Deep brain stimulation for treatment resistant obsessive compulsive disorder; an observational study with ten patients under real-life conditions

Deep brain stimulation for obsessive compulsive disorder leads to symptom changes of comorbid irritable bowel syndrome

Introduction

Irritable bowel syndrome (IBS) is a common condition characterized by abdominal pain and altered bowel habits, affecting around 11% of individuals globally. It is linked to dysregulation of the brain-gut axis, with altered activity and connectivity in various brain regions. IBS patients often have psychiatric comorbidities like anxiety, or obsessive-compulsive disorder (OCD). Deep brain stimulation (DBS) is an established treatment option for severe, therapy-refractory OCD. It has been suggested that DBS for OCD could also have a beneficial effect on accompanying IBS-symptoms.

Methods and patients

Nine patients with treatment-refractory OCD who underwent DBS in the bed nucleus striae terminalis (BNST) have been included in this study (4 males, 5 females, mean age: 39.1 ± 11.5 years). Patients were examined with the Gastrointestinal Symptom Rating Scale for Irritable Bowel Syndrome (GSRS-IBS) as well as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) both before the beginning of DBS as well as throughout several follow-up visits for 12 months following the start of DBS.

Results

Three patients displayed clinically relevant levels of IBS-symptoms at baseline (GSRS-IBS scores at or beyond 32). All of those three patients showed a reduction of the GSRS-IBS score at the last follow-up (12-40%). For the other 6 patients, 5 of them showed also a reduction of the GSRS-IBS compared to the score at baseline. The mean score for all patients showed a descriptive trend toward score reduction throughout the study period and until the last follow up visit after 12 months. The mean Y-BOCS decreased from 31.11 at baseline to 16.50 at the last follow-up. Out of the 9 patients, 7 (78%) were considered responders with Y-BOCS scores decreasing between 37% to 74%. Moderate-to-large correlations between both scales could be observed at both the 9-month and the 12-month follow-up visit. However, none of these associations was statistically significant.

Conclusion

In this study, we found alleviation of IBS symptoms after DBS of the BNST, along with improvement in OCD symptoms. Future research using larger sample sizes should address whether the reductions are tied to the improvement of OCD symptoms or if DBS exerts positive effects on IBS independently of OCD symptoms.

Neuronavigated Right Orbitofrontal 20 Hz Theta Burst Transcranial Magnetic Stimulation Augmentation for Obsessive-Compulsive Disorder with Comorbid Depression and Anxiety Disorders: An Open-Label Study

BACKGROUND

Despite the availability of pharmacotherapy and psychotherapy for treating obsessive-compulsive disorder (OCD), alternative approaches need to be explored due to the high likelihood of treatment resistance. Neuronavigated 20 Hz theta burst stimulation (TBS-20 Hz), targeting the bilateral dorsolateral prefrontal cortex (DLPFC) augmented with the right orbitofrontal cortex (ROFC), was tested for treating OCD comorbid with depression and anxiety disorders.

METHODS

A retrospective chart review was performed on fourteen patients treated for moderate-to-severe OCD in a private outpatient clinic. Twelve patients had comorbid major depressive disorder (MDD), and thirteen patients had either generalized anxiety disorder (GAD) or panic disorder (PD). Patients completed the Y-BOCS-SR, BDI-II, and BAI rating scales weekly, which were used to measure the changes in OCD, depression, and anxiety symptoms, respectively.

RESULTS

Neuronavigated TBS-20 Hz was sequentially applied to the right DLPFC (RDLPFC), left DLPFC (LDLPFC), and ROFC. A total of 64% (9/14) of patients achieved remission from OCD (Y-BOCS-SR ≤ 14) in an average of 6.1 weeks of treatment (SD = 4.0). A total of 58% (7/12) of patients remitted from MDD (BDI < 13) in an average of 4.1 weeks (SD = 2.8), and 62% (8/13) of patients remitted from GAD/PD (BAI < 8) in an average of 4.3 weeks (SD = 2.5).

CONCLUSIONS

The neuronavigated TBS-20 Hz sequential stimulation of RDLPFC and LDLPFC, followed by ROFC, significantly reduced OCD, MDD, and GAD/PD symptoms. Randomized sham controls are warranted to validate these results.

Ketamine Infusion in a Resistant Obsessive-Compulsive Disorder Patient in Bangladesh with Severe Suicidal Ideation: A Case Report

Treatment of resistant obsessive-compulsive disorder (OCD) typically results in insufficient symptom alleviation, and even long-term medication often fails to have the intended effect. Ketamine is a potent non-competitive antagonist of the N-methyl-D-aspartate (NMDA) receptor. Studies have shown that low-dose ketamine infusion results in a considerable reduction in obsessive-compulsive symptoms and a rapid resolution of suicidal ideation. This is a case report on the effect of intravenous ketamine infusion on a patient with resistant OCD and severe suicidal ideation. Intravenous (IV) ketamine was given once a week over consecutive three weeks with necessary precautions. Psychometric tools such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Clinical Global Impressions Scale (CGI-S), the Beck Scale for Suicidal Ideations (BSSI), and Depression Anxiety and Stress Scale 21 (DASS-21) were applied before and after infusions. Obsessive-compulsive symptoms and suicidal severity started to decrease rapidly after the first infusion. However, after a transient improvement, these symptoms again began to increase after a stressful incident on the second day of the first infusion. All the symptoms measured by validated rating scales showed continued improvement after the following two infusions. The improvement was sustained until discharge (one week after the last infusion) and subsequent follow-up in the sixth and 12th weeks. The role of ketamine in reducing suicidal thoughts and behavior is already established. Very few studies emphasized its effectiveness in improving severe/resistant obsessive-compulsive symptoms. This pioneering work may offer scope for similar research in the relevant field.