Refractory Obsessive-compulsive Disorder Research Articles

Treatment-Refractory OCD Responding to Maintenance Electroconvulsive Therapy

Treatment-Refractory OCD Responding to Maintenance Electroconvulsive Therapy

Poster #202 ANTIPSYCHOTIC POLYPHARMACY IN SCHIZOPHRENIC INPATIENTS ATA UNIVERSITY PSYCHIATRIC HOSPITAL IN KOREA: A COMPARISON OF 2005 AND 2010

Deep brain stimulation (DBS) is regarded as an effective way to treat refractory obsessive-compulsive disorder (OCD). Little is known about the effects of DBS cessation following a longer period of stimulation.To determine the relapse and rebound effects of psychiatric symptoms, and their impact on Quality of Life (QoL) following acute cessation of DBS in OCD patients.We included 16 out of 32 patients who were treated with DBS between April 2005 and January 2011 at the Academic Medical Center, Amsterdam. After treatment for at least one year, patients entered a 1-week phase in which DBS was switched off. We evaluated psychiatric symptoms and QoL at three time points: before DBS surgery (pre-DBS), following at least one year of DBS treatment (DBS-on) and following 1 week of DBS off (DBS-off). Psychiatric symptoms were assessed with the Yale-Brown obsessive-compulsive disorder scale (Y-BOCS), the Hamilton anxiety rating scale (HAM-A) and the Hamilton depression rating scale (HAM-D). QoL was assessed using the World Health Organization QOL scale (WHOQOL-Bref).Switching from DBS-on to DBS-off, Y-BOCS scores increased with 50%, HAM-A scores with 80% and HAM-D scores with 83%. In the DBS-off period, HAM-A and HAM-D scores exceeded pre-surgery levels with approximately 40%, suggesting a rebound phenomenon. Furthermore, a deterioration of physical and psychological QoL to levels comparable with pre-surgery was found during DBS-off.Acute DBS cessation causes a relapse of obsessions and compulsions and a rebound of anxiety and depression. Additionally, improvements on QoL disappear.

Community treatment of severe, refractory obsessive-compulsive disorder

Despite the existence of effective psychological and pharmacological interventions for obsessive-compulsive disorder (OCD), there are a large proportion of individuals for whom intervention is not effective. The study reports on the results of a community treatment service for individuals with treatment-refractory OCD who have not benefitted from previous cognitive behavioural or pharmacological treatment by community mental health services. A total of 205 individuals accepted for treatment by a specialist community OCD treatment service in London were provided with a combination of behavioural, cognitive, and pharmacological treatment within a specialist OCD service, with 158 completing treatment. Treatment was associated with significant reduction in clinician-rated and self-reported OCD symptoms after 12 weeks, with further reductions in OCD symptoms over a subsequent 12-week period. A significant reduction in symptoms of depression was also observed after 12 and 24 weeks. Approximately 40% of individuals treated experienced clinically significant improvement in their symptoms, with approximately 10% deemed to have recovered by the end of treatment. Our results add to previous research into refractory OCD, and provide support for the existence of specialist community treatment services which may provide assistance to individuals who have not responded to previous treatment.

Aripiprazole augmentation in 13 patients with refractory obsessive-compulsive disorder: A case series

Objectives. The primary treatment for obsessive–compulsive disorder (OCD) is selective serotonin reuptake inhibitors (SSRI). However, approximately a third of patients do not respond to SSRIs and remain chronically affected. Methods. Therefore, we added aripiprazole to SSRI therapy for 13 patients with treatment-refractory OCD (subjects who failed to respond to SSRI therapy for at least 2 months, and for an average of 508 days). Participants underwent at least 7 weeks of treatment with aripiprazole augmentation. Results. Patients were evaluated using the Y-BOCS and GAF scales. Aripiprazole (3–12 mg)/SSRI co-therapy significantly improved Y-BOCS and GAF scores. However, many patients needed to take antiparkinsonian drugs to control extrapyramidal symptoms. Conclusions. These results suggest that aripiprazole augmentation of SSRI therapy may be effective for treatment-refractory OCD.

