Peer-Review ReportDeep Brain Stimulation in the Treatment of Obsessive-Compulsive Disorder
Introduction
Obsessive-compulsive disorder (OCD) is a chronic disorder characterized by persistent obsessive, intrusive thoughts generating anxiety, and related compulsions (tasks or rituals) with the function of neutralizing the distress. It is the 10th most common cause of disability in the world, affecting approximately 2% of the population (11). It is considered to be one of the most disabling psychiatric disorders, creating manifest functional impairment that will influence work, leisure activities, and interaction with family and the social environment. OCD is, however, not only associated with suffering for the patients, and a reduced quality of life, but also with a significant mortality (3). Recent studies suggest that 10% to 27% of the patients might attempt suicide during their lifetime (3).
Even though the majority of patients with OCD will respond at least partly to selective serotonin-reuptake inhibitors and cognitive-behavioral psychotherapy (CBT), there remains a significant portion in whom these methods will cause little or no relief of the patient’s symptoms (36). It is estimated that about 10% of the patients will demonstrate severe therapy-refractory symptoms 16, 17.
In these patients, stereotactic lesional procedures (capsulotomy and cingulotomy) have constituted an alternative for a few well-selected patients. The results have varied, and the irreversibility of the procedure has raised concern regarding nontransient side effects 38, 59.
Recently, stereotactic deep brain stimulation (DBS) has emerged as a possible treatment for therapy-refractory OCD. Although chronic electrical stimulation using stereotactically implanted electrodes have a long history going back to the 1950s, the modern era began in the end of the 1980s and has expanded, especially during the last decade 9, 12, 28, 69. Today DBS is an established treatment for movement disorders such as Parkinson disease (PD), and more than 60,000 patients have undergone operations worldwide (46).
New indications for DBS are emerging, and regarding psychiatric disorders, several studies have been presented regarding Tourette syndrome 2, 8, 18, 29, 31, 63, 64, 75, major depressive disorder 10, 14, 34, 39, 44, 60, and OCD 1, 4, 5, 6, 7, 15, 17, 22, 23, 24, 25, 26, 27, 30, 32, 33, 38, 42, 45, 50, 51, 52, 53, 55, 65, 67, 68. The goal of this report is to review the modern literature regarding DBS in the treatment of OCD.
Section snippets
Studies and Methods
The literature was searched regarding DBS for OCD. Relevant publications were obtained using the PubMed database and references from the consulted reports. Duplicate inclusion of patients included in multiple publications from the same institution was avoided.
DBS
The surgical procedure differs little between OCD and movement disorders (14). After mounting of the stereotactic frame, magnetic resonance imaging is performed for identification of the target. A burr hole is made a few centimeters from the midline in accordance with the precalculated trajectory, and the electrode is advanced to the target. The DBS electrode has a diameter of 1.27 mm and 4 contacts of 1.5 or 3 mm in length, separated by 0.5, 1.5, or 4 mm, depending on the model. The effect and
Pathophysiology
Although recent neuroimaging studies are increasing our knowledge regarding the mechanism behind OCD, the understanding of the pathophysiological background is still limited 30, 38, 48, 56, 57, 58, 61, 73. The suggested models are instructive, but there must be little doubt that the reality is far more complex. Even if functional neuroimaging holds promise for the future, it has as yet had limited impact on the current status of DBS for OCD. The best target for an intervention with DBS cannot
Results
The results are summarized in Table 1 and presented in further detail regarding the larger studies in Table 2.
The first patients treated with DBS for OCD underwent implantation in the anterior IC in the same target as used for capsulotomies 25, 50, 51. Four collaborating groups have individually and in various combinations presented parts of a study recently summarized by Greenberg et al. (25). The results were reported for 26 patients after a mean time of 24 months. Cases lost to follow-up
Discussion
Although the study is limited, the effects of unilateral NA DBS are modest compared to the bilateral procedures. It is of interest that an effect was only achieved by Huff et al. (32) when using the 2 deepest contacts in the NA, whereas Denys et al. (17) had no effect here, but only at the above-lying contacts in the IC. At the same time, the target in the IC has been moved to a more posterior and somewhat deeper location: this is why the deepest contact will often be in the NA (25). Thus, when
References (76)
- et al.
Deep brain stimulation for refractory obsessive-compulsive disorder
Biol Psychiatry
(2005) - et al.
Deep brain stimulation in Tourette's syndrome: two targets?
Mov Disord
(2006) - et al.
