. 7, still reported serious impairment in social and occupational functioning at the most recent follow-up despite being classified as a responder at the most recent follow-up with 70% reduction in YBOCS than preoperatively. This dissociation between symptomatic improvement and functional recovery was observed in 6.3% (1/16) of the entire cohort and in 11.1% (1/9) of patients with a favorable surgical outcome [Table 4]. Patients frequently described profound subjective improvements following surgery. Examples of such dramatic improvement in functioning as reported by responders are illustrated by case histories/vignettes that can be found in the supplementary material, e.g., Patient 5. We are looking forward to publishing a report containing detailed case histories of all the patients in our cohort.

Adverse effects

Adverse effects were categorized as immediate (within the 1^st postoperative month) or delayed (beginning 1 month or more after surgery). All adverse effects and their management are summarized in Table 6.

Table 6:

Adverse effects, forms of relapse and their management.

Immediate adverse effects and their management

Immediate adverse effects occurred in six patients (37.5%). One patient (6.3%) developed transient tremor that resolved within 1 week after treatment with propranolol (10 mg twice daily). Three patients (18.8%) experienced urinary urgency and hypomanic/manic symptoms, including reduced need for sleep, which responded to quetiapine. Two patients (12.5%) developed transient confusional states secondary to small frontal hematomas. One patient (6.3%) developed psychogenic myoclonus that was resistant to conventional anti-myoclonic medications but resolved spontaneously within 10 days. All immediate adverse effects were transient, with complete resolution within the first postoperative month.

Delayed adverse effects description

Eleven patients (68.8%) experienced delayed adverse effects during a median follow-up of 19 months (range, 6–25 months). These adverse effects were classified into four categories: subjective memory impairment, relapse of OCD symptoms, depression, and anxiety.

Subjective memory impairment was reported by one nonresponder (Patient 10) at 15 months after surgery. Depression without concurrent OCD relapse developed in one responder (Patient 12). Notably, this patient had only mild depressive symptoms before surgery (BDI score of 14/63), but developed severe depression 1 month postoperative requiring treatment. Relapse of OCD symptoms, either complete or partial, occurred in nine patients (56.3%) following an initial period of marked clinical improvement, which we termed the “honeymoon period.” The median duration of this period before relapse was 3 months (range, 1–18 months). All nine patients who relapsed had both OCD and depression before surgery. Eight patients experienced simultaneous recurrence of OCD symptoms and depressive symptoms during follow-up, with little or no interval between their onsets. Patient 5 was the only exception, developing relapse of OCD symptoms without accompanying depression. Patient 7 also differed slightly, with the relapse of depression occurring at 1-month postoperative and the relapse of OCD developing 6 months later.

The clinical manifestations of the relapse/recurrence of OCD were not always identical to the patient’s preoperative symptom profile. Patient 5 illustrates this phenomenon. Before surgery, her illness was dominated by severe sexual obsessions, which resolved completely within two weeks after cingulotomy and remained absent throughout follow-up. However, at 3-month follow-up, she developed prominent checking compulsions, which had not been a major feature of her illness before surgery. These symptoms responded well to CBT, and by 7 months, she again met responder criteria, demonstrating a 66% reduction in Y-BOCS score from baseline. This improvement was maintained throughout subsequent follow-ups.

Overall, postoperative depression accompanied OCD relapse in eight patients (50%), whereas only one patient (Patient 12) developed isolated postoperative depression without OCD recurrence. No other persistent neuropsychological deficits or personality changes were observed.

Relapsed OCD, depression and anxiety management

Management of postoperative relapse was individualized according to each patient’s clinical presentation. Interventions included optimization of pharmacotherapy with antidepressants and antipsychotics, CBT, TBS, ECT, and neurofeedback for anxiety. ECT was used only in Patient 7, as depression was severe. Whereas neurofeedback was employed in Patient 11 because anxiety was the predominant residual symptom.

Additional surgical interventions were required in selected patients. Patient 4 underwent radiofrequency anterior capsulotomy 6 months after an unsuccessful anterior cingulotomy, while Patient 11 underwent radiosurgical anterior capsulotomy 16 months after cingulotomy.

