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Neurosurgical treatment of obsessive-compulsive disorder

Published online by Cambridge University Press:  06 August 2018

M. A. Jenike
M. A. Jenike*
Affiliation:
Harvard Medical School, Massachusetts General Hospital
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Abstract

Background Case reports suggest that neurosurgical operations can improve symptoms in patients with severe treatment-refractory obsessive-compulsive disorder (OCD). However, it is unclear which procedure is best and which may produce the most side-effects.

Method I review the literature on the efficacy and complications of four frequently used neurosurgical procedures (cingulotomy, capsulotomy, limbic leucotomy and subcaudate tractotomy) that are used to treat refractory OCD.

Results Since the vast majority of patients who underwent surgery were severely and chronically disabled, it is likely that these procedures were of assistance in alleviating some of their symptoms. It is currently impossible to determine which surgical procedure is the best for a particular patient.

Conclusions Despite a lack of controlled data and inconsistencies in the literature, it appears that when nonsurgical treatments have failed to improve OCD symptoms significantly in severely ill patients, at least partial relief can be obtained by some people with OCD by neurosurgery Results of cumulative studies strongly support the need for continued research in this area.

Type
Research Article
Information
The British Journal of Psychiatry , Volume 173 , Issue S35: New perspectives in research and treatment of obsessive-compulsive disorder , August 1998 , pp. 79 - 90
Copyright
Copyright © 1998 The Royal College of Psychiatrists 

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References

Alexander, G. E. (1986) Parallel organization of functionally segregated circuits linking basal ganglia and cortex. Annual Review of Neuroscience, 9, 357–381.CrossRefGoogle ScholarPubMed
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). Washington, DC: APA.Google Scholar
Åsberg, M., Montgomery, S., Perris, C., et al (1978) The Comprehensive Psychopathological Rating Scale. Acta Psychiatrica Scandinavia, (suppl. 271), 5–27.CrossRefGoogle Scholar
Baer, L., Rauch, S. L., Ballantine, H. T., et al (1994) Cingulotomy for intractable obsessive-compulsive disorder: prospective long-term follow-up of 18 patients. Archives of General Psychiatry, 52, 384–392.CrossRefGoogle Scholar
Ballantine, H. T. Jr. (1985) Neurosurgery for behavioral disorders. In Neurosurgery (eds Wilkins, R. H. & Rengachary, S. S.), pp. 25–27. New York: Elsevier/ North Holland Biomedical Press.Google Scholar
Ballantine, H. T., Levy, B. S., Dagi, T. F., et al (1977) Cingulotomy for psychiatric illness: report of 13 years'experience. In Neurosurgical Treatment in Psychiatry, Pain and Epilepsy (eds Sweet, W., Obrador, S. & Martin-Rodriguez, J. G.). Baltimore, MD: University Park Press.Google Scholar
Ballantine, H. T., Bouckoms, A. J., Thomas, E. K., et al (1987) Treatment of psychiatric illness by stereotactic cingulotomy. Biological Psychiatry, 22, 807–819.CrossRefGoogle ScholarPubMed
Barraclough, B. (1977) Evaluation of the surgical treatment of functional mental illness: proposed for a prospective controlled trial. In Neurosurgical Treatment in Psychiatry Pain, and Epilepsy (eds Sweet, W., Obrador, S. & Martin-Rodriguez, J. G.), p. 175. Baltimore, MD: University Park Press.Google Scholar
Bartlett, J. R. & Bridges, P. K. (1977) The extended subcaudate tractotomy lesion. In Neurosurgical Treatment in Psychiatry Pain, and Epilepsy (eds Sweet, W H., Obrador, S. & Martin-Rodriguez, J. G.), p. 387. Baltimore, MD: University Park Press.Google Scholar