Suicide in patients treated for obsessive-compulsive disorder: a prospective follow-up study
J Affect Disord
(2010) - et al.
Treatment of patients with intractable obsessive-compulsive disorder with anterior capsular stimulation. Case report
J Neurosurg
(2003) - et al.
Distinct striatal targets in treating obsessive-compulsive disorder and major depression
J Neurosurg
(2009) - et al.
Deep brain stimulation of the ventral caudate nucleus in the treatment of obsessive-compulsive disorder and major depression. Case report
J Neurosurg
(2004) - et al.
Deep brain stimulation for OCD and major depression
Am J Psychiatry
(2005) - et al.
Deep brain stimulation in Tourette's syndrome
Mov Disord
(2007) - et al.
Combined (thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson disease
Appl Neurophysiol
(1987) - et al.
Nucleus accumbens deep brain stimulation decreases ratings of depression and anxiety in treatment-resistant depression
Biol Psychiatry
(2010)
Obsessive-compulsive disorder: update on assessment and treatment
J Psychiatr Pract
Are complications less common in deep brain stimulation than in ablative procedures for movement disorders?
Stereotact Funct Neurosurg
Deep brain stimulation in the treatment of depression
Acta Psychiatr Scand
Lack of benefit of accumbens/capsular deep brain stimulation in a patient with both tics and obsessive-compulsive disorder
Neurocase
Pharmacotherapy of obsessive-compulsive disorder and obsessive-compulsive spectrum disorders
Psychiatr Clin North Am
Deep brain stimulation of the nucleus accumbens for treatment-refractory obsessive-compulsive disorder
Arch Gen Psychiatry
Efficient internal pallidal stimulation in Gilles de la Tourette syndrome: a case report
Mov Disord
Deep brain stimulation of the anterior internal capsule for the treatment of Tourette syndrome: technical case report
Neurosurgery
Effect of subthalamic nucleus stimulation on obsessive-compulsive disorder in a patient with Parkinson disease. Case report
J Neurosurg
Hold your horses: impulsivity, deep brain stimulation, and medication in parkinsonism
Science
Deep-brain stimulation of the nucleus accumbens in obsessive-compulsive disorder: clinical, surgical and electrophysiological considerations in two consecutive patients
Neurol Sci
Deep brain stimulation for treatment-refractory obsessive-compulsive disorder: psychopathological and neuropsychological outcome in three cases
Acta Psychiatr Scand
Deep brain stimulation for intractable obsessive-compulsive disorder: pilot study using a blinded, staggered-onset design
Biol Psychiatry
Deep brain stimulation of the ventral internal capsule/ventral striatum for obsessive-compulsive disorder: worldwide experience
Mol Psychiatry
Three-year outcomes in deep brain stimulation for highly resistant obsessive-compulsive disorder
Neuropsychopharmacology
Neuronal correlates of obsessions in the caudate nucleus
Biological psychiatry
Deep brain stimulation between 1947 and 1987: the untold story
Neurosurg Focus
Gilles de la Tourette syndrome and deep brain stimulation
Eur J Neurosci
High-frequency stimulation of deep brain structures in obsessive-compulsive disorder: the search for a valid circuit
Eur J Neurosci
Tourette's syndrome and deep brain stimulation
J Neurol Neurosurg Psychiatry
Unilateral deep brain stimulation of the nucleus accumbens in patients with treatment-resistant obsessive-compulsive disorder: outcomes after one year
Clin Neurol Neurosurg
Preliminary study in patients with obsessive-compulsive disorder treated with electrical stimulation in the inferior thalamic peduncle
Neurosurgery
A patient with a resistant major depression disorder treated with deep brain stimulation in the inferior thalamic peduncle
Neurosurgery
Neuromodulation of the inferior thalamic peduncle for major depression and obsessive-compulsive disorder
Acta Neurochir Suppl
Deep brain stimulation of the nucleus accumbens and the internal capsule in therapeutically refractory Tourette-syndrome
J Neurol
Deep brain stimulation for treatment-refractory obsessive-compulsive disorder: the search for a valid target
Neurosurgery
Cited by (0)
Conflict of interest statement: This work was supported by grants from the Swedish Research Council, University Hospital of Umeå, and from the Foundation for Clinical Neuroscience at the University Hospital of Umeå. Marwan Hariz is supported by the Parkinson Appeal U.K. and the Edmond J. Safra Philanthropic Foundation. He has occasionally received honoraria from Medtronic for speaking at meetings. The authors have nothing further to acknowledge.