Neurocognitive Response to Deep Brain Stimulation for Obsessive-Compulsive Disorder: A Case Report

Back to table of contents Previous article Next article Communications and UpdatesFull AccessNeurocognitive Response to Deep Brain Stimulation for Obsessive-Compulsive Disorder: A Case ReportJon E. Grant, J.D., M.D., Brian L. Odlaug, B.A., and Samuel R. Chamberlain, M.D., Ph.D.Jon E. GrantMinneapolisSearch for more papers by this author, J.D., M.D., Brian L. OdlaugMinneapolisSearch for more papers by this author, B.A., and Samuel R. ChamberlainCambridge, United KingdomSearch for more papers by this author, M.D., Ph.D.Published Online:1 Dec 2011https://doi.org/10.1176/appi.ajp.2011.11071108AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: When obsessive-compulsive disorder (OCD) symptoms are severe and refractory to both cognitive-behavioral therapy (CBT) and medication, deep brain stimulation (DBS) may be of value (1). Although OCD research has examined the effects of DBS on cognition (2), few studies have used translational computerized paradigms capable of fractionating dissociable aspects of cognition and their neural substrates. Neurocognitive assessments have the potential to help elucidate the underlying mechanisms of action of DBS in OCD and the optimal brain target.Case Report“Mr. T” is a 30-year-old man with a 5-year history of OCD with primary contamination obsessions and washing compulsions. He had stopped socializing, had dropped out of school, and was unemployed because of his OCD. Past adequate trials of all serotonin reuptake inhibitors, both as monotherapy and with multiple augmentation strategies, and 20 weeks of CBT using exposure response prevention provided only limited benefits.After ethical review board approval, Mr. T underwent bilateral implantation of electrodes targeting the nucleus accumbens. At the time of surgery, his Yale-Brown Obsessive Compulsive Scale score was 32 while taking the following medications: clomipramine, 250 mg/day; ziprasidone, 120 mg/day; and clonazepam, 1 mg t.i.d. His medication dosages were unchanged before and after the cognitive testing.We performed cognitive assessments at baseline (prestimulation) and again 8 months after DBS began. Tasks from the Cambridge Neuropsychological Test Automated Battery included the stop-signal test (assessing ability to suppress prepotent motor responses), the intradimensional/extradimensional set shift task (examining rule learning and behavioral flexibility), and the Cambridge Gamble Task (assessing decision making). The results of these assessments are summarized in Table 1.TABLE 1. Cambridge Neuropsychological Test Automated Battery (CANTAB) Test Performance After Deep Brain Stimulation (DBS) Compared With Normative DataaMeanzIndividual TestsBefore DBSAfter DBSBefore DBSAfter DBSStop-signal test reaction time (msec)211.58204.70–1.0–0.8Stop-signal test median go reaction time (msec)449.00379.000.10.5Intradimensional/extradimensional set shift task, pre-extradimensional errors6.007.000.2–0.1Intradimensional/extradimensional set shift task, extradimensional errors1.002.000.80.6Cambridge Gamble Task, overall proportion bet0.600.570.60.4Cambridge Gamble Task, quality of decision making1.001.000.50.5a Normative data are taken from the Cambridge Cognition CANTAB database except for the stop-signal test, where data were unavailable and therefore were taken instead from Chamberlain et al. (3).TABLE 1. Cambridge Neuropsychological Test Automated Battery (CANTAB) Test Performance After Deep Brain Stimulation (DBS) Compared With Normative DataaEnlarge tableBefore the DBS, Mr. T generally exhibited cognitive performance akin to healthy comparison subjects except for evidence of stop-signal reaction time impairment (z=1.0). His stop-signal reaction time performance changed little after DBS (posttreatment z=0.8); however, the DBS resulted in significant improvement in Mr. T's OCD symptoms, and his Yale-Brown Obsessive Compulsive Scale score decreased to 10. Mr. T returned to college and now has a social life and works part-time.DiscussionThis case indicates that DBS, targeting the nucleus accumbens, was associated with significant therapeutic benefits in treatment-refractory OCD in the absence of effects on response inhibition, set shifting, or decision making. The lack of effect of accumbens DBS on the stop-signal deficit accords with translational research indicating that accumbens damage (unlike cortical damage) has no effect on response inhibition on an equivalent animal task (4). While impaired response inhibition appears to be a trait marker for OCD, and was evident in Mr. T at baseline, DBS to the accumbens does not appear to ameliorate this problem. This case illustrates the value of DBS in patients with refractory OCD and the importance of including cognitive tests in such studies to identify meaningful predictors for successful DBS in OCD on an individual level.MinneapolisCambridge, United KingdomDr. Grant has received research grants from Forest Pharmaceuticals, the National Center for Responsible Gaming, National Institute on Drug Abuse, NIMH, and Psyadon Pharmaceuticals. Mr. Odlaug reports no financial relationships with commercial interests. Dr. Chamberlain has consulted for Cambridge Cognition, P1Vital, and Shire Pharmaceuticals.Accepted for publication in September 2011.