Baxter, L. R. (1990) Neuroimaging in obsessive-compulsive disorder. In Obsessive-Compulsive Disorders: Theory and Management (2nd edn) (eds Jenike, M. A., Baer, L. & Minichiello, W E.), pp. 167–185. Chicago, IL: Yearbook Medical Publishing.Google Scholar
Baxter, L. R., Schwartz, J. M., Mazziotta, J. C., et al (1988) Cerebral glucose metabolic rates in non-depressed patients with obsessive-compulsive disorder. American Journal of Psychiatry, 145, 1560–1563.Google Scholar
Baxter, L. R., Schwartz, J. M., Bergman, K. S., et al (1992) Caudate glucose metabolic rate changes with both drug and behavior therapy for OCD. Archives of General Psychiatry, 49, 681–689.CrossRefGoogle Scholar
Behar, K., Rapoport, J. L., Berg, C. J., et al (1984) Computerized tomography and neuropsychological test measures in adolescents with obsessive-compulsive disorder. American Journal of Psychiatry, 141, 363–368.Google ScholarPubMed
Bingley, T., Leksell, L., Meyerson, B. A., et al (1977) Long-term results of stereotactic capsulotomy in chronic obsessive-compulsive neurosis. In Neurosurgical Treatment in Psychiatry (eds Sweet, W H., Obrador, S. & Martin-Rodriguez, J. G.), pp. 287. Baltimore, MD: University Park Press.Google Scholar
Bingley, T. & Person, A. (1978) EEG studies on patients with chronic obsessive-compulsive neurosis before and after psychosurgery. Electroencephalography and Clinical Neurophysiology, 44, 691.CrossRefGoogle ScholarPubMed
Blaauw, G. & Braakman, R. (1988) Pitfalls in diagnostic stereotactic brain surgery. Acta Neurochirurgica, 42 (suppl.), 161.Google ScholarPubMed
Bouckoms, A. J. (1988) Ethics of psychosurgery. Acta Neurochirurgica, 44 (suppl.), 173.Google ScholarPubMed
Bouckoms, A. J. (1991) The role of stereotactic cingulotomy in the treatment of intractable depression. In Advances in Neuropsychiatry and Psychopharmacology 2: Refractory Depression (ed. Amsterdam, J. A.), p. 2. New York: Raven Press.Google Scholar
Breiter, H. C. R., Filipek, R A., Kennedy, K. N., et al (1994) Retrocallosal white matter abnormalities in patients with obsessive-compulsive disorder. Archives of General Psychiatry, 51, 663–664.Google ScholarPubMed
Bridges, P. K. (1987) (letter) British Journal of Hospital Medicine, 8, 147.Google Scholar
Bridges, P. K., Göktepe, E. O. & Maratos, J. (1973) A comparative review of patients with obsessional neurosis and with depression treated by psychosurgery. British Journal of Psychiatry, 123, 663–674.CrossRefGoogle ScholarPubMed
Burzaco, J. (1981) Stereotactic surgery in the treatment of obsessive-compulsive neurosis. In Biological Psychiatry (eds Perris, C., Struwe, G. & Jansson, B.), p. 1103. Amsterdam: Elsevier/North Holland Biomedical Press.Google Scholar
Chiocca, E. A. & Martuza, R. L. (1990) Neurosurgical therapy of obsessive-compulsive disorder. In Obsessive-Compulsive Disorders: Theory and Management (eds Jenike, M. A., Baer, L. & Minichiello, W. E.), pp. 283–294. Chicago, IL: Year Book Medical Publishers.Google Scholar
Cooper, J. (1970) The Leyton Obsessional Inventory. Psychological Medicine, 1, 48–64.CrossRefGoogle ScholarPubMed
Corkin, S. (1980) A prospective study of cingulotomy. In The Psychosurgery Debate (ed. Valenstein, E. S.), p. 264. San Francisco, CA: W H. Freeman & Co.Google Scholar
Corkin, S., Twitchell, T. E. & Sullivan, E. V. (1979) Safety and efficacy of cingulotomy for pain and psychiatric disorder. Modern Concepts in Psychiatric Surgery (eds Hitchcock, E. R., Ballantine, H. T. & Yerson, B. A.), pp. 253–272. New York: Elsevier/North Holland Biomedical Press.Google Scholar
