Obsessive-compulsive disorder (OCD) is a psychiatric disease characterized by anxiety-provoking thoughts (obsessions) leading to repeated, time-consuming behaviors (compulsions) that may or may not provide temporary relief. With an approximate prevalence of 2 to 3% of the general population and 0.6% in Indian population, OCD is a debilitating disorder that can significantly affect nearly every aspect of a patient’s life, and in some cases, lead to suicide. In a meta-analysis of a database of the Food and Drug Administration, the annual suicide risk rate in OCD patients with minimal and no comorbidity, participating in a trial of selective serotonergic reuptake inhibitiors (SSRI) was 105/10000 and the annual suicide attempt risk was 1468/100000. Although OCD has been recognized and studied in the psychiatric literature for nearly a century, only relatively recently has the disease been evaluated in a neuroscientific context. The application of functional imaging techniques, such as functional magnetic resonance imaging and positron emission tomography (PET) scans, to this patient population, coupled with advances in the safety and efficacy of functional neurosurgical intervention, has led to a renaissance of research in this area. Despite the vast array of new, selective psychotropic medications available today, however, many neuropsychiatric illnesses remain refractory and, consequently, some patients remain severely disabled. These patients might be considered appropriate candidates for surgery if the overall result and level of functioning could be improved.
Imaging correlates of OCD
Studies comparing volumes of specific brain regions in patients with OCD have often yielded conflicting and inconsistent results. Brain regions of interest have included the head of the caudate nucleus, the orbitofrontal cortex, and the anterior cingulate gyrus. With respect to the CN especially, studies have found increases, decreases, and no change in volume between OCD patients and healthy controls on magnetic resonance image (MRI) scans. The source of this apparent discrepancy in the volumetric literature may be methodological in nature. Furthermore, it has been suggested that the heterogeneity of OCD, a disease with several unique classifications and subtypes, can be responsible for the inconsistent volume differences among various structures as reported in the literature.
Functional imaging in OCD
PET examines cerebral metabolism using flurodeoxyglucose. PET studies on patients with OCD confirm that elevated glucose metabolism occurs in the bilateral thalamus, caudate, and OFC regions. In an another study of the patients who check, hypermetabolism was found in the putamen/globuspallidus, the thalamus, and the right inferior frontal cortex; in those who wash, the greatest activation was identified in the OFC, the cingulated gyrus (CG), and the ventrolateral prefrontal cortex.
Mr. V, 62 years old Engineer from, Karnataka was an anxious, determined, short tempered, reserved and dominating personality. He developed depression after the demise of his father in 1990. He was treated for the same in Mysore. One year later his symptom progressed to anxiety, dominated by obsessive and compulsive symptoms, which gradually increased in severity. He had taken voluntary retirement and had not been working since past 15 years. He was also unable to withdraw his pension, as he could not sign for himself. His obsessive symptoms included insisting on repeated checking and verifyingdocuments, cheques and money. His compulsions included repeated washing of the hands (about 80-100 times at the time of admission), spending long time in the toilet (about 3-4hrs), repeatedly asking the same questions and verifying the answers multiple times. There were no ideas of reference on persecution. There were no hallucinations. Since the last two years he had been confined to home due to these symptoms.His disease had significantly affected his and his caregiver’s quality of life. He had been on SSRIs and SDAs, including Fluoxetine, Fluvoxamine, Sertraline, Clomipramine, Escitalopram and many others, in maximum doses. He had also undergone behavioural therapy during these 15 years (more than 20 out patient sessions) under the care of psychiatrist without any significant change in his symptoms. At the time of admission he was on a daily dose of Risperidone 2mg, Quetiapine 75mg, Alprzolam .5mg, Escitalopram 10 mg and fluoxetine 100mg. The referring psychiatrist and the psychiatrist who independently assessed him for surgery both were satisfied with the duration of the treatment (medical and behavioural therapy) and had found to be adequate to establish intractability.
On examination He was intelligent, anxious, well oriented and had normal memory. He had preserved insight, co-operative and repetitive. His thought process had occasional tangentiality but can be brought back to rational thinking. He had no other focal neurological deficits.