Rebound symptoms following battery depletion in the NIH OCD DBS cohort: Clinical and reimbursement issues

Deep brain stimulation (DBS) is a promising treatment for medication refractory obsessive compulsive disorder (OCD); however, there may be neuropsychiatric symptoms from unintended battery failure. Previous studies indicated rebound symptoms from impulse generator (IPG) failure in Parkinson's disease, dystonia, and essential tremor. Unique to OCD is that battery failure may precipitate neuropsychiatric symptoms rather than motor symptoms. Six patients with medication refractory OCD received implants as part of the previously reported National Institutional Health (NIH) DBS cohort. All available clinical data and adverse event data was reviewed. The average age of cohort was 42.2 years (30-59 years), and the average baseline Y-BOCS score was 33.8 (31-38). All six subjects were observed to have increased OCD symptomatology during IPG failure; however, Y-BOCS scores remained less than pretreatment range, in five subjects. One of the subjects had a Y-BOCS score greater than pretreatment during the period of IPG failure. In addition, Y-BOCS scores improved back to baseline after IPG replacement in five subjects. Other symptoms potentially related to battery failure included: suicidality (n = 1), mood disturbance (n = 2), panic attacks (n = 1), fatigue (n = 2), and a restless sensation in the arms and legs (n = 1). A small number of subjects reported no side effects associated with IPG failure because of preemptive replacement (n = 2). This is a preliminary case series detailing the side effects resulting from IPG failure during OCD DBS. Preemptive battery replacement was an effective strategy for avoiding these issues, and timeliness in insurance reimbursement may be considered in the future. Additionally the use of rechargeable batteries may also help this issue. NCT00057603.

Deep brain stimulation in addiction: a review of potential brain targets

Deep brain stimulation (DBS) is an adjustable, reversible, non-destructive neurosurgical intervention using implanted electrodes to deliver electrical pulses to areas in the brain. DBS is currently investigated in psychiatry for the treatment of refractory obsessive-compulsive disorder, Tourette syndrome and depressive disorder. Although recent research in both animals and humans has indicated that DBS may be an effective intervention for patients with treatment-refractory addiction, it is not yet entirely clear which brain areas should be targeted. The objective of this review is to provide a systematic overview of the published literature on DBS and addiction and outline the most promising target areas using efficacy and adverse event data from both preclinical and clinical studies. We found 7 animal studies targeting six different brain areas: nucleus accumbens (NAc), subthalamic nucleus (STN), dorsal striatum, lateral habenula, medial prefrontal cortex (mPFC) and hypothalamus, and 11 human studies targeting two different target areas: NAc and STN. Our analysis of the literature suggests that the NAc is currently the most promising DBS target area for patients with treatment-refractory addiction. The mPFC is another promising target, but needs further exploration to establish its suitability for clinical purposes. We conclude the review with a discussion on translational issues in DBS research, medical ethical considerations and recommendations for clinical trials with DBS in patients with addiction.