Corsellis, J. & Jack, A. B. (1973) Neuropathological observations on yttrium implants and on undercutting in the orbitofrontal areas of the brain. In Surgical Approaches in Psychiatry (eds Laitinen, L. V. & Livingston, K. E.), p. 90. Baltimore, MD: University Park Press.Google Scholar
Cummings, J. L. & Frankel, M. (1985) Gilles de la Tourette syndrome and the neurological basis of obsessions and compulsions. Biological Psychiatry, 20, 1117–1126.CrossRefGoogle ScholarPubMed
Earp, J. D. (1979) Psychosurgery. The position of the Canadian Psychiatric Association. Canadian Journal of Psychiatry, 24, 353.CrossRefGoogle ScholarPubMed
Eysenck, S. B., White, O. & Eysenck, H. J. (1976) Personality and mental illness. Psychological Reports, 3, 1011–1022.CrossRefGoogle Scholar
Flor-Henry, P. (1983) Cerebral Basis of Psychopathology. Boston, MA: John Wright.Google Scholar
Flor-Henry, P., Yeudall, L. T., Koles, Z. J., et al (1975) Neuropsychological and power spectral EEG investigations of the obsessive compulsive syndrome. Biological Psychiatry, 14, 119–130.Google Scholar
Fodstad, H., Strandman, E., Karlsson, B., et al (1982) Treatment of chronic obsessive-compulsive states with stereotactic anterior capsulotomy or cingulotomy. Acta Neurochirurgica, 62, 1–23.CrossRefGoogle ScholarPubMed
Foltz, E. L. & White, L. E. (1962) Pain relief by frontal cingulotomy. Journal of Neurosurgery, 19, 89.CrossRefGoogle Scholar
Garber, H. J., Ananth, J. V., Chiu, L. C., et al (1989) Nuclear magnetic resonance study of obsessive-compulsive disorder. American Journal of Psychiatry, 146, 1001–1005.Google ScholarPubMed
O., Göktepe, E., Young, L. B. & Bridges, P. K. (1975) A further review of the results of stereotactic subcaudate tractotomy. British Journal of Psychiatry, 126, 270–280.Google Scholar
Goodman, W. K., Price, L. H. & Rasmussen, S. A., et al (1989) The Yale-Brown Obsessive-Compulsive Scale. Archives of General Psychiatry, 46, 1006–1011.CrossRefGoogle ScholarPubMed
Hassler, R. & Dieckman, G. (1973) Relief of obsessive-compulsive disorders, phobias and tics by stereotactic coagulation of the rostral intralaminar and medial-thalamic nuclei. In Surgical Approaches in Psychiatry (eds Laitinen, L. V. & Livingston, K. E.), p. 206. Baltimore, MD: University Park Press.Google Scholar
Herner, T. (1961) Treatment of mental disorders with frontal stereotactic thermo-lesions. A follow-up of 116 cases. Acta Psychiatrica Scandinavica (suppl. 36).Google Scholar
Insel, T. R. (1992) Toward a neuroanatomy of OCD. Archives of General Psychiatry, 49, 739–744.CrossRefGoogle Scholar
Insel, T. R., Donnelly, E. F., Lalakea, M. L., et al (1983) Neurological and neuropsychological studies of patients with obsessive-compulsive disorder. Biological Psychiatry, 18, 741–751.Google ScholarPubMed
Insel, T. R. & Akiskal, H. S. (1983) Obsessive-compulsive disorder with psychotic features: a phenomenologic analysis. American Journal of Psychiatry, 143, 1527.Google Scholar
Jenike, M. A. (1990) Approaches to the patient with treatment-refractory obsessive-compulsive disorder. Journal of Clinical Psychiatry, 51 (suppl. 2), 15.Google Scholar
Jenike, M. A., Baer, L., Minichiello, W. E., et al (1986) Coexistent obsessive-compulsive disorder and schizotypal personality disorder: a poor prognostic indicator. Archives of General Psychiatry, 43, 296.Google ScholarPubMed
Jenike, M. A., Baer, L., Minichiello, W. E. (eds) (1990) Obsessive-Compulsive Disorders: Theory and Management (2nd edn). Chicago, IL: Year Book Medical Publishers.Google Scholar
Jenike, M. A., Baer, L., Ballantine, H. T., et al (1991) Cingulotomy for refractory obsessive-compulsive disorder. A long-term follow-up of 33 patients. Archives of General Psychiatry 48, 548.CrossRefGoogle ScholarPubMed