Relapse-free survival analysis, confidence intervals, and effect sizes

The initial postoperative response rate was 75.0% (12/16 patients; 95% CI, 47.6–92.7%). During follow-up, relapse occurred in 56.3% of the overall cohort (9/16 patients; 95% CI, 29.9–80.2%) and in 75.0% of the initial responders (9/12 patients). The median time to relapse was 3 months (range, 1–18 months), indicating that most relapses occurred within the early postoperative period. Kaplan–Meier analysis demonstrated a progressive decline in relapse-free survival over time, with several patients experiencing relapse within the first 6 months after surgery, while in a smaller proportion of patients, response was maintained throughout follow-up. At the most recent follow-up, 56.3% of patients (9/16; 95% CI, 29.9–80.2%) remained at least partial responders, including 50.0% responders (8/16) and 6.3% partial responders (1/16). Immediate adverse effects occurred in 37.5% of patients (6/16; 95% CI, 15.2–64.6%) and were transient, whereas delayed adverse effects were observed in 68.8% (11/16; 95% CI, 41.3–89.0%). Significant improvements were observed between baseline and last follow-up assessments for OCD severity, depression, anxiety, and global functioning. The magnitude of these changes was large, as demonstrated by the corresponding Wilcoxon effect sizes, supporting clinically meaningful improvement beyond statistical significance alone. Exploratory analyses comparing patients who relapsed with those who did not relapse did not identify significant associations with age, sex, duration of illness, baseline symptom severity, or surgical procedure type; however, these analyses were limited by the small sample size.

• Initial responders: 12/16 (75.0%)

• Patients who relapsed: 9/12 (75.0% of responders)

• Median time to relapse: 3 months (reported cohort value)

• Estimated median relapse-free survival: ≈4 months

• Relapse-free survival among cohort, at 6 months: ≈33%

• Long-term sustained relapse-free response, among cohort: ≈25%.

The Kaplan–Meier curve [Figure 3] demonstrates two distinct patient populations:

Figure 3:

The Kaplan–Meier curve identified two distinct patient trajectories: an early-relapse group, with most relapses occurring within the first 1–6 months after surgery, and a durable-response group that remained relapse-free throughout follow-up. These findings emphasize the importance of close postoperative follow-up during the early months, when relapse risk is greatest and timely intervention may help maintain clinical benefit. CI: Confidence interval.

• Early-relapse group – most relapses occurred within 1–6 months after surgery

• Durable-response group – a smaller subset maintained long-term benefit without relapse throughout follow-up.

This pattern supports our central hypothesis that close monthly postoperative follow-up is critical, as the majority of relapses occurred during the early postoperative period when intervention may restore or maintain clinical benefit. This finding is one of the most novel aspects of the study because few psychosurgery series have examined relapse timing and relapse management in such detail.

Dependency between OCD and depression outcome

Improvement in OCD symptoms was closely associated with improvement in depressive symptoms. At the most recent follow-up, OCD and depression outcomes were concordant in nearly all patients, with both conditions either improving or remaining resistant to treatment. The only exceptions were Patients 7 and 11, in whom OCD symptoms improved sufficiently to meet responder and partial responder criteria, respectively, while depression remained refractory despite postoperative management. Notably, no patient demonstrated improvement in depression without a corresponding improvement in OCD symptoms.

DISCUSSION

Disabling disorder

OCD is one of the top ten disabling disorders according to the WHO newsletters worldwide, affecting 1–3% of individuals throughout their lifetime and presenting with intrusive thoughts, known as obsessions, and repetitive actions known as compulsions.[10,12] OCD is a heterogeneous condition and it results from a complex interplay of genetic and environmental risk factors.[20] While the combination of medication and psychotherapy is generally effective, established and emerging evidence supports using surgical and neuromodulation techniques for treatment-resistant cases.[5] The advent of the stereotaxic frame in the past century greatly enhanced the precision of lesion-focused treatments for chronic psychiatric conditions. Dorsal anterior cingulotomy and anterior capsulotomy are the most frequently used ablation techniques. Dorsal anterior cingulotomy targets the cingulum bundle to interrupt communication between key limbic areas, whereas anterior capsulotomy ablates the anterior limb of the internal capsule to disconnect the orbitofrontal cortex and the dorsal anterior cingulate cortex[21] from the basal ganglia.