Psicocirurgia para tratamento de transtorno obsessivo-compulsivo

ResumoO transtorno obsessivo-compulsivo (TOC) é uma patologia incapacitante tanto na esfera social como na ocupacional. Está associado a uma morbidade bastante alta quando comparado a outras condições psiquiátricas e estima-se atualmente uma prevalência de 2% a 3% na população. Alguns estudos sugerem uma provável relação com uma disfunção do córtex frontal e do cíngulo, envolvendo o circuito de Papez. Esse circuito parece mediar os sintomas ansiosos, visto que lesões cirúrgicas dessas áreas afetam a ansiedade geralmente associada ao TOC. A neurocirurgia ablativa para o tratamento de distúrbios psiquiátricos foi muito utilizada até o desenvolvimento de psicofármacos efetivos. Recentemente, com os avanços técnicos do procedimento cirúrgico, auxiliado pelo conhecimento neurofisiológico, a psicocirurgia tornou-se mais precisa e segura. Porém, sua indicação se restringe como uma alternativa ao tratamento de pacientes com TOC refratário à terapia comportamental e/ ou medicamentosa.

Deep brain stimulation increases impulsivity in two patients with obsessive–compulsive disorder

Deep brain stimulation (DBS) is an adjustable, reversible, nondestructive neurosurgical intervention using implanted electrodes to deliver electrical pulses to areas in the brain. DBS has recently shown promising results as an experimental treatment of refractory obsessive-compulsive disorder (OCD). The novelty of the treatment requires careful observation of symptoms and possible side effects in patients. This case report describes two patients with treatment-refractory OCD in whom increased voltage of deep brain stimulation targeted at the nucleus accumbens increased impulsivity. Voltage increase of stimulation resulted in an immediate inflation of self-confidence, irritability and impulsive behaviour and was reversed only after lowering the voltage. The mechanisms behind DBS are not yet fully understood. Possibly, stimulation in the area of the nucleus accumbens affects the corticostriatal circuitry, which plays an important role in impulsivity. Location and amplitude of stimulation might be critical in inducing these behaviours. These two cases underline the importance of a careful clinical assessment of impulsive behaviours during DBS for OCD.

Compulsion or Chronobiology? A Case of Severe Obsessive-Compulsive Disorder Treated with Cognitive-Behavioral Therapy Augmented with Chronotherapy

Individuals with treatment-resistant obsessive compulsive disorder (OCD) have elevated rates of delayed sleep phase. This report describes a patient with severe OCD who had failed prior trials of pharmacotherapy and psychotherapy, and whose symptoms were associated with delayed bedtimes and delays in the time she initiated her nighttime compulsions. Case report. A 54 year-old woman with OCD kept sleep/symptom logs as an adjunct to traditional cognitive-behavioral therapy for OCD. At presentation, she reported habitual bedtime = 06:00, wake time = 13:00, sleep latency ' 5 min, and total sleep time = 6.5-7.5 h. Later time of initiating her compulsions was associated with longer time performing the compulsions (r = 0.86, p < 0.001). Cognitive-behavioral therapy with adjunctive chronotherapy was associated with substantial improvement. OCD patients with nighttime compulsions may receive light exposure that results in delayed sleep times/circadian phase. Chronotherapy may enhance outcomes for refractory OCD patients, particularly those who perform compulsions at night.

