More on Deep Brain Stimulation for OCD

By Neuroskeptic | February 24, 2010 9:38 am

Over the past few years, deep brain stimulation (DBS) has emerged as a promising treatment for severe psychiatric disorders that haven’t responded to conventional approaches. A new paper from the University of Florida reports on a trial of DBS in obsessive-compulsive disorder (OCD), and unlike most DBS studies, it was placebo-controlled: Deep Brain Stimulation for Intractable Obsessive Compulsive Disorder.


Six patients were implanted with electrodes in the “ventral capsule/ventral striatum” (VC/VS). This area has previously been used as a DBS target for OCD. The original reason for choosing to implant electrodes in this region was that it’s long been known that destroying the anterior limb of the internal capsule (capsulotomy) alleviates OCD symptoms in many cases, especially if the ventral (lower) part is removed.

Did it work? Yes, but not for everyone. Out of the 6 patients who entered the trial, all of whom were extremely ill despite having tried multiple medications and psychotherapy, 4 (66%) eventually responded well. The other 2 unfortunately got little or no benefit over the 12 month trial period.

The study had a double-blind, placebo-controlled phase: the patients weren’t told when the DBS electrodes were going to be switched on. As the graphs show, in the 3 patients who were randomly selected to have them switched on early, 2 responded pretty much immediately, while in the 3 patients whose electrodes were left off, none responded until they were turned on 30 days later, although the response at this point was fairly gradual.

One person (S1), who responded very well initially, suddenly relapsed about a year later. Upon investigation, it turned out that the battery powering their electrodes had worn out, although no-one knew this until the OCD symptoms returned, so this can’t have been a placebo effect. They recovered after getting a new battery.

Overall there are few surprises here. These results confirm what we already knew about DBS: it works in many people, but not all, with response rates of around 60%; When it works, it works very well; but sometimes the effects take weeks or months to become fully apparent. This could be either because DBS starts some gradual process of change in the brain which takes time to work; or it could be that it often takes a long time to find the right stimulation parameters (voltage, frequency, etc.) which provide a good response, since this has to be done by trial-and-error. Most likely, it’s a bit of both.

What I found most interesting was that the VC/VS stimulation didn’t just treat people’s obsessions and compulsions. It also had a mood-improving effect, and crucially, it sounds as though mood was the first thing to improve, with OCD symptoms following days or weeks later:

Finding the optimal settings for an individual subject proved challenging…unlike other experiences with DBS, there is not a clear positive symptom (e.g., tremor improvement) to gauge settings. In this study… the goal was to select parameters that produced some benefit in mood or anxiety symptoms acutely, with minimal side effects.

and mood was the first thing that got worse when the DBS was accidentally turned off for whatever reason:

Worsening in mood or increased anxiety were typically the first symptoms reported following battery depletion or inadvertent inactivation by metal detectors. Other signs of depression, such as diminished energy or interest, also emerged within days of device interruption… Exacerbation of OCD symptoms generally lagged the emergence of affective or anxiety symptoms.

And in fact, four people experienced temporary hypomania, i.e. abnormally elevated mood, which is usually seen in bipolar disorder, although none of the patients in this study had a history of bipolar. People also commonly reported increased alertness, motivation, and difficulty falling asleep.

This all fits with the fact that VC/VS stimulation has been used as a DBS target for clinical depression, as well as for OCD. Indeed, this suggests that DBS probably works in essentially the same way in both conditions. The drugs that are used to treat OCD are all antidepressants – specifically serotonin-based ones – so this makes sense too.

With luck, research on DBS in animals and humans will finally allow us to understand the neural basis of mood states like depression, and mania – something which, despite decades of research on drugs like antidepressants and mood stabilizers, is still deeply mysterious

ResearchBlogging.orgGoodman, W., Foote, K., Greenberg, B., Ricciuti, N., Bauer, R., Ward, H., Shapira, N., Wu, S., Hill, C., & Rasmussen, S. (2010). Deep Brain Stimulation for Intractable Obsessive Compulsive Disorder: Pilot Study Using a Blinded, Staggered-Onset Design Biological Psychiatry, 67 (6), 535-542 DOI: 10.1016/j.biopsych.2009.11.028

CATEGORIZED UNDER: dbs, mental health, papers
  • http://www.blogger.com/profile/11302076828795198187 Cervantes

    Uhoh, here it comes.