Psychiatric neurosurgery

Psychiatric neurosurgery has evolved considerably over the past century, progressing from early anatomical resections to stereotactic lesioning techniques using radiofrequency and radiosurgery, and more recently to neuromodulation with deep brain stimulation. Contemporary psychosurgery is no longer viewed as an isolated surgical procedure but rather as one component of a comprehensive multidisciplinary treatment strategy involving psychiatrists, neurosurgeons, psychologists, neuroradiologists, anesthesiologists, and specialized nursing staff. Careful patient selection, rigorous ethical oversight, standardized outcome assessment, and long-term postoperative follow-up are essential prerequisites for achieving optimal outcomes. In the present study, all patients were evaluated and managed within such a dedicated multidisciplinary framework, representing the first structured psychosurgery program for treatment-resistant OCD established in Egypt and, to the best of our knowledge, in the Arab region.[2,11,19,24]

Cultural specificity and challenges

The epidemiology, clinical picture, and management of OCD in Arab populations are strongly influenced by cultural and societal factors. Regarding epidemiology, Tanios et al. (2015)[28] reported that there are patterns characterizing the epidemiology of anxiety disorders in the Arab region. They have mentioned the following factors among others: extended family, the implication of being married in Arab society and to what extent it affects the social positions of the individuals, especially women. They have also indicated that Arab men tended to underreport their experience of psychiatric symptoms and disorders which is probably related to their perceived stigmatizing impact and exposing men’s vulnerability when they are expected to be resilient and always in control. In the same study, the authors have most importantly stated that several countries in the Arab region and the Middle East have witnessed long-lasting wars, which implicate endless risk factors for the development of nearly all mental illnesses (Tanios et al., 2015).[28] It is to be noted that the aforementioned study was published in 2009, when OCD was still classified as an anxiety disorder. Four years later, DSM-5 (American Psychiatric Association, 2013) removed OCD from the Anxiety Disorders section and classified it separately under the section “OCD and related disorders.” Furthermore, this study was published 2 years before the start of the “Arab Spring” and the devastating civil wars that followed it in the region.

Regarding the clinical picture of OCD, it is very well known that there are variations in OCD symptomatology across different cultures (Hassan et al., 2024).[15] Religious obsessions and scrupulosity, for example, may be misinterpreted as expressions of heightened piety rather than manifestations of psychiatric illness. Unfortunately, this may delay seeking professional help for many painful years during which the patient’s life may dramatically deteriorate in all aspects. Hassan et al. (2024)[15] stated that “For example, in some religions, the frequent use of sacred phrases and repeated performance of religious rituals are viewed as signs of devotion and piety. This may lead to a positive social response to an individual who might be displaying OCD symptoms, albeit in a manner considered socially acceptable and even encouraged.” Another study by Rady et al. (2012)[26] reported on the religious attitudes in adolescents with obsessive-compulsive symptoms and disorder. They found that adolescents with less religious devotion/commitment are less probable to develop OCD. Those results are in line with those of Okasha et al. (1994)[22] who reported that OCD is associated with Muslim rituals of ablution and prayer (Rady et al., 2012; Okasha et al., 1994).[22,26]

Regarding management, although medical treatment is well expected to be identical in Western and Eastern societies, psychotherapy and its application will most probably differ across cultures. Furthermore, in the article by Hassan et al. (2024),[15] the authors state that “Religion-Adapted CBT” has been reported by some studies to have greater success than secular CBT (Hassan et al., 2024).[15] This is in agreement with other authors, e.g., Cucchi et al. (2020) and Hamdan (2008)[8,13] who reported that it seems helpful to modify the traditional Western secular CBT protocols so that they are congruent and consistent with Middle Eastern and Islamic cultural values (Cucchi et al., 2020; Hamdan, 2008).[8,13]

A very important cultural challenge/consideration in Egypt and the Arab world is the persistent stigma surrounding mental disorders. Some families attribute OCD symptoms to supernatural or spiritual causes or view them as divine punishment. There are also cultural beliefs and misconceptions that patients are feigning symptoms or are personally responsible for their condition. Such beliefs may contribute to patients being subjected to verbal or physical abuse by their families, particularly during the early stages of illness. The families of the patients may put unacceptable delay in seeking professional help because they are merely “ashamed” of visiting the psychiatrist. Consequently, the illness becomes chronic, and the life of the patient is damaged and deteriorated, in some instances beyond repair.

In addition, many patients initially seek help from spiritual healers Okasha et al. 2025,[24] some of whom may employ harmful or abusive practices under the guise of exorcism. Geographic barriers, particularly for patients in rural areas, further limit access to specialized care. All the abovementioned factors may delay diagnosis and limit access to evidence-based treatments, including SSRIs and CBT.

Financial burden represents another major challenge. One patient in our cohort reported spending more than 250,000 Egyptian pounds in 8 years, seeking unsuccessful treatments before undergoing surgery, an amount that represents a substantial economic burden in a developing country such as Egypt.