Review of structural neuroimaging in patients with refractory obsessivecompulsive disorder

The notion that some special brain regions may be involved in the pathogenesis of obsessive-compulsive disorder (OCD) dates back to the beginning of the twentieth century. Structural neuroimaging studies in the past 2 decades have revealed important findings that facilitate understanding of OCD pathogenesis. Current knowledge based on functional and structural neuroimaging investigations largely emphasizes abnormalities in fronto-striatal-thalamic-cortical and orbitofronto-striato-thalamic circuits in the pathophysiology of OCD. However, these neuroimaging studies did not focus on refractory OCD. The present review mainly focused on structural neuroimaging performed in OCD, which had been ignored previously, and highlighted current evidence supporting that orbito-frontal cortex and thalamus are key brain regions, and that the hippocampus-amygdala complex is associated with refractoriness to the available treatment strategies. However, to fully reveal the neuroanatomy of refractoriness, longitudinal studies with larger samples are required.

Depression in comorbid obsessive-compulsive disorder and posttraumatic stress disorder

Previous findings suggested a unique role that depression symptoms might play in the comorbid relationship between obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD). However, the nature of this role remains unclear. Thus, the current study examined ways in which OCD and PTSD symptoms vary as a function of depression, as well as the mediating role of depression in the OCD-PTSD relationship, in 104 individuals seeking treatment for refractory OCD. Findings revealed that depressed individuals in the treatment-refractory OCD sample report higher levels of overall obsessing and greater severity of PTSD. In addition, depression appeared to mediate the relation between OCD and PTSD. Implications of findings are discussed.

P02-544 - Differential Impact of Deep Brain Stimulation or Anterior Capsulotomy on General Functioning, Personality Features and Quality of Life in OCD

IntroductionResearch on deep brain stimulation (DBS) for treatment refractory obsessive-compulsive disorder (OCD) shows promising effects on symptoms severity.ObjectivesTo compare outcomes between DBS and bilateral capsulotomy on general functioning, personality traits and quality of life.MethodsConsecutive patients with severe and treatment refractory OCD underwent DBS in the anterior limb of the internal capsule (DBS; n = 14) or anterior capsulotomy (CAPS; n = 14). They were tested before surgery (baseline-BL) and after a mean follow-up time (FU) of 19 months (range 14-31 months). Changes in OCD severity were recorded and global assessment of functioning, personality traits, and quality of life were compared between groups.ResultsStatistically significant differential improvements (p &lt; 0.05, Bonferroni corrected) were seen in*General assessment of functioning (Mn ± 95%CI) GAF: DBS_BL:32.9 ± 3.6; DBS_FU:68.6 ± 7.2; CAPS_BL:35.0 ± 2.7; CAPS_FU:56.4 ± 5.9)*Personality traits on MMPI (T-score Mn ± 95%CI) Scale 2-depression: DBS_BL:83.7 ± 6.5; DBS_FU:61.9 ± 6.3; CAPS_BL:81.2 ± 8.6; CAPS_FU:77.6 ± 8.7 Scale 9-mania: DBS_BL:48.8 ± 7.3; DBS_FU:57.0 ± 4.2; CAPS_BL:53.8 ± 7.5; CAPS_FU:45.6 ± 6.2 Scale 0-social introversion: DBS_BL:66.8 ± 5.2; DBS_FU:56.1 ± 4.1; CAPS_BL:67.7 ± 7.0; CAPS_FU:66.4 ± 5.8)* Quality of life: Q-LES-Q Endicott (Mn ± 95%CI) overall score (1-5): DBS_BL:1.2 ± 0.3; DBS_FU:3.4 ± 0.6; CAPS_BL:1.5 ± 0.3; CAPS_FU:2.6 ± 0.4 and in the sub domains feelings (%): DBS_BL:36.8 ± 4.2; DBS_FU:68.6 ± 8.8; CAPS_BL:39.1 ± 5.1; CAPS_FU:54.0 ± 5.9 leisure activities (%): DBS_BL:30.6 ± 5.9; DBS_FU:68.5 ± 7.9; CAPS_BL:40.2 ± 5.4; CAPS_FU:58.3 ± 7.1 social relationships (%):DBS_BL:43.9 ± 5.5; DBS_FU:70.2 ± 8.0; CAPS_BL:46.9 ± 6.8; CAPS_FU:60.1 ± 6.9ConclusionThese findings suggest a superior impact of DBS over capsulotomy on general functioning, personality traits and quality of life. Limits of this study are the small numbers, the fact that DBS and CAPS patients were from a slightly different OCD population and were not randomized to treatment, and differences in postoperative follow-up.

