1. Consideration of Deep Brain Stimulation in Refractory OCD
Jorel Martinez, MD
PYG4
Consideration of Deep Brain Stimulation in Refractory OCD

2. Case:
Patient AB
37M w/ no PMH and PPH of GAD, MDD, panic disorder, ADHD and OCD
Presented to UCMC 2 years ago:
Sertraline 50mg daily
Quetiapine 200mg QHS
Ambien CR 12.5mgQHS
Adderall 30mg daily
We started lyrical 75mg BID

3. Case: OCD SX Intrusive/obsessional thoughts Patient AB
Past Psychiatric History
First saw psychiatrist in early teens. Previously experienced tic-vocalizations, does not remember any past psychiatric meds. rTMS in the past w/ equivocal result.
OCD SX
Intrusive/obsessional thoughts
Content related to attire, grooming, order or movements (symmetry and perfection)

4. Case:
Social History
Raised in Park Ridge by married parents, 4 sisters
Father is a physician
Denies physical/sexual/verbal abuse
Switched high schools several times (“not comfortable”)
Attended two different colleges, did not graduate
Started a Health Wellness company and worked with his father
Lives with parents (on and off)
No long term romantic relationship

5. Case: Med trials with UCMC Started on selegiline patch
(after washouts) w/ dose titration 12mg/day, seroquel, ambien continued
Clonazepam 0.5mg TID added
Went to PHP at Rogers Behavioral w/ dramatic improvement then precipitous decline in subsequent weeks
Switched selegeline to fluvoxamine 300mg (improvement)
Adderall Restarted and increased to 60mg daily
CBT 3x per week

6. Case: Patient Symptoms: Estimated YBOCS Last visit was July 2017
Lowest score: 20 (1st month after PHP)
Highest score 35 (first switched to selegeline)
Last visit was July 2017
Patient continued to have OCD symptoms w/ signifcant distress and poor quality of life

7. What is Deep Brain Stimulation?
A Neurosurgical Procedure
2 holes are drilled in the skull
2 leads from a DBS device are implanted using MRI guidance
LEADS
Diameter is 1.27mm
Four independently programmable 3mm contacts spaced 4mm apart

8. What is Deep Brain Stimulation?
What is the mechanism by which it is proposed to treat OCD?
What does the evidence tell us about the efficacy of DBS for refractory OCD?
What are the risks and ethical implications of recommending OCD?

9. Deep Brain Stimulator Leads
Contact 3
Contact 2
Contact 1
Contact 0

10. What is Deep Brain Stimulation?
The leads are implanted on the trajectory of the anterior capsule on the coronal plane
The distal contact is extended into ventral striatum
The most dorsal contact is placed at the dorsal margin of the anterior capsule

11. Deep Brain Stimulation Lead Location

12. Deep Brain Stimulation Lead Location

13. What is Deep Brain Stimulation?
In the OR
Set in bipolar mode, contact 3 is set to positive and 0-2 are set to negative
Stimulation 130hz, pulse widths of 90 and 200micro-seconds, at 2-6V.
Improvement in mood/anxiety, spontaneity, verbal expressiveness, increased alertness/HR indicate proper placement

14. What is Deep Brain Stimulation?
At the same time or 1 week later:
Implantable Programmable Neurostimulators
Placed in pectoral or abdominal region
4 makers
Medtronic
Synergy
Kinetra
Soletra
Wires tunneled subcutaneously from leads to device

15. What is Deep Brain Stimulation?
In approximately 3 weeks:
Either monopolar, or bipolar testing is done with stimulation at each contact point.
The physician programmer determines the settings with most benefit to OCD sx with least discomfort using patient report in real time.

16. What is Deep Brain Stimulation?
Adjustments and reprogramming are performed as needed
DBS stimulation is continuous until battery depletion occurring between 5-13 months
Replaced via OP surgery w/ local anesthesia

17. Mechanism By Which DBS treats OCD

18. What is OCD? OCD Presence of compulsions, obsessions or both
SX are time-consuming or causing significant distress
Clusters around 4 major themes
Symmetry (repeating, ordering, counting)
Forbidden thoughts (sexual, religious, aggressive)
Cleanliness (or contamination)
Hoarding behaviors

19. OCD Appears to involve pathways connecting: striatum (basal ganglia)
Thalamus
ventral and orbital pre-frontal cortex
Emotional inputs are received processed and regulated

20. OCD Striatocortical circuitry Reversal Learning
allows cortex to exert inhibitory control and drive flexible patterns of behavior
Reversal Learning
uses negative feedback to alter ineffective/unproductive behavior

21. OCD patients and unaffected family
activation of lateral orbitofrontal cortex and other cortical regions during reversal learning
connectivity between lateral PFC and dorsal striatum
 connectivity between ventral striatum and VTA
Is this where we should stimulate?

22. Different OCD sx with distinct neural correlates?
Cleansing
activation of ventromedial PFC and R caudate nucleus
Hoarding
Activation of L precentral gyrus + R orbitofrontal cortex
Checking
Activation of putamen, global pallidus, thalamus

23. What does the Evidence Tell Us?

24. OCD Appears to involve pathways connecting: striatum (basal ganglia)
Thalamus
Published in 2008 in Molecular Psychiatry
Following four study groups over 8 years
Improvement in efficacy in later years as lead placement has become more posterior
N=26

25. Patient Selection
SCIDS- used to screen to ensure OCD is primary diagnosis
OCD duration of 5+ years
YBOCS symptom severity ≥28

26. Patient Selection YBOCS symptom severity ≥28 TX refractory
3+ three month trials of SSRI (one of which clomipramine)
Trials of SSRI + BZD or antipsychotic required
Behavioral therapy 20+ Sessions

27. Exclusion Criteria HX of Psychotic Disorder Mania in Past 3 Years
Abnormal MRI
Current/Unstable Substance Abuse
Severe Personality Disorder

28. ODC onset ranged from 7-34 years
Illness duration from 8 to 41 year
MEAN YBOCS was 34+/-0.5

29. What is Deep Brain Stimulation?
“DBS lead implantation site became systematically more posterior during these studies based on clinical results observed, other empirical results and theoretical considerations.”

30. Results: Figure 4
“DBS lead implantation site became systematically more posterior during these studies based on clinical results observed, other empirical results and theoretical considerations.”

31. Results: YBOCS Scores Mean Δ between baseline and treatment phase:
73% had 25% decrease in YBOCS at last follow up

32. Results: By category Proportion of subtype with >35% YBOCS
Checking/Obsessions: 100% (6/6)
Symmetry: 55.6% (5/9)
Cleanliness: 45.5% (5/11)
Hoarding: (0/0)

33. Concerns about the evidence
Small N
No SHAM (leave device turned off)
Changes to procedure (increasingly posterior lead placement)

34. MEDICATION ALTERNATIVES
Inositol
Evidence
IV Citalopram or Clomipramine
Lithium, Clonidine
Opioids
Memantine
D-cycloserine
Evidence?

35. PROCEDURE ALTERNATIVES
Cingulotomy/Capsulotomy
Thalotomomy/pallidotyomy
Location/evidence
Radiosurgery “Gamma Knife” (no incision)
Location, evidence
ECT
Evidence?
rTMS
Vagal Nerve Stimulation

36. Risks/EThics