Among the regional literature on the subject, a previous study by Okasha (1999)[23] addressed mental health in the Middle East. More recently, Okasha et al. (2025)[24] reviewed the mental health services in Egypt, the Middle East, and North Africa. They reported that, although much improvements have occurred in the last two decades regarding psychiatric services in our region, tremendous obstacles still exist (Okasha et al., 2025).[24]

Introducing psychosurgery in Egypt and the Arab world presented additional challenges because of limited public and professional awareness and persistent misconceptions regarding psychiatric surgery. To improve awareness, we published our first case report in 2023 describing neurosurgery for mental disorders. Since then, referrals from other psychiatric centers have increased.

An important strength of our study is the use of a dedicated multidisciplinary team that evaluated and followed every patient before and after surgery. All postoperative assessments and treatment decisions were performed by the same team throughout follow-up, minimizing inter-rater variability. Furthermore, patients attended multiple clinic visits before surgery to confirm the diagnosis of treatment-resistant OCD, establish eligibility, and become familiar with the multidisciplinary team and postoperative follow-up protocol.

Outcome after surgery

The results show that both cingulotomy and capsulotomy by radiofrequency could contribute to reducing OCD symptoms of severely ill, treatment-refractory patients as measured by YBOCS at last follow-up versus YBOCS at baseline. Correlated reductions in comorbid depression and anxiety were also observed.

Most importantly, it is to be noted that our study is not controlled (i.e., it lacks a control group). Thus, although improvement occurred after surgery in the symptoms of OCD, depression, and anxiety, causality cannot be established. In other words, due to the lack of a control group, we cannot state/establish that surgery was the cause of improvement in the target symptoms.

Our results are consistent with previous retrospective[5,9,18,21,27] and prospective studies[2,3,9] on the same subject. All patients had failed to improve with available nonsurgical treatments and had been severely ill for a median of 12.5 (2–35) years.

Another important note is that our patients continued to receive multiple psychiatric treatments after surgery. Examples of such psychiatric treatments are medical treatments (selective serotonin reuptake inhibitors, mood stabilizers, antipsychotics), CBT, TBS, neurofeedback, and, in selected cases, additional ablative procedures. Thus, improvements in the target symptoms during follow-up cannot be attributed solely to surgery. Alternatively, the improvements observed during follow-up likely reflect the combined effects of surgery and ongoing multidisciplinary treatment rather than surgery alone.

Response rate with time

Our findings suggest that clinical improvement following psychosurgery may continue to evolve beyond the early postoperative period, with some patients demonstrating additional gains up to one year after surgery. In our cohort, Patient 4 exhibited further improvement at 12 months following capsulotomy (and at 18 months following the initial cingulotomy), indicating that delayed or progressive improvement may occur in selected cases. These observations are consistent with the study by Dougherty et al. (2002),[9] who reported that clinical benefit after psychosurgery may increase over time. However, they contrast with the findings of Jenike (1998),[19] who reported that maximal improvement typically occurs within the first 3 months postoperatively, with minimal subsequent change.

Relapse after surgery

The pattern of relapse observed in our cohort is consistent with previous studies describing recurrence following ablative psychosurgery for both neurological and psychiatric indications. Rasmussen et al. (2018), in their study of gamma ventral capsulotomy for intractable OCD, reported transient early improvement in approximately one-quarter of patients, which subsequently resolved by the three-month follow-up. [27] Similarly, Hay et al. (1993)[16] described relapse occurring at 12 and 24 months in two patients after initial postoperative improvement.

In contrast to these reports, a higher proportion of patients in our cohort experienced relapse of OCD symptoms (9/16; 56.3%), with a median time to relapse of 3 months (mean: 4.5 months; range: 1–18 months). Unlike most prior studies, we also systematically evaluated the management of relapse and recurrence in an attempt to restore or maintain clinical benefit. Our findings suggest that structured postoperative management, combined with close monthly follow-up – particularly during the early postoperative period – may contribute to recovery of response in a substantial subset of patients.

Using this approach, the initial response rate of 12/16 patients declined after relapse to 3/16; however, targeted postoperative interventions allowed 5 of the relapsed patients to regain responder status, while one additional patient remained a partial responder. This patient may have deteriorated further unless properly managed. At the final follow-up, the overall response rate increased to 9/16 patients, including 3 patients in whom response was maintained throughout follow-up without relapse and 6 patients who regained or maintained at least a partial response following relapse management.

Relapse-free survival analysis demonstrated that although 75% of patients initially responded to treatment, most relapses occurred early, with a median time to relapse of 3 months and an estimated median relapse-free survival of approximately 4 months. Kaplan–Meier analysis identified two distinct clinical patterns: an early-relapse group, in which most recurrences occurred within the first 6 postoperative months and a durable-response group that maintained long-term benefit throughout follow-up. Relapse-free survival among our cohort at 6 months was approximately 33%, whereas sustained long-term relapse-free response was observed in about 25% of patients. These findings highlight the critical importance of close postoperative monitoring during the early months after surgery, when timely intervention may help restore or maintain clinical benefit. To our knowledge, few psychosurgical series have evaluated relapse timing and relapse management in such detail, making this observation one of the novel contributions of the present study.

