All of the following cases are of patients who have refractory obsessive-compulsive disorder. They have shown no beneficial results from drugs or other forms of therapy. Most have comorbid disorders and are unable to function well in society. All of these studies were done before the approval by the FDA of deep brain stimulation for treatment of obsessive-compulsive disorder on March 28, 2005. In each study, quadripolar stimulating electrodes were placed bilaterally in the anterior limb of the internal capsule with the pulse generator implanted in the subclavicular area. The device used in all of the following studies was made by Medtronic, Inc. You can draw your own conclusions of the effectiveness of DBS on OCD from the following cases.
* Double-blind studies are easy with DBS since the patients cannot tell whether the device is on or off.
Y-BOCS (Yale-Brown Obssesive Compulsive Scale) is a psychiatric questionaire developed to assess the severity of OCD. It is a self-rated scale of patients' OCD symptoms. A higher score indicates worse symptoms.
A 35 year old homosexual man was diagnosed with obsessive-compulsive disorder at 12 years of age. His different obsessions include concerns with dirt, germs, illnesses, fear of saying dirty or stupid words, washing rituals, checking compulsions (door locks), rereading-rewriting-recalculating rituals, excessive list-making, counting rituals, and a need to confess. During the first year with implantation of the stimulator device, he reported an increase in his ability to work as an artist. However, having wires and electrodes in his body frightened him. The rest of his symptoms only decreased slightly with high electrode stimulation, which resulted in the battery having to be replaced every 5 months. After fifteen months, he opted to remove the deep brian stimulator and undergo a bilateral anterior capsulotomy. The chart to the right compares his results with the following two cases. After capsulotomy, his boyfriend and his mother described him as more mature and assertive (9).
A 52 year old married woman was diagnosed with severe OCD symptoms at 24 years of age. Her main symptoms include excessive concerns with urine and feces, compulsive hand washing and a compelling urge to ask questions. She was unable to do housekeeping, and, for the 3 years preceding implantation of the deep brain stimulator, she had been almost continuously hospitalized for OCD and major depression. After implantation of the deep brain stimulator, she felt less anxious and more in control. The urge to ask questions persisted, but she was able to keep it to herself. After a year of continuous stimulation, she stated that her condition was much improved from before surgery(9).
A single 38 year old woman was diagnosed with OCD at 16 years of age. She was preoccupied by the thought that objects might not be real or did not exist. Her main symptoms included intrusive sexual thoughts and impulses, washing and counting rituals, compulsive buying and the urge to touch things. She was fired from her job in administration at age 32 due to the severity of her symptoms. She was unable to maintain steady work and returned home to live with her parents. Directly following implantation, she was less anxious and felt more relaxed and laid back. Some compulsions remained, but they hardly interfered with her social activities because she was capable of controlling them. When stimulation was switched off, the symptoms and anxiety returned almost immediately. This demonstrates that the stimulation, not the device itself, produces the results. The chart above compares her results with corresponding amplitudes of stimulation to Case 2's results (9).
With the onset of OCD symptoms at age six, a 52 year old male participated in a double-blinded study of DBS. His symptoms, which were unresponsive to medication included repeating, reentering, order/symmetry, and counting. After implantation, he experienced a slight regression of his OCD symptoms when the stimulators were ON rather than OFF, but these effects were not large enough to be statistically meaningful. He did not complain of any side effects. When the study was completed, he opted to remove the device (12).
A 27 year old female was diagnosed with OCD at age sixteen. She was unable to continue working as a nurse due to the severity of her OCD symptoms, which include intrusive images of violence and sex, mental arranging, counting and cleaning. She participated in a double-blinded study of DBS, showing a clinically detectable decline in symptoms with stimulation ON, during the first period of the study, and clear worsening with stimulation OFF, during the second period. However, during the third period, she had a strong “placebo” effect with the stimulator OFF. She explained that she could tell the stimulator was ON during the first period and OFF during the second, and, thus, she assumed it would be turned ON again in the third period*. Her side effects included throbbing, buzzing, nausea, and diarrhea. A PET scan showed stimulation was associated with prominent decreases in metabolic activity over the orbitofrontal cortex. At the end of the study, she was disappointed that the improvement during the third period was not a result of the stimulator, but she opted to continue stimulation at the same settings as during the first period. Over a 7 month period, she showed improvement in her OCD symptoms, and returned to work. However, two months later, after loosing her new job, she committed suicide, leaving a note saying the suicide was due to depression, not her OCD symptoms, which had been vastly reduced (12).
A 48 year old female was diagnosed with OCD at age 32. She was unemployed and experienced the following symptoms: contamination, cleaning, checking/repeating, and symmetry. After implantation, she experienced mild tingly sensations. The chart on the right shows how the stimulation effected her OCD symptoms (BL - basal level, before the device was implanted) with higher numbers indicating more severe symptoms. As follows, she showed little to no response when the stimulators were OFF, but an elevated mood, increased activity and reduction of OCD symptoms with the stimulators ON. The mood changes were abrupt. A PET scan showed stimulation was associated with decreases in metabolic activity over the orbitofrontal cortex. At the end of the study, she decided to continue with the stimulation with no change in settings. Over the next 8 months, she became able to live a normal life, except for a couple of recurrences of OCD symptoms. One was due to the battery running out, and the other due to a break in her lead (12).
An unemployed 34 year old male was diagnosed with OCD at age 17 years. His symptoms were repeating and “just right” behavior. He showed no consistent or meaningful effects from stimulation during the blinded phase, but he did have jaw sensations as a side effect of the implantation. A PET scan showed no change in metabolic activity of the orbitofrontal cortex. After completion of the study, he underwent many adjustments of the stimulation parameters seeking benefits. After over a year of stimulation with many different lead configurations and parameters, he still had not sustained any meaningful improvement (12).