He was evaluated by two psychiatrists independently, who established the diagnosis of OCD as per DSM IV criteria. The neurosurgeon (author) also concurred with them and decided to offer surgical option. He underwent neuropsychological testing that included Minnesota multiphasic personality inventory and RORSCHACH. The MMPI revealed “Fake Bad” protocol/psychoses. The F% was 66.67% implying weakening ties with realty. It was reported as obsessive compulsive personality disorder and psychoses. However, it was also noted that the patient was very defensive in taking the tests (and was also tired). His YBOCS was 38/40 and Hamilton depression score was 24. His Beck’s anxiety inventory reflected a score of 26 revealing moderate degree of anxiety. The Mini-Mental State Examination score was 30, revealing a normal cognitive profile. Based on the clinical history, patient interview and results of various assessments, the team of pschiatrists concluded that this was a case of intractable OCD and qualified for surgical intervention. There were two options availabe for surgery: DBS or ablative surgery(Lesion). Patient and his wife came from a city that was four hours drive from Banglore (the closest town to have flight connections with Mumbai). They had not travelled independently in many years and felt that it would be difficult for them to make frequent visits to Mumbai for postoperative programing. Hence, they decided to opt for lesion. The case was than referred to the psychiatric surgery review board, which comprised of a neurosurgeon, neurologist and psychiatrist not involved in surgery or patient care. They found that the surgical treatment was a logical otion for improving patients’ condition.
As the patient could not sign (because of OCD) an informed consent was obtained from his sister and wife. Patients’ consent for surgery was recorded on video. A preoperative planning MRI was performed one day prior to surgery. IR and T2 weighted coronal images were used to identify the internal capsule. A surgical target 3 mm anterior to the posterior border of anterior commisure and 2 mm inferior to the AC-PC plane was selected. This was the bottom of the target. On the day of surgery, a stereotactic CT scan was performed and fused with the preoperative MRI. The target was approached through a precoronal burr hole under local naesthesia. Neurophysiological response was noted starting from 20mm above the target to 3mm below the target on right side and 15mm above till 3mm below the target on left side. The response in the form of decrease in anxiety, more calmness and pseudosmile were noted nearer the targets. Radiofrequency lesioning was done bilaterally at 75 degree Celsius for 60seconds.
Post op CT scan confirmed appropriate target. He had good improvement in his OCD symptoms but had severe confusion and disorientation in the initial three postoperative days. He was also having high-grade fever and hyponatremia, for which no identifiable apparent cause. Reduction in the dosage of psychotropic medications was done on consultation with the Psychiatrist. At the time of discharge he had very good relief of his OCD symptoms. The YBOCS at the time of discharge (1 week postoperatively) was 9 and the depression score was 6. He had no anxiety. After three months of follow up the family reported that his obsession were as well controlled as after surgery, he had lesser anxiety and depression. The apathy has reduced. His progress and medical management is being done by the referring psychiatrist who has been keenly interested in the surgical option.
Case Story 2nd Patient
Anterior capsulotomy surgery for intractable OCD
Rodney King, a 51 years old gentleman, travelled from Australia to get his OCD and Depression treated @ Jaslok Hospital (JH), by Dr. Paresh K. Doshi Though Rod had started experiencing minor symptoms of OCD right from his teen age, his brother’s death in a car accident when he was 13 years old triggered the disease. He experienced intrusive images of people who were close to him being either injured or dead. He had concerns regarding cleanliness. He had unwanted thoughts of items being contaminated by germs. He washed his hands excessively and spent large amounts of time wiping down tables, door handles, stove knobs and other every-day items. He might wash the contents of his wallet because of concern that they were contaminated. He had difficulty going out in public. He repeated his movements and retraced his steps.