Jenike, M. A., Breitere, H. C. R., Baer, L., et al (1996) Cerebral structural abnormalities in patients with obsessive-compulsive disorder: A quantitative morphometric magnetic resonance imaging study. Archives of General Psychiatry, 53, 625–632.CrossRefGoogle ScholarPubMed
Kellner, C. H., Jolley, R. R., Holgate, R. C., et al (1991) Brain MRI in obsessive-compulsive disorder. Psychiatry Research, 36, 45–49.CrossRefGoogle ScholarPubMed
Kelly, D. (1972) Physiological changes during operations on the limbic system in man. Conditional Reflex, 7, 127.CrossRefGoogle ScholarPubMed
Kelly, D. (1980) Anxiety and Emotions. Physiological Basis and Treatment. Springfield, III: Charles C. Thomas.Google Scholar
Knight, G. C. (1972) Bifrontal stereotaxic tractotomy in the substantia innominata: an experience of 450 cases. In Psychosurgery (eds Hitchcock, E., Laitinen, L. & Vaernet, K.), p. 269. Springfield, IL: Charles C. Thomas.Google ScholarPubMed
Kullberg, G. (1977) Differences in effects of capsulotomy and cingulotomy. In Neurosurgical Treatment in Psychiatry Pain, and Epilepsy (eds Sweet, W H., Obrador, W. S. & Martin-Rodriguez, J. G.), pp. 301–308. Baltimore, MD: University Park Press.Google Scholar
LaPlane, E., Levasseur, M., Pillon, B., et al (1989) Obsessions-compulsions and behavioural changes with bilateral basal ganglia lesions: a neuropsychological, magnetic resonance imaging and positron tomography study. Brain, 112, 699–725.CrossRefGoogle Scholar
Leksell, L. & Baclund, E. O. (1979) Stereotactic gamma capsulotomy. In Modern Concepts in Psychiatric Surgery (eds Hitchcock, E. R., Ballantine, H. T. Jr & Meyerson, B. A.), pp. 213. Amsterdam: Elsevier/North Holland Biomedical Press.Google Scholar
Lezak, M. D. (1995) Neuropsychological Assessments (3rd edn). New York: Oxford University Press.Google Scholar
Lovett, L. M. & Shaw, D. M. (1987) Outcome in bipolar affective disorder after stereotactic tractotomy. British Journal of Psychiatry, 151, 113–116.CrossRefGoogle ScholarPubMed
Luxenberg, J. S., Swedo, S. E., Flament, M. F., et al (1988) Neuroanatomical abnormalities in obsessive-compulsive disorder detected with quantitative X-ray computed tomography. American Journal of Psychiatry, 145, 1089–1093.Google ScholarPubMed
Malizia, A. (1991) Indications for psychosurgery. Biological Psychiatry (suppl. 11S). Abstract S-13–12-02.Google Scholar
Martuza, R. L., Chiocca, E. A., Jenike, M. A., et al (1990) Stereotactic radiofrequency thermal cingulotomy for obsessive compulsive disorder. Journal of Neuropsychiatry and Clinical Neurosciences, 2, 331–336.Google ScholarPubMed
McDougle, C. J., Goodman, W. K., Price, L. H., et al (1990) Neuroleptic addition in fluvoxamine-refractory obsessive compulsive disorder: An open case series. American Journal of Psychiatry, 147, 552–554.Google Scholar
Meyerson, B. A. & Mindus, P. (1988) Capsulotomy as a treatment of anxiety disorders. In Modern Stereotactic Neurosurgery (ed. Lunsford, L. D.), p. 353. Boston, MA: Martinus Nijhoff.CrossRefGoogle Scholar
Mindus, P. (1988) Capsulotomy, a psychosurgical intervention considered in cases of anxiety disorders unresponsive to conventional therapy. In Pharmacological Treatment of Anxiety (eds Strandberg, K., Beerman, B. & Lönnerholm, G.), p. 151. Swedish National Board of Health and Wellfare. Uppsala: Almqvist & Wiksell.Google Scholar
Mindus, P. (1991) Capsulotomy in Anxiety Disorders. A Multi-Disciplinary Study. Thesis, Stockholm: Karolinska Institute.Google Scholar
Mindus, P., Bergström, K., Levander, S. E., et al (1987) Magnetic resonance images related to clinical outcome after psychosurgical intervention in severe anxiety disorder. Journal of Neurology, Neurosurgery and Psychiatry, 50, 1288–1293.CrossRefGoogle ScholarPubMed
