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Cureus May 2024Obsessive-compulsive disorder (OCD) is a prevalent and debilitating mental health condition. This literature review examines the latest strategies in managing and... (Review)
Review
Obsessive-compulsive disorder (OCD) is a prevalent and debilitating mental health condition. This literature review examines the latest strategies in managing and treating OCD, with an emphasis on psychotherapy, pharmacological interventions, and neurosurgical options. A comprehensive literature search utilizing PubMed, Google Scholar, ClinicalKey, and Embase databases was conducted. Utilizing chosen keywords, the resulting articles were filtered based on inclusion and exclusion criteria. Included articles were used to discuss current research regarding OCD treatment and management. Findings reveal the efficacy and obstacles of treatments such as cognitive-behavioral therapy, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and evidence-based neurosurgical methods, offering a broad perspective on OCD management. We discuss the limitations of these established treatments and examine the innovative response of neurosurgery in treating patients with OCD. This review highlights the importance of individualized treatment plans and areas for future research.
PubMed: 38883111
DOI: 10.7759/cureus.60496 -
Brain Stimulation 2023Despite advances in the treatment of psychiatric diseases, currently available therapies do not provide sufficient and durable relief for as many as 30-40% of patients....
Future directions in psychiatric neurosurgery: Proceedings of the 2022 American Society for Stereotactic and Functional Neurosurgery meeting on surgical neuromodulation for psychiatric disorders.
OBJECTIVE
Despite advances in the treatment of psychiatric diseases, currently available therapies do not provide sufficient and durable relief for as many as 30-40% of patients. Neuromodulation, including deep brain stimulation (DBS), has emerged as a potential therapy for persistent disabling disease, however it has not yet gained widespread adoption. In 2016, the American Society for Stereotactic and Functional Neurosurgery (ASSFN) convened a meeting with leaders in the field to discuss a roadmap for the path forward. A follow-up meeting in 2022 aimed to review the current state of the field and to identify critical barriers and milestones for progress.
DESIGN
The ASSFN convened a meeting on June 3, 2022 in Atlanta, Georgia and included leaders from the fields of neurology, neurosurgery, and psychiatry along with colleagues from industry, government, ethics, and law. The goal was to review the current state of the field, assess for advances or setbacks in the interim six years, and suggest a future path forward. The participants focused on five areas of interest: interdisciplinary engagement, regulatory pathways and trial design, disease biomarkers, ethics of psychiatric surgery, and resource allocation/prioritization. The proceedings are summarized here.
CONCLUSION
The field of surgical psychiatry has made significant progress since our last expert meeting. Although weakness and threats to the development of novel surgical therapies exist, the identified strengths and opportunities promise to move the field through methodically rigorous and biologically-based approaches. The experts agree that ethics, law, patient engagement, and multidisciplinary teams will be critical to any potential growth in this area.
Topics: Humans; United States; Neurosurgery; Deep Brain Stimulation; Neurosurgical Procedures; Mental Disorders; Psychosurgery
PubMed: 37217075
DOI: 10.1016/j.brs.2023.05.011 -
Frontiers in Psychiatry 2021Surgical treatment for psychiatric disorders, such as obsessive-compulsive disorder (OCD) and depression, using ablative techniques, such as cingulotomy and capsulotomy,... (Review)
Review
Surgical treatment for psychiatric disorders, such as obsessive-compulsive disorder (OCD) and depression, using ablative techniques, such as cingulotomy and capsulotomy, have historically been controversial for a number of scientific, social, and ethical reasons. Recently, with the elucidation of anatomical and neurochemical substrates of brain function in healthy controls and patients with such disorders using various functional neuroimaging techniques, these criticisms are becoming less valid. Furthermore, by using new techniques, such as deep brain stimulation (DBS), and identifying more precise targets, beneficial effects and the lack of serious complications have been demonstrated in patients with psychiatric disorders. However, DBS also has many disadvantages. Currently, magnetic resonance-guided focused ultrasound surgery (MRgFUS) is used as a minimal-invasive surgical method for generating precisely placed focal thermal lesions in the brain. Here, we review surgical techniques and their potential complications, along with anterior limb of the internal capsule (ALIC) capsulotomy by radiofrequency lesioning and gamma knife radiosurgery, for the treatment of OCD and depression. We also discuss the limitations and technical issues related to ALIC capsulotomy with MRgFUS for medically refractory OCD and depression. Through this review we hope MRgFUS could be considered as a new treatment choice for refractory OCD.