    “In Larry Niven's Known Space stories, a wirehead is someone who has been fitted with an electronic brain implant (called a “droud” in the stories) to stimulate the pleasure centers of their brain. In the Known Space universe, wireheading is the most addictive habit known (the only given example of withdrawal is Louis Wu), and wireheads usually die from neglecting themselves in favor of the ceaseless pleasure. Wireheading is so powerful and easy that it becomes an evolutionary pressure, selecting against that portion of Known Space humanity without self-control. Wireheading need not use an actual brain implant; the pleasure center can be remotely activated by a small device called a “tasp” (important in the Ringworld novels).”

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Well, interestingly, the authors say that even the two patients who didn't get any benefit in terms of their OCD symptoms, wanted to keep getting the DBS because it made them feel good…

    “wireheading is the most addictive habit known”, indeed…

  • Anonymous

    Even more addictive than masturbation??? LOL. Just kidding…

  • http://www.zeropointmagicwand.com/ Amega Products

    Very Interesting topic. So that could be very addictive.

    Try to visit our site for better health wellness.

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  • Anonymous

    Nice try for a N= 6. Perhaps not surprisingly, there is a lot of statistical variability noted in outcome. But understandable given the minuscule sample size. Still, I thought the findings regarding non OCD effects (e.g. mood, etc) reinforced the general and always replicated finding that most psychiatric treatments have non-specific effects. I mean SSRI's reportedly treat everything under the sun from depression, anxiety, OCD and what not. And now anti-psychotics treat mood disorders, blah, blah, blah. There is nothing to write home to Mom about this data.

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Anonymous: Very true. DBS also seems to be rather non-specific: DBS in this location has been used to treat depression as well as OCD, but there are half a dozen other locations that have also been used for depression with similar results…

  • Anonymous

    Just a follow up point regarding the seeming non-specificity of psychiatric treatments. I note that 4 of 6 or 2/3 of the small sample responded to DBS in the manner of symptom reduction. This “two thirds” response rate also seems to cut across psychiatric illnesses for mood disorders and anxiety disorders, irrespective of treatment modality (DBS, drugs, therapy). It is just plain weird.

  • Anonymous

    Perhaps we have found a cosmological constant of 2/3 as applied to mental illness treatment outcome? LOL.

  • http://tabletpc-shop.info/tablet_apad2.html apad 2

    I believe one and all must look at it.

  • Anonymous

    Was hopeful when my daughter's therapist mentioned this…but upon reading this, I believe this would cause her to cycle into manic episodes as she has severe bipolar I disorder with severe OCD as well. She can't take the OCD meds as they trigger the mania, nor can she try any of the other alternative therapies. I keep hoping the scientists can hone in on the “one” center of the brain that focuses on the OCD without triggering the mania.

  • Anonymous

    My sister interviewed with Dr. Ward and Dr. Kelly Foote many years ago about being included in the clinical trial for DBS. At the time, she was diagnosed with severe intractable OCD and major depressive disorder. She did not have Medicare and she lived too far away so she was not included as candidate for the the clinical trial. She finally got her disability determination and will get Medicare in two years (or less, hopefully). I do hope that we can try again to be included in the next round of clinical trials. You have no idea what it's like to live with someone who has such a debilitating disease. My sister is bombarded by intrusive thoughts around the clock and severe depression leaves her feeling “stuck” like she's in quick sand. Getting her to brush her teeth requires goading and coaching. I'm exhausted. I'm thinking about getting a Cattle Prop or a Stun Gun to get her to take a bath once in a while. I pray that DBS for OCD is found to be effective and therefore will be FDA approved. My sister is driving the whole family nuts.

  • Anonymous

    Hello anonymous (4-Aug 2012) – just to let you know, the FDA has approved DBS for OCD under something called an “HDE” Humanitarian Device Exemption, which I believe has case-by-case medicare reimbursement. There are many resources for patient education out there (OC Foundation, for example).
    There is also a significant multi-center study for DBS for OCD that has centers in MN, FL, NY etc. I know an individual in one of the studies. ID NCT00640133 http://clinicaltrials.gov/ct2/show/NCT00640133?term=dbs+sinai&rank=2

    also, for what it is worth, here's a list of nationwide doctors/practices set up for OCD DBS (last updated in 2011): http://www.medtronic.com/patients/obsessive-compulsive-disorder-ocd/wcm_prod024701
    [Disclaimer: PLEASE DO NOT INTERPRET MY COMMENT AS AN INDUCEMENT TO SEEK THIS TREATMENT. CONSULT WITH QUALIFIED PROFESSIONALS.}

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No brain. No gain.

About Neuroskeptic

Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.

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