Mindus, P., Nyman, H., Rosenquist, A., et al (1988) Aspects of personality in patients with anxiety disorders undergoing capsulotomy. Acta Neurochirurgica, 44 (suppl.), 138–144.Google ScholarPubMed
Mindus, P., Nyman, H. (1991) Normalization of personality characteristics in patients with incapacitating anxiety disorders after capsulotomy. Acta Psychiatrica Scandinavica, 83, 283–291.CrossRefGoogle ScholarPubMed
Mindus, P. & Jenike, M. A. (1992) Neurosurgical treatment of malignant obsessive-compulsive disorder. In Psychiatric Clinics of North America: Obsessional Disorders (ed. Jenike, M. A.), pp. 921–938. Philadelphia, PA: W B. Saunders & Co.Google Scholar
Mitchell-Heggs, N., Kelly, D. & Richardson, A. (1976) Stereotactic limbic leucotomy – a follow-up at 16 months. British Journal of Psychiatry, 128, 226–240.CrossRefGoogle Scholar
Modell, J. G., Mountz, J. M., Curtis, G. C., et al (1989) Neurophysiologic dysfunction in basal ganglia/limbic striatal and thalamocortical circuits as a pathogenetic mechanism of obsessive-compulsive disorder. Journal of Neuropsychiatry, 1, 27–36.Google ScholarPubMed
Nauta, W. J. H. (1986) Circuitous connections linking cerebral cortex, limbic system, and corpus striatum. In The Limbic System. Functional Organization and Clinical Disorders (eds Doane, B. K. & Livingstone, K. E.), p. 43. New York: Raven Press.Google Scholar
Nordahl, T. E., Benkeifat, C., Semple, W. E., et al (1989) Cerebral glucose metabolic rates in obsessive-compulsive disorder. Neuropsychopharmacology, 2, 23–28.CrossRefGoogle ScholarPubMed
Osler, W. (1989) The Cerebral Palsies of Children. Classics of Neurology and Neurosurgery Library, Gryphon Editions.Google Scholar
Otto, M. (1990) Neuropsychology of obsessive-compulsive disorder. In Obsessive Compulsive Disorders: Theory and Management (2nd edn) (eds Jenike, M. A., Baer, L. & Minichiello, W E.), pp. 132–148. Chicago, II: Yearbook Medical Publishing.Google Scholar
Otto, M., Pollack, M. H., Jenike, M. A., et al (1998) Anxiety disorders and their treatment. In Harvard Guide to Psychiatry, in press.Google Scholar
Pitman, R. K., Green, R. C., Jenike, M. A., et al (1987) Clinical comparison of Tourette syndrome and obsessive-compulsive disorder. American Journal of Psychiatry, 144, 1166–1171.Google ScholarPubMed
Poynton, A., Bridges, P. K., Bartlett, J. R. (1981) Psychosurgery in Britain now. British Journal of Neurosurgery, 2, 297.CrossRefGoogle Scholar
Rapoport, J., Elkins, R., Langer, D. H., et al (1981) Childhood obsessive-compulsive disorder. American Journal of Psychiatry, 138, 12.Google ScholarPubMed
Rauch, S. L. & Jenike, M. A. (1993) Neurobiological models of obsessive-compulsive disorder. Psychosomatics, 34, 20–32.CrossRefGoogle ScholarPubMed
Rauch, S. L. & Jenike, M. A., Alpert, N. M., et al (1994) Regional cerebral blood flow measured during symptom provocation in obsessive-compulsive disorder using 15-O labeled CO2 and positron emission tomography. Archives of General Psychiatry, 1, 62–70.CrossRefGoogle Scholar
Richardson, A. (1973) Stereotactic limbic leucotomy. Surgical technique. Postgraduate Medical Journal, 49, 860.CrossRefGoogle ScholarPubMed
Robinson, S., Winnik, H. Z. & Weiss, A. A. (1976) Obsessive psychosis: justification for a separate clinical entity. Israeli Annals of Psychiatry 30, 372.Google Scholar
Rylander, G. (1979) Stereotactic radiosurgery in anxiety and obsessive-compulsive states: psychiatric aspects. In Modern Concepts in Psychiatric Surgery (eds Hitchcock, E. R., Ballantine, H. T. Jr & Meyerson, B. A.), p. 235. Amsterdam: Elsevier/North Holland Biomedical Press.Google Scholar
