P. Cosyns

Deep brain stimulation for treatment-refractory obsessive-compulsive disorder: psychopathological and neuropsychological outcome in three cases

Objective:u2002 Investigation of deep brain stimulation (DBS) as a last‐resort treatment alternative to capsulotomy in treatment‐refractory obsessive‐compulsive disorder (OCD).

Deep brain stimulation for psychiatric disorders

Abstract: Over the last decade, deep brain stimulation (DBS) has revolutionized the practice of neurosurgery, particularly in the realm of movement disorders. It is no surprise that DBS is now being studied in the treatment of refractory psychiatric disease. Deep brain stimulation has inherent advantages over previous lesioning procedures. It is fully reversible, and stimulation can be adjusted according to a patient’s changing symptoms and disease progression. Coupled with the fact that the stimulation can generally be turned on or off without the patient’s awareness, DBS provides a unique opportunity for double-blinding studies. To undertake DBS for psychiatric conditions, appropriate surgical targets must be chosen. What is most strongly supported is the role of cortico-striato-thalamocortical (CSTC) loops in the pathophysiology of psychiatric symptoms. Recent functional imaging studies have consistently found evidence that corroborate this model of psychiatric symptom pathogenesis. Based on the psychiatric and cognitive effects seen in recent movement disorder surgery, it is apparent that modulation of neural systems subserving psychiatric phenomenon can be accomplished by DBS. The few published studies on DBS for obsessive-compulsive disorder (OCD) suggest that this can be done safely. While efficacy data are still uncertain, initial data are promising.

Behavioural and physiological effects of electrical stimulation in the nucleus accumbens: a review

Electrical stimulation (ES) in the brain is becoming a new treatment option in patients with treatment-resistant obsessive-compulsive disorder (OCD). A possible brain target might be the nucleus accumbens (NACC). This review aims to summarise the behavioural and physiological effects of ES in the NACC in humans and in animals and to discuss these findings with regard to neuroanatomical, electrophysiological and behavioural insights. The results clearly demonstrate that ES in the NACC has an effect on reward, activity, fight-or-flight, exploratory behaviour and food intake, with evidence for only moderate physiological effects. Seizures were rarely observed. Finally, the results of ES studies in patients with treatment-resistant OCD and in animal models for OCD are promising.

Applicants for stereotactic neurosurgery for psychiatric disorders: role of the Flemish advisory board.

Objective:u2002 Research on stereotactic neurosurgery for psychiatric disorders (SNPD) is rapidly evolving. Knowledge on patients undergoing SNPD is of crucial importance. We describe applicants for SNPD and examine the necessity for a multidisciplinary advisory board.

Electrical stimulation of the brain for psychiatric disorders.

Despite advances in therapies, there remain psychiatric patients who are extremely ill and cannot be helped by classic psychiatric treatments, including psychotherapy and drug therapy. Certain of these patients may be helped by use of bilateral brain lesioning. The complication rate of standard stereotactic psychosurgery techniques is very low. The main rationale for the continued experimental use of deep brain stimulation (DBS) in neurosurgery for mental disorders is its reversibility. This reversibility is not an advantage in terms of the benefits obtained, but rather if side effects emerge. In addition, electrical stimulation may provide patients with some autonomy for their treatment. The first, very preliminary results of electrical stimulation for obsessive-compulsive disorder and for a small heterogeneous group of patients with other psychiatric disorders have been published. Electrical stimulation of the brain for psychiatric disorders may become a new treatment option for certain intractable psychiatric disorders. Nevertheless, the mechanism of action of DBS in psychiatric disorders is unknown, and the experience with this modality is extremely limited. The first results look promising, but this treatment option may prove unusable for some time because of a lack of knowledge of appropriate brain stimulation targets and technical problems such as the availability of sufficient current supply.

DBS and the Treatment of Obsessive Compulsive Disorder

Obsessive-compulsive disorder (OCD) affects ca. 2% of the general population [1]. The cardinal symptoms of OCD are intrusive thoughts (obsessions) and/or repetitive behaviors (compulsions) that persist despite the patient’s attempts to eliminate them. The obsessions and compulsions are accompanied by marked, overwhelming anxiety and are distressing and timeconsuming. In addition, patients tend to avoid objects or situations that provoke obsessions or compulsions. Their functioning becomes increasingly limited by avoidance behaviors and they are burdened by shame and demoralization. Although the majority of the patients recognize the exaggerated nature of their obsessions and senselessness of their compulsions, they feel enslaved and are compelled to engage in their rituals. They cannot simply dismiss the obsessional ideas and large amounts of time are spent on compulsive rituals. The bizarre and exaggerated aspects of the symptoms result in a deep sense of shame and may lead to social isolation and depression. Comorbidity of OCD with depression is considerable: up to 67% of patients with primary OCD have a lifetime history positive for major depressive disorder [2]. Both pharmacotherapy and cognitive behavioral psychotherapy (CBT) have proven to be effective in the treatment of OCD. However, standard treatments do not work for some patients: full or partial remission is only seen in approximately 60–80%, while the remaining patients experience only a minimal or no response. Notwithstanding the important advances made over the last decades in the efficacy, safety, and tolerance of treatments for OCD, up to 7.1% of the patients show persistent disabling symptoms in spite of combined pharmacological and psychotherapeutic treatment [3]. For these patients who remain severely disabled despite these state-of-the-art approaches new treatment strategies are needed.

P02-544 - Differential Impact of Deep Brain Stimulation or Anterior Capsulotomy on General Functioning, Personality Features and Quality of Life in OCD

Introduction Research on deep brain stimulation (DBS) for treatment refractory obsessive-compulsive disorder (OCD) shows promising effects on symptoms severity. Objectives To compare outcomes between DBS and bilateral capsulotomy on general functioning, personality traits and quality of life. Methods Consecutive patients with severe and treatment refractory OCD underwent DBS in the anterior limb of the internal capsule (DBS; nxa0=xa014) or anterior capsulotomy (CAPS; nxa0=xa014). They were tested before surgery (baseline-BL) and after a mean follow-up time (FU) of 19 months (range 14-31 months). Changes in OCD severity were recorded and global assessment of functioning, personality traits, and quality of life were compared between groups. Results Statistically significant differential improvements (pxa0 Conclusion These findings suggest a superior impact of DBS over capsulotomy on general functioning, personality traits and quality of life. Limits of this study are the small numbers, the fact that DBS and CAPS patients were from a slightly different OCD population and were not randomized to treatment, and differences in postoperative follow-up.