Perception of response

As previously reported in retrospective studies such as Jenike et al. (1991), a subset of patients attributed clinical improvement to factors other than surgery despite objective evidence of postoperative benefit.[18] In our cohort, three patients who met responder criteria at the most recent follow-up attributed their improvement primarily to nonsurgical factors.

Patient 4, who demonstrated a 97.5% reduction in Y-BOCS score at 2 years following sequential cingulotomy and capsulotomy, reported that surgery had not contributed to his improvement and instead attributed recovery to religious factors. In contrast, his family reported marked functional improvement following surgical intervention.

Patient 7, who achieved a 70% reduction in Y-BOCS score, attributed improvement to high-dose escitalopram and prior TBS. However, this interpretation is inconsistent with his clinical history, as he had previously failed multiple adequate antidepressant trials, including high-dose SSRIs, without sustained benefit. In addition, the TBS protocol administered was targeted for depression rather than OCD, and its effects would not be expected to persist over extended follow-up.

Patient 6, despite a 67.5% reduction in Y-BOCS score and significant improvements in social and occupational functioning after more than two decades of severe illness and major disability, the patient stated that the only difference in his life after surgery was that he had stopped smoking.

These discrepancies between subjective attribution and objective clinical outcomes may reflect impaired illness insight in severely and chronically affected patients, as well as the complex psychological mechanisms underlying recovery from long-standing psychiatric disability. Overall, our findings are consistent with those of Jenike et al. (1991) who similarly observed that some patients among their cohort had markedly improved in target symptoms; however, they attributed clinical improvement to causes other than surgery.[18]

Limitations

This study has several important limitations. First, the sample size was small, comprising only sixteen patients who underwent psychosurgical procedures (cingulotomy, capsulotomy, or both). The limited cohort size reflects multiple systemic and contextual barriers rather than study design alone. Cultural barriers and challenges have been addressed above in the section “Cultural specificity and challenges.”

Unfortunately, due to all of the abovementioned factors, only a minority of mentally ill patients in our community ultimately reach psychiatric services. Moreover, they most probably reach such services at a delayed time point in the course of their illnesses. It is to be expected that surgical intervention will be the most delayed and the most inaccessible step in the therapeutic pathway.

Furthermore, when psychosurgery was introduced in Egypt and the Arab world, it was met with skepticism and resistance from many psychiatrists, some of whom were unfamiliar with the procedure or held negative preconceptions regarding its use. These factors collectively contributed to the small sample size. As the first center in Egypt and the Arab world to offer these procedures, most referrals were obtained through academic dissemination, including presentations at national and international conferences. While these findings are preliminary, they may contribute to improving awareness and acceptance of psychosurgical interventions in the region.

A further limitation is the absence of a control group. However, this limitation is common in studies evaluating neurosurgical interventions for psychiatric disorders. Improvement occurred after surgery, but causality cannot be established. In many cases, the use of randomized controlled designs is considered ethically challenging in patients with severe, treatment-refractory illness. Consequently, the effectiveness of these procedures has largely been inferred from observational and noncontrolled studies. As noted by the Canadian Psychiatric Association,[4,17] the use of sham neurosurgical procedures is ethically problematic, and therefore, clinical evaluation must rely on systematic and objective assessment of treated patients rather than placebo-controlled trials.

CONCLUSION

Both anterior cingulotomy and anterior capsulotomy were associated with significant reductions in OCD symptom severity, as well as improvements in comorbid depressive and anxiety symptoms. We observed that delayed improvement could be observed in some patients. Immediate postoperative adverse effects were generally transient, while delayed relapse of OCD symptoms was common during follow-up. These findings suggest that close, structured monthly postoperative monitoring, combined with ongoing multidisciplinary management, may play an important role in restoring or maintaining clinical improvement. As the first study of its kind conducted in Egypt and the Arab world, these results also highlight the cultural, social, and systemic challenges involved in introducing and implementing psychiatric neurosurgery in this setting.

Data Availability

All raw data are presented within the manuscript, and any additional data or supporting materials are available from the authors upon reasonable request.

Ethical approval:

This study is approved by Tanta University, IRB No. 36264PR347/9/23 dated 20/9/2023.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

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