Switching from serotonin reuptake inhibitors to agomelatine in patients with refractory obsessive-compulsive disorder: a 3 month follow-up case series

BackgroundSerotonin reuptake inhibitors (SRIs) currently represent the cornerstone of obsessive-compulsive disorder (OCD) pharmacotherapy. However, OCD is characterized by high rates of partial and/or absent response to standard, recommended treatments, often prompting pharmacological and non-pharmacological augmentation or switching of strategies. Agomelatine, a novel melatonin agonist and selective serotonin antagonist (MASSA) antidepressant approved for major depressive disorder (MDD) has recently been additionally proposed as a treatment for anxiety disorders such as social anxiety disorder (SAD) and panic disorder (PD), but not yet OCD. Nonetheless, agomelatine may have a role in the management of OCD, essentially due to its anxiolytic 5-hydroxytryptamine (HT)2C blockade action, while melatonin (MT)1 and MT2 modulation might contribute to circadian rhythm restoration if impaired.MethodsThis case series reports the outcome of six patients with or without comorbid mood and/or other anxiety disorders who were treated with SRIs at adequate doses for at least 8 weeks, showing partial or no response. Patients were then switched to agomelatine 50 mg/day, and followed up for 12 weeks.ResultsThree out of six patients, in particular those with relevant circadian rhythm subjective impairment, showed a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score reduction of ≥35%. No relevant side effects were observed, but initial, transient, self-remitting dizziness in one patient and weight gain in another were seen.ConclusionsAlthough clinical confounding factors (subthreshold bipolarity and eventually the presence of impaired circadian rhythms) and methodological boundaries (lack of control and neurophysiological recording, tiny sample size and short follow-up) limit the validity of this preliminary observation, it does indicate agomelatine may have a role in some SRI-refractory OCD cases, thus prompting the validity of investigation by further controlled studies, even for drug-naïve OCD patients.

Results Following Gamma Knife Radiosurgical Anterior Capsulotomies for Obsessive Compulsive Disorder

Obsessive compulsive disorder (OCD), in its severe form, can cause tremendous disability for affected patients. To evaluate the results following bilateral radiosurgical anterior capsulotomy for severe medically refractory OCD. We performed gamma knife anterior capsulotomy (GKAC) on 3 patients with extreme, medically intractable OCD. According to our protocol, all patients were evaluated by at least 2 psychiatrists who recommended surgery. The patient had to request the procedure, and had to have severe OCD according to the Yale-Brown Obsessive Compulsive Scale (YBOCS). Patient ages were 37, 55, and 40 years, and pre-radiosurgery YBOCS scores were 34/40, 39/40, and 39/40. Bilateral lesions were created with 2 4-mm isocenters to create an oval volume in the ventral internal capsule at the putaminal midpoint. A maximum dose of 140 or 150 Gy was used. There was no morbidity after the procedure, and all patients returned immediately to baseline function. All patients noted significant functional improvements, and reduction in OCD behavior. Follow-up was at 55, 42, and 28 months. The first patient reduced her YBOCS score from 34 to 24. One patient with compulsive skin picking and an open wound had later healing of the chronic wound and a reduction in the YBOCS score from 39 to 8. At 28 months, the third patient is living and working independently, and her YBOCS score is 18. Within a strict protocol, gamma knife radiosurgery provided improvement of OCD behavior with no adverse effects. This technique should be evaluated further in patients with severe and disabling behavioral disorders.

Anterior capsulotomy for refractory OCD: First case as per the core group guidelines

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 2–3% of the general population and 0.6% in the 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.