PubMed: 33889100
DOI: 10.3389/fpsyt.2021.640832 -
Stereotactic and Functional Neurosurgery 2022Serendipity and observations have a noble tradition in medicine, including neurology, and are responsible for many medical treatments (carbamazepine for tic douloureux,... (Review)
Review
BACKGROUND
Serendipity and observations have a noble tradition in medicine, including neurology, and are responsible for many medical treatments (carbamazepine for tic douloureux, amantadine for Parkinson's disease, gabapentin for restless legs…). We aimed at examining the contribution of serendipity and observations to functional neurosurgery. Scholarly publications relevant to the history of functional neurosurgery for movement and psychiatric disorders were reviewed, starting from the pre-stereotactic era. The documents were scrutinized with respect to indications for surgery, surgical methods, and brain targets, in view of determining whether serendipitous discoveries and other observations contributed to various functional neurosurgical procedures.
SUMMARY
James Parkinson's observation that tremors disappeared in the arm of a person with shaking palsy after a hemiparetic stroke encouraged neurosurgeons in the first half of the 20th century to perform ablative procedures on central motor pathways. Following a lobotomy performed by Browder that extended too far medially in a psychiatric patient with coexisting Parkinson's disease (PD), it was noted that the Parkinsonian signs improved. This encouraged Russel Meyers to carry out open surgery on the caudate nucleus and basal ganglia in PD. Cooper introduced ligation of the anterior choroidal artery as a treatment for PD following a surgical accident during a pedunculotomy. Cooper later started to perform stereotactic surgery on the ventrolateral thalamus following the pathological finding that an intended pallidal lesion had in fact targeted the thalamus. Leksell discovered the ideal location of a pallidal lesion being in the posteroventral area empirically, long before the advent of the basal ganglia model of PD. Modern Deep Brain Stimulation (DBS) that started in the thalamus for tremor was the result of an observation by Benabid that intraoperative high-frequency stimulation during a thalamotomy reduced tremor. Both the discoveries of the anterior limbic subthalamic nucleus as a DBS target for OCD and the medial forebrain bundle as a DBS target for depression occurred by chance. Hamani and Lozano observed memory flashbacks in a patient who was undergoing DBS for obesity, which led to the discovery of the fornix as a potential DBS target for Alzheimer's disease.
KEY MESSAGES
In the history of functional neurosurgery, serendipity and observations have resulted in discoveries of several procedures, brain targets for lesioning or DBS as well as new clinical surgical indications. In this era of neuromodulation, this technology should be exquisite in allowing potential serendipitous discoveries, provided that clinicians remain both observant and prepared.
Topics: Deep Brain Stimulation; History, 20th Century; Humans; Neurosurgery; Observation; Parkinson Disease; Psychosurgery; Stroke; Tremor
PubMed: 35882210
DOI: 10.1159/000525794 -
Frontiers in Integrative Neuroscience 2022In this review, we describe the evolution of modern ablative surgery for intractable psychiatric disease, from the original image-guided cingulotomy procedure described... (Review)
Review
In this review, we describe the evolution of modern ablative surgery for intractable psychiatric disease, from the original image-guided cingulotomy procedure described by Ballantine, to the current bilateral anterior cingulotomy using MRI-guided stereotactic techniques. Extension of the single lesion bilateral cingulotomy to the extended bilateral cingulotomy and subsequent staged limbic leucotomy (LL) is also discussed. Other ablative surgeries for psychiatric disease including subcaudate tractotomy (SCT) and anterior capsulotomy (AC) using modern MRI-guided ablative techniques, as well as radiosurgical capsulotomy, are described. Finally, the potential emerging role of MR-guided focused ultrasound (MRgFUS) for treating conditions such as major depressive disorder (MDD) and obsessive-compulsive disorder (OCD) is discussed.
PubMed: 35464603
DOI: 10.3389/fnint.2022.797533 -
Journal of Psychiatry & Neuroscience :... Sep 2020Several neuroablative procedures are available for severe and treatment-resistant obsessive-compulsive disorder (OCD), but limited knowledge about their relative... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Several neuroablative procedures are available for severe and treatment-resistant obsessive-compulsive disorder (OCD), but limited knowledge about their relative clinical advantages and disadvantages poses obstacles for treatment decision-making.
