Deep brain stimulation and ablation for obsessive compulsive disorder: evolution of contemporary indications, targets and techniques

Abstract

Surgical therapy for treatment-resistant obsessive compulsive disorder (OCD) remains an effective option for well-selected patients managed within a multidisciplinary setting. Historically, lesions within the limbic system have been used to control both obsessive thoughts and repetitive compulsions associated with this disease. We discuss classical targets as well as contemporary neuromodulatory approaches that have been shown to provide symptomatic relief. Recently, deep brain stimulation (DBS) of the anterior limb of the internal capsule/ventral striatum received Conformité Européene (CE) mark and Food and Drug Administration (FDA) approvals for treatment of intractable OCD. Remarkably, this is the first such approval for neurosurgical intervention in a strictly psychiatric indication in modern times. This target is discussed in detail along with alternative targets currently being proposed. We close with a discussion of gamma knife capsulotomy, a modality with deep historical roots. Further directions in the surgical treatment of OCD will require better preoperative predictors of postoperative responses, optimal selection of individualized targets, and rigorous reporting of adverse events and standardized outcomes. To meet these challenges, centers must be equipped with a multidisciplinary team and patient-centered approach to ensure adequate screening and follow up of patients with this difficult-to-treat condition.

Psychosurgery Reduces Uncertainty and Increases Free Will? A Review

“…The anterior limb of the internal capsula is targeted both with lesioning as with stimulation for obsessive‐compulsive disorders (Table ). Lesioning has a successful outcome in 50–70% of patients .…”

Analysis of Gene Expression Changes in the Rat Hippocampus After Deep Brain Stimulation of the Anterior Thalamic Nucleus

“…Results from a phase I clinical trial of bilateral forniceal stimulation have shown a delay in the rate of cognitive decline and a reversal of the glucose hypometabolic uptake seen in Alzheimer's disease as well as activation of the memory circuitry 8,44 . Furthermore, in recent years neurosurgeons have conducted DBS trials for treating neuropsychiatric disorders such as OCD (Obsessive Compulsive Disorder), treatment-resistant depression, Tourette syndrome and addiction 10,[45][46][47][48][49][50][51][52][53][54][55] .…”

Anaesthesia for deep brain stimulation

“…For psychiatric disorders, such as obsessive-compulsive disorder, targets include the subcallosal cingulate gyrus [8], the anterior limb of the internal capsule [9], and the nucleus accumbens [10 ■ ]. There are several other targets that are Food and Drug Administration-approved or off-label/experimental for a variety of conditions including epilepsy, depression, Tourette syndrome, headache, obesity, Alzheimer's disease, and the minimally conscious state, which are beyond the scope of this short review.…”