Elsevier

World Neurosurgery

Volume 80, Issue 6, December 2013, Pages e245-e253
World Neurosurgery

Peer-Review Report
Deep Brain Stimulation in the Treatment of Obsessive-Compulsive Disorder

https://doi.org/10.1016/j.wneu.2012.10.006Get rights and content

Background

Deep brain stimulation (DBS) has emerged as a treatment for severe cases of therapy-refractory obsessive-compulsive disorder (OCD), and promising results have been reported. The literature might, however, be somewhat unclear, considering the different targets used, and due to repeated inclusion of individual patients in multiple publications. The aim of this report was to review the literature on DBS for OCD.

Methods

The modern literature concerning studies conducted on DBS in the treatment of OCD was reviewed.

Results

The results of DBS in OCD have been presented in 25 reports with 130 patients, of which, however, only 90 contained individual patients. Five of these reports included at least 5 individual patients not presented elsewhere. Sixty-eight of these patients underwent implantation in the region of the internal capsule/ventral striatum, including the nucleus accumbens. The target in this region has varied between groups and over time, but the latest results from bilateral procedures in this area have shown a 50% reduction of OCD scores, depression, and anxiety. The subthalamic nucleus has been suggested as an alternative target. Although beneficial effects have been demonstrated, the efficacy of this procedure cannot be decided, because only results after 3 months of active stimulation have been presented so far.

Conclusions

DBS is a promising treatment for therapy-refractory OCD, but the published experience is limited and the method is at present an experimental therapy.

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

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    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.

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