METHODS
We searched PubMed, Embase, Scopus, Web of Knowledge and the Cochrane Library for reports up to February 2019. We reviewed the literature on the effectiveness (assessed using the Yale-Brown Obsessive Compulsive Scale [Y-BOCS]) and safety of various neuroablative interventions for severe and treatment-resistant OCD.
RESULTS
We included 23 studies involving 487 patients in the systematic review; 21 studies with 459 patients entered meta-analysis. Overall, neuroablation achieved a response rate (proportion of patients with ≥ 35% reduction in Y-BOCS) of 55%. Most of the adverse events (88.4%) were mild and transient. The top 3 adverse events were headache (14.9%), cognitive deficits (9.1%) and behaviour problems (8.1%). Severe or permanent adverse events included personality changes (2.3%) and brain edema or brain cyst (1.5%). The response rates associated with capsulotomy, limbic leucotomy and cingulotomy were 59% (95% confidence interval [CI] 54-65), 47% (95% CI 23-72) and 36% (95% CI 23-50), respectively. Interventions with different coverages of the dorsal part of the internal capsule were associated with different adverse-event profiles but were unlikely to modify clinical effectiveness.
LIMITATIONS
The level of evidence of most included studies was relatively low.
CONCLUSION
Ablative surgeries are safe and effective for a large proportion of patients with severe and treatment-resistant OCD. Among the available procedures, capsulotomy seemed to be the most effective. Further research is needed to improve clinical effectiveness and minimize risks.
Topics: Humans; Obsessive-Compulsive Disorder; Outcome Assessment, Health Care; Psychosurgery; Radiofrequency Ablation
PubMed: 32549057
DOI: 10.1503/jpn.190079 -
Neurologia I Neurochirurgia Polska 2021Deep brain stimulation (DBS) has achieved substantial success as a treatment for movement disorders such as Parkinson's Disease (PD), essential tremor (ET), and... (Review)
Review
INTRODUCTION
Deep brain stimulation (DBS) has achieved substantial success as a treatment for movement disorders such as Parkinson's Disease (PD), essential tremor (ET), and dystonia. More recently, a limited number of basic and clinical studies have indicated that DBS of the nucleus accumbens (NAc) and other neighbouring structures of the reward circuit may be an effective intervention for patients with treatment-refractory addiction.
MATERIAL AND METHODS
We performed a structured literature review of human studies of DBS for addiction outlining the clinical efficacy and adverse events. We found 14 human studies targeting mostly the NAc with neighbouring structures such as anterior limb of the internal capsule (ALIC). Five studies including 12 patients reported the outcomes for alcohol dependence. Nine studies including 18 patients reported the outcomes for addictions to various psychoactive substances. The most common indication was addiction to heroin, found in 13 patients, followed by methamphetamine, 3 patients, cocaine, one patient, and polysubstance drug abuse in one patient.
CONCLUSIONS
The limited clinical data available indicates that DBS may be a promising therapeutic modality for the treatment of intractable addiction. In general, the safety profile of DBS in patients with addiction is good. Based on the data published in the literature, the NAc is the most often targeted, and is probably the most effective, structure of the reward circuit in the treatment of addiction in humans. Given the ever-expanding understanding of the psychosurgery of addiction, DBS could in the future be a treatment option for patients suffering from intractable addictive disorders.
Topics: Deep Brain Stimulation; Humans; Internal Capsule; Nucleus Accumbens; Substance-Related Disorders; Treatment Outcome
PubMed: 34633060
DOI: 10.5603/PJNNS.a2021.0065 -
Brain Sciences Jun 2023Science and philosophy have tried to understand the origin of emotions for centuries. However, only in the last 150 years have we started to try to understand them in a... (Review)
Review
Science and philosophy have tried to understand the origin of emotions for centuries. However, only in the last 150 years have we started to try to understand them in a neuroscientific scope. Emotions include physiological changes involving different systems, such as the endocrine or the musculoskeletal, but they also cause a conscious experience of those changes that are embedded in memory. In addition to the cortico-striato-thalamo-cortical circuit, which is the most important of the basal ganglia, the limbic system and prefrontal circuit are primarily involved in the process of emotion perceptions, thoughts, and memories. The purpose of this review is to describe the anatomy and physiology of the different brain structures involved in circuits that underlie emotions and behaviour, underlying the symptoms of certain psychiatric pathologies. These circuits are targeted during deep brain stimulation (DBS) and knowledge of them is mandatory to understand the clinical-physiological implications for the treatment. We summarize the main outcomes of DBS treatment in several psychiatric illness such as obsessive compulsive disorder, refractory depression, erethism and other conditions, aiming to understand the rationale for selecting these neural systems as targets for DBS.