Schalling, D., Asberg, M., Edman, G., et al (1987) Markers of vulnerability to psychopathy: temperament traits associated with platelet MAO activity. Acta Psychiatrica Scandinavica, 16, 172.CrossRefGoogle Scholar
Schilder, P. (1938) The organic background of obsessions and compulsions. American Journal of Psychiatry, 94, 1397–1414.CrossRefGoogle Scholar
Snaith, P. (1987) The case for psychosurgery (letter). British Journal of Hospital Medicine, 8, 147.Google Scholar
Solyom, L., Di Nicola, V. F., Phil, M., et al (1985) Is there an obsessive psychosis? Aetiological and prognostic factors of an atypical form of obsessive-compulsive neurosis. Canadian Journal of Psychiatry, 30, 372.CrossRefGoogle ScholarPubMed
Ström-Olsen, R. & Carlisle, S. (1971) Bifrontal stereotactic tractotomy: A follow-up study of its effects on 210 patients. British Journal of Psychiatry, 118, 141–154.CrossRefGoogle ScholarPubMed
Stuss, D. T. & Benson, D. F. (1986) Personality and emotion. In The Frontal Lobes (eds Struss, D. T. & Benson, D. F.), p. 121. New York: Raven Press.Google Scholar
Swedo, S. E., Rapoport, J. L., Cheslow, D. L., et al (1989a) High prevalence of obsessive-compulsive symptoms in patients with Sydenham's chorea. American Journal of Psychiatry, 146, 246–249.Google ScholarPubMed
Swedo, S. E., Shapiro, M. B., Grady, C. I., et al (1989b) Cerebral glucose metabolism in childhood-onset obsessive-compulsive disorder. Archives of General Psychiatry, 46, 518–523.CrossRefGoogle ScholarPubMed
Swedo, S. E., Pietrini, P., Leonard, H. L., et al (1992) Cerebral glucose metabolism in childhood-onset OCD. Archives of General Psychiatry, 49, 690–694.CrossRefGoogle Scholar
Sweet, W. H. & Meyerson, B. A. (1990) Neurosurgical aspects of primary affective disorders. In Neurological Surgery (ed. Youmans, J. R.). Philadelphia, PA: W. B. Saunders.Google Scholar
Tan, E., Marks, I. M. & Marset, P. (1971) Bimedial leucotomy in obsessive-compulsive neurosis: a controlled serial inquiry. British Journal of Psychiatry, 118, 155–164.CrossRefGoogle Scholar
Valenstein, E. S. (1980) Review of the literature on postoperative evaluation. In The Psychosurgery Debate (ed. Valenstein, E. S.), pp. 141. San Francisco, CA: W. H. Freeman & Co.Google Scholar
Vasko, T. & Kullberg, G. (1979) Results of psychological testing of cognitive functions in patients undergoing stereotactic psychiatric surgery. In Modern Concepts in Psychiatric Surgery (eds Hitchcock, E. R., Ballantine, H. T. Jr & Meyerson, B. A.), p. 303. Amsterdam: Elsevier/North Holland Biomedical Press.Google Scholar
Ward, C. D. (1988) Transient feelings of compulsion caused by hemispheric lesions: three cases. Journal of Neurology, Neurosurgery and Psychiatry, 51, 266–268.CrossRefGoogle ScholarPubMed
Waziri, R. (1990) Psychosurgery for anxiety and obsessive-compulsive disorders. In Handbook of Anxiety. Treatment of Anxiety (eds Noyes, R. J., Roth, M. & Burrows, G. D.). Amsterdam: Elsevier Science Publishers.Google Scholar
Weilburg, J. B., Mesulam, M. M., Weintraub, S., et al (1989) Focal striatal abnormalities in a patient with obsessive-compulsive disorder. Archives of Neurology, 46, 233–235.CrossRefGoogle Scholar
Whitty, C. W. M., Duffield, J. E., Tow, P. M., et al (1952) Anterior cingulectomy in the treatment of mental disease. Lancet, i, 475–481.CrossRefGoogle Scholar
World Health Organization (1992) The Tenth Revision of the International Classification of Diseases and Related Health Problems. (ICD-10). Geneva: WHO.Google Scholar
Zielinski, C. M., Taylor, M. A. & Juzwin, K. R. (1991) Neuropsychological deficits in obsessive-compulsive disorder. Neuropsychiatry, Neuropsychology & Behavioural Neurology, 4, 110–126.Google Scholar
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