Sahib S. Khalsa, MD, PhD Resident Physician, UCLA Anxiety Disorders Program, Department of Psychiatry, UCLA David Geffen School of Medicine, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA Jason E. Schiffman, MD, MA, MBA Chief Resident Physician, UCLA Anxiety Disorders Program, Department of Psychiatry, UCLA David Geffen School of Medicine, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA Alexander Bystritsky, MD, PhD Director, UCLA Anxiety Disorders Program, Professor of Psychiatry and Biobehavioral Sciences, Department of Psychiatry, UCLA David Geffen School of Medicine, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA
Deep brain stimulation (DBS). With this approach, small electrodes are inserted under precise stereotactic MRI guidance. The advantage of DBS over ablative surgery is the ability to adjust and customize neurostimulation. Following implantation, modifiable parameters of electrode stimulation include electrode polarity, intensity, frequency, and laterality. A specially trained psychiatrist can conduct parameter optimization during long-term follow-up.
Clinical Point
The advantage of DBS over ablative surgery is the ability to adjust and customize neurostimulation
The first trial of DBS for OCD was reported in 1999 (N = 4), with the initial target selected based on the site of anterior capsulotomy. Three patients derived clinically observed benefit, although no validated questionnaires were administered.51 Since then, at least 7 studies with blinded stimulation have been conducted, totaling 62 patients.52
In recent years, structures adjacent to the internal capsule also have been targeted based on the approach employed in ventral capsulotomy. Across all trials, response rates for this approach consistently have been in the 50% range, with average Y-BOCS score reductions ranging from 6.8 to 31 points.53 Some patients have reported rapid improvements in anhedonia, and this approach is being employed in treatment-resistant depression.
Postoperative complications occur more often with DBS than with lesion approaches because of the prosthetic nature of the procedure (eg, increased risk of infection, lead malfunction, etc.). Additionally, batteries must be periodically explanted and replaced. Reported stimulation-related side effects include mood changes (transient sadness, anxiety, euphoria, and hypomania), sensory disturbances (olfactory, gustatory, and motor sensations), and cognitive changes (confusion and forgetfulness). These side effects typically are stimulation-dependent and disappear after altering stimulation parameters.
Table 2
Invasive therapies for treatment-resistant OCD
Therapy
Quality of evidence
Reversible
Electroconvulsive therapy
Poor
Vagal nerve stimulation
Poor
Repetitive transcranial magnetic stimulation
Limited
Irreversible (surgical)
Anterior capsulotomy. Target: anterior limb of the internal capsule
Fair
Anterior cingulotomy. Target: anterior cingulate and cingulum bundle
Fair
Subcaudate tractotomy. Target: substantia innominata, just inferior to the caudate nucleus
Fair
Limbic leucotomy. Target: anterior cingulotomy combined with subcaudate tractotomy
Hyman BM, Pedrick C. The OCD workbook. Your guide to breaking free from obsessive compulsive disorder. 3rd ed. Oakland, CA: New Harbinger Publications Inc; 2010.
Baer L. Getting control: overcoming your obsessions and compulsions. Revised ed. New York, NY: Plume; 2000.
Drug Brand Names
Alprazolam • Xanax
Aripiprazole • Abilify
Citalopram • Celexa
Clomipramine • Anafranil
Clonazepam • Klonopin
Dextroamphetamine • Adderall
Duloxetine • Cymbalta
Fluoxetine • Prozac
Fluvoxamine • Luvox
Haloperidol • Haldol
Ketamine • Ketalar
Memantine • Namenda
Methylphenidate • Ritalin
Morphine • MS Contin
Olanzapine • Zyprexa
Ondansetron • Zofran
Pindolol • Visken
Quetiapine • Seroquel
Riluzole • Rilutek
Risperidone • Risperdal
Sertraline • Zoloft
Tramadol • Ultram
Venlafaxine • Effexor
Ziprasidone • Geodon
Disclosures
Drs. Khalsa and Schiffman report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Bystritsky receives grant support from AstraZeneca, Brainways, Takeda, and Transcept and is a founder, stockholder, and consultant for BrainSonix.