PubMed: 37371421
DOI: 10.3390/brainsci13060943 -
Journal of Neurosurgery Jan 2022Obsessive-compulsive disorder (OCD) is among the most debilitating and medically refractory psychiatric disorders. While cingulotomy is an anatomically targeted...
OBJECTIVE
Obsessive-compulsive disorder (OCD) is among the most debilitating and medically refractory psychiatric disorders. While cingulotomy is an anatomically targeted neurosurgical treatment that has shown significant promise in treating OCD-related symptoms, the precise underlying neuroanatomical basis for its beneficial effects has remained poorly understood. Therefore, the authors sought to determine whether lesion location is related to responder status following cingulotomy.
METHODS
The authors reviewed the records of 18 patients who had undergone cingulotomy. Responders were defined as patients who had at least a 35% improvement in the Yale-Brown Obsessive Compulsive Scale (YBOCS) score. The authors traced the lesion sites on T1-weighted MRI scans and used an anatomical registration matrix generated by the imaging software FreeSurfer to superimpose these lesions onto a template brain. Lesion placement was compared between responders and nonresponders. The placement of lesions relative to various anatomical regions was also compared.
RESULTS
A decrease in postoperative YBOCS score was significantly correlated with more superiorly placed lesions (decrease -0.52, p = 0.0012). While all lesions were centered within 6 mm of the cingulate sulcus, responder lesions were placed more superiorly and posteriorly along the cingulate sulcus (1-way ANOVA, p = 0.003). The proportions of the cingulum bundle, cingulate gyrus, and paracingulate cortex affected by the lesions were the same between responders and nonresponders. However, all responders had lesions covering a larger subregion of Brodmann area (BA) 32. In particular, responder lesions covered a significantly greater proportion of the posterior BA32 (1-way ANOVA, p = 0.0064).
CONCLUSIONS
Lesions in patients responsive to cingulotomy tended to be located more superiorly and posteriorly and share greater coverage of a posterior subregion of BA32 than lesions in patients not responsive to this treatment.
Topics: Brain Mapping; Drug Resistance; Gyrus Cinguli; Humans; Image Processing, Computer-Assisted; Magnetic Resonance Imaging; Neuropsychological Tests; Neurosurgical Procedures; Obsessive-Compulsive Disorder; Psychosurgery; Retrospective Studies; Treatment Outcome
PubMed: 34243154
DOI: 10.3171/2020.11.JNS202211 -
Neurologia Medico-chirurgica Nov 2020As in many Western countries, deep brain stimulation (DBS) is already being used daily in Japan to clinically treat neurological diseases such as Parkinson's disease,... (Review)
Review
As in many Western countries, deep brain stimulation (DBS) is already being used daily in Japan to clinically treat neurological diseases such as Parkinson's disease, essential tremor, and dystonia. Additionally, in both Europe and the United States, numerous case reports as well as multicenter randomized controlled trials have examined its use for treatment-refractory mental illnesses such as obsessive compulsive disorder (OCD) and major depressive disorder. Based on a number of the reports, the European Union (EU) and the USA Food and Drug Administration (FDA) granted limited approval of DBS for treatment-resistant OCD in 2009. Furthermore, a systematic review and meta-analysis in 2015 showed that DBS therapy for patients with treatment-resistant OCD had efficacy and was safe. Unlike the EU and the USA, DBS is not used to treat OCD or other psychiatric disorders in Japan, even though people with treatment-resistant OCD and their physicians and families urgently need additional treatments. This situation results from the "Resolution of total denial for psychosurgery," which the Japanese Society of Psychiatry and Neurology adopted in 1975. We believe that the appropriateness of using DBS for treating psychiatric disorders including OCD should be considered after thorough discussion and consideration based on accurate and objective understanding. Currently, the field of psychiatry in Japan seems to lack scientific consideration as well as scientific understanding in this area. Under these circumstances, we hope that this review article will help psychiatrists and other relevant parties in Japan to gain an accurate and scientific understanding of DBS.
Topics: Deep Brain Stimulation; Humans; Japan; Obsessive-Compulsive Disorder
PubMed: 33071277
DOI: 10.2176/nmc.ra.2020-0196