If he experienced an intrusive thought whilst performing an action, he would make himself repeat the action. He exhibited checking behaviours, e.g. when driving he constantly checked in the rear vision mirror to make sure that he had not hit anyone. After throwing out rubbish, he had to re-check to make sure he had not thrown out anything valuable. When shopping, he spent large periods of time deciding what to buy, even when considering mundane items. He exhibited counting phenomena, e.g. he counted letters in people’s names or the number of windows in buildings. His excessive hand washing had resulted in him causing scars to his hands because of the methylated spirits he has used. These symptoms took up the majority of his day and interfered with his everyday life. They had interfered severely in his ability to form relationships. As the disease progressed he started becoming more depressed. During the course of his illness he had tried virtually all the possible treatments available to control his disease. All drugs used to help him little (except Chlomipramine) but they brought in intolerable side effects like gastric upset. Some of the drugs made him put on excessive weight because of which he is >150 Kg. today. He also tried around 40 ECTs (Electro-convulsive therapies), > 20 cognitive and behavioural therapy, transcranial magnetic stimulation and rTMS, with a little and transient improvement.
During this time he found out about the surgical option and went to Melbourne for getting operated. He was refused surgery and this shattered him. He bought a nail gun to perform lobotomy on himself. He also tried to commit suicide (six times) to get rid of his illness. He got married, and had one son, but the marriage did not last long enough and ended up in a bitter divorce. Presently he is unemployed and lives with his mother. He found out about the surgery being offered by Dr. Paresh K. Doshi and approached him. After due deliberation with Rod’s psychiatrist and the local multidisciplinary team, Rod was offered surgery on the 18th December. He underwent anterior capsulotomy. During the surgery itself Rod found that his anxiety decreased, he felt bright, happier and his obtrusive thoughts became insignificant. He is now back with his mother and preparing to go back to Australia.
Guidelines by the National Advisory Committee for Psychosurgery in India (1st Meeting)
In India, in March 2009, eminent psychiatrists from around India gathered to review the current data on Psychosurgery and form National guidelines for Psychosurgery in India. As per these guidelines surgical treatment for OCD and Depression only should be offered under Psychosurgery. Jaslok hospital and Research Centre has formed a Psychosurgery review board in accordance to these guidelines. A meeting of the specially constituted National Advisory Committee for Psychosurgery in India was held at the Hotel Hyatt Regency on Sunday the 8th of March 2009.
Participating members of the said National Advisory Group unanimously approved the following recommendations:
- DBS / ablations may be considered a viable treatment option for treatment resistant patients of OCD and Depression at the present time.
- A protocol drawn by the Multicenter Study group for OCD surgery for selection of patients for DBS will be circulated to the group for reference and will be implemented for selecting patients of OCD for considering Neurosurgical intervention.
- Any centre desirous of undertaking surgical program should form a review committee of one or more psychiatrists, neurologist and a neurosurgeon not involved directly in the treatment for reviewing suitability for surgery. This is recommended to ensure that patients are adequately assessed. This committee will not play the role of IRB. The role of such a committee will be to ensure that all measures s recommended by the International OCD DBS group are fulfilled.
P.S: A news item of FDA (USA) approval for implantable electrodes for OCD is enclosed
US FDA approval
In affiliation with A daily news briefing on psychiatry and mental health, prepared by the editors at Custom Briefings, exclusively for members of the APA .
FDA approves implantable deep brain stimulation device to treat severe OCD.
The Wall Street Journal (2/20, Dooren) reports that on Feb. 19, the Food and Drug Administration (FDA) “approved the first implantable device designed to deliver electrical therapy to the brain to suppress symptoms associated with severe obsessive-compulsive disorder (OCD).” This “device, known as Reclaim DBS (deep brain stimulation) Therapy, is made by Medtronic, Inc.,” and “was approved to treat patients with OCD in cases where drug and psychotherapy have failed.” It “was approved under the” agency’s “humanitarian-device exemptions rules which are” aimed at facilitating “the development of medical devices intended to treat or diagnose a disease or condition affecting fewer than 4,000 people per year in the US.”
The device “is implanted near a person’s collar bone or abdomen and is connected by wires to the brain,” the AP (2/20) points out. “It works by sending electric pulses.” The device “should be available in by the middle of 2009,” and is “expected to be used in patients who have remained very ill” with OCD, “despite aggressive use of medications and cognitive behavioral therapy.” In the meantime, “Medtronic plans to start studying the device as a potential therapy for treatment-resistant depression.”