Clinical efficacy of sequential psychotherapy combined with selective serotonin reuptake inhibitors on refractory obsessive-compulsive disorder

Objective To evaluate the efficacy of sequential psychotherapy combined with selective serotonin reuptake inhibitors(SSRI) s on refractory obsessive-compulsive disorder(OCD). Methods 50 patients with refractory OCD were given to sequential psycho therapy in the original basis of the SSRIs drugs treatment. The patients were given psychoanalysis,cognitive behavioral therapy and reality therapy for 8 weeks at the end of in the first stage, second stage and the third stage. The efficacy was assessed by the Yale-Brown Obsessive Compulsive Scale(Y-BOCS) before treatment,8 weeks, 16 weeks, and 24 weeks after treatment, respectively. Results The total score of the YBOCS before the treatment and at the 24th week after treatment was (21.10 ±4.69) and ( 10.18±6. 14). According to the score-reducing rate of the YBOCS , recovery rate was 34.0%, effective rate was 42.0%. Conclusion Sequential psychotherapy combined with SSRIs is an effective treatment for refractory OCD. Key words: Sequential Psychotherapy; Selective serotonin reuptake inhibitors; Refractory obsessive compulsive disorder

A New Approach to Deep Brain Stimulation for OCD

Deep brain stimulation (DBS) for refractory obsessive-compulsive disorder (OCD) usually targets behavior-generating systems like the ventral striatum

Decrease of Prefrontal Metabolism After Subthalamic Stimulation in Obsessive-Compulsive Disorder: A Positron Emission Tomography Study

High-frequency bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) is a promising treatment in refractory obsessive-compulsive disorder (OCD). Using the crossover, randomized, and double-blind procedure adopted by the STOC study, 10 patients treated with high-frequency bilateral STN DBS underwent am 18-fluorodeoxyglucose positron emission tomography (PET) investigation to highlight the neural substratum of this therapeutic approach. The median Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores for all 10 patients were 31 (minimum = 18, maximum = 36) with "Off-Stimulation" status and 19 (minimum = 0, maximum = 30) with "On-Stimulation" status (p = .05). The OCD patients in Off-Stimulation status showed a hypermetabolism in the right frontal middle and superior gyri, right parietal lobe, postcentral gyrus, and bilateral putamen compared with healthy control subjects. A significant decrease in cerebral metabolism was observed in the left cingulate gyrus and the left frontal medial gyrus in On-Stimulation conditions compared with Off-Stimulation conditions. In addition, the improvement assessed by Y-BOCS scores during the On-Stimulation conditions was positively correlated with PET signal changes at the boundary of the orbitofrontal cortex and the medial prefrontal cortex, between PET signal changes and the Y-BOCS scores modifications in On-Stimulation status. This study suggests that the therapeutic effect of STN DBS is related to a decrease in prefrontal cortex metabolism.

Dementia Developing in Late-onset and Treatment-refractory Obsessive-compulsive Disorder

Although several studies have been conducted in an attempt to characterize the phenotype and underlying pathophysiology of individuals with early-onset obsessive-compulsive disorder (OCD), the literature on patients who develop OCD later in life remains sparse. To describe clinical outcomes in the 7-year follow-up of a patient with late-onset OCD. Single case report. A 64-year-old woman exhibiting a 7-year history of treatment-refractory late-onset OCD developed significant cognitive deterioration. We suggest that the association between late-onset treatment refractory OCD and dementia may stem from at least 3 different scenarios. First, dementia may be an inexorable end-point of some forms of malignant, primary, and late-onset obsessional illness. Second, late-onset OCD and dementia may result from a common pathophysiologic basis, such as in fronto-temporal dementia. Finally, the association between both conditions may result by the interaction between vulnerability toward OCD-type symptoms and the nonspecific effects of a neurodegenerative process. In our case, although subclinical OCD was likely to be "unmasked" by cognitive decline and/or bilateral caudate vascular lesions, ensuing cognitive deterioration could be ascribed to development of Alzheimer dementia. Our observation suggests that treatment refractoriness in an individual with late-onset OCD may indicate underlining organicity.