Deep brain stimulation for refractory obsessive-compulsive disorder

Several epidemiological studies confirmed that Anxiety Disorders as a group are the most prevalent psychiatric conditions in the United States. The importance of these conditions is underlined by the fact that they cause significant disability, poor quality of life, alcohol and drug abuse. Anxiety disorders are treatable conditions and respond to the front-line interventions such as serotonin reuptake inhibitors and cognitive behavioral therapy. However, only about 60% of patients respond to those treatments to any significant degree. Many still have residual symptoms or stay treatment refractory. The group of anxiety patients that is resistant to the treatment has been shown to have very poor quality of life and have highest rate of suicidal attempts than any other disorders. Many biological, treatment specific and social factors are affecting treatment resistance. In this paper, we are attempting to review reasons for the treatment resistance. In addition, we would like to review current strategies that could be helpful in reducing treatment resistance and aiding people chronically suffering from these severe and disabling conditions.

Recent studies on the epidemiology of obsessive-compulsive disorder (OCD) estimate 50 million patients suffer from OCD worldwide, thus making it a global problem. The treatment of OCD has changed substantially over the last 2 decades following the introduction of selective serotonin reuptake inhibitors, which provide symptom improvement in ~60% of patients. However, some patients remain resistant to the standard pharmacologic and behavioral treatments. Although some Needs AssessmentIn the last decade, brain stimulation approaches to neuropsychiatric disorders have been increasingly investigated and are currently defining a "third way" of treatment besides the traditional ones, pharmacologic therapy and psychotherapy. Although some of these techniques are well-established treatments for specific conditions (ie, electroconvulsive therapy for severe depression or deep brain stimulation and transcranial magnetic stimulation in motor disorders) their efficacy in severe or treatment-resistant obsessive-compulsive disorder is still under investigation. Nevertheless, they represent a potential, helpful approach in this highly debilitating condition not only amongst the therapeutic approaches to obsessive-compulsive disorder but also as research means able to elucidate the specific dysfunctional neurocircuits underlying the clinical symptomatology. Learning ObjectivesAt the end of this activity, the participant should be able to:• Differentiate the specific techniques of brain stimulation investigated in the treatment of obsessive-compulsive disorder (OCD) in terms of efficacy, invasiveness, tolerability, and side effects.• Understand the main hypotheses through which these techniques might modify the dysfunctional circuits of OCD.• Understand the potential of these techniques in the field of treatment-resistant OCD, on one hand, and their current investigational state that requires further controlled clinical trials, on the other hand. Target Audience Neurologists and psychiatrists Accreditation StatementMount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide Continuing Medical Education for physicians.Mount Sinai School of Medicine designates this educational activity for a maximum of 3.0 Category 1 credit(s) toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the educational activity.It is the policy of Mount Sinai School of Medicine to ensure fair balance, independence, objectivity and scientific rigor in all its sponsored activities. All faculty participating in sponsored activities are expected to disclose to the audience any real or apparent discussion of unlabeled or investigational use of any commercial product or device not yet approved in the United States.This activity has been peer-reviewed and approved by Eric Hollander, MD, professor of psychiatry, Mount Sinai School of Medicine. Review Date: November 1, 2005. To Receive Credit for This ActivityRead this article, and...

ResumenLa estimulación cerebral profunda para las enfermedades psiquiátricas que son refractarias a los distintos tratamientos convencionales, se está realizando actualmente debido en gran parte a los conocimientos adquiridos en la cirugía para los trastornos del movimiento, sobre todo la enfermedad de Parkinson (EP). La depresión, los trastornos obsesivo-compulsivos (TOC) y el síndrome de Gilles de la Tourette son problemas córtico-estriato-tálamo-corticales relacionados con los circuitos límbicos de los ganglios basales.En esta revisión se analizan las distintas dianas quirúrgicas para las diferentes patologías neuro-psiquiá-tricas. Para el TOC actualmente existen dos dianas, el complejo estriado ventral (VS)-núcleo accumbens (Nacc) y el núcleo subtalámico (NST). Para la depresión refractaria, el área subgenual (área 25 de Brodmann) y el VS/Nacc. Para el Tourette, el ventralis oralis interno y centromediano parafascicularis (Voi, CM/Pf) del tálamo y el globo pálido interno (GPi). En la actualidad no existe una única diana específica en cualquiera de las patologías, ya que los resultados clínicos tras la estimulación pueden considerarse similares. Por otro lado, una misma diana quirúrgica puede mejorar diferentes patologías.