Treating obsessive-compulsive disorder (OCD): Is surgery an option?

By Rachel Kallus, PsyD

Over the last few years, organizing has evolved from your least favorite chore to a trendy topic on social media, Netflix reality shows, and loads of advertisements. Organizing icons and brands like Marie Kondo and The Container Store have become household names we refer to constantly. With people spending more time at home, keeping things neat and in order has become a higher priority for many. However, there is a fine line between healthy tidiness and excessive (or obsessive) cleaning and organizing, which is commonly associated with obsessive-compulsive disorder (OCD). Many people can recognize common signs of OCD, such as frequent cleaning, putting items in order, or repeatedly checking on items or appliances in the house. Nevertheless, there are several considerations involved in the scientific diagnosis of OCD2. To meet the criteria, an individual must experience time consuming or clinically distressing obsessions and compulsions that are not explained by another condition or disorder. Obsessions are recurrent thoughts, impulses, or images that are unwanted and distressing. These obsessions are accompanied by attempts to ignore, suppress, or neutralize the obsession. Additionally, compulsions are repetitive behaviors or mental acts that the individual performs in order to alleviate distress or negative outcomes associated with an obsession. For example, an individual might have persistent thoughts that their hands are loaded with germs (i.e., an obsession). When attempts to ignore those thoughts fail, the individual might repetitively wash their hands (5, 10, 15 times or more) in order to get rid of those germs (i.e., the compulsion). If obsessions and compulsions become time consuming and distressing, a diagnosis of OCD and appropriate treatment may be warranted.

When an individual experiences distress associated with OCD, there are many treatment modalities from which they can choose. Treatment types vary from talk therapy and medication to brain surgery5. Medications are frequently used, and antidepressants are often used as a first line of defense. There are several selective serotonin reuptake inhibitors (SSRI’s; i.e., a class of antidepressants) that are FDA approved for OCD. Aside from medications, many people choose to pursue psychotherapy or intensive therapy programs, which have been shown to effectively treat OCD. Cognitive behavioral therapy (CBT) is commonly used to teach symptom management. CBT often includes exposing individuals to their obsession in real time and teaching them to resist a reaction. Imagine a therapy where you play with dirt and germs! Intensive outpatient programs are used for severe OCD, and these programs often utilize CBT principles as well. More recently, treatment options targeting the brain have been implemented when OCD symptoms have not responded to other types of treatment6.

A brain surgery called deep brain stimulation (DBS) (Figure 1) has become an area of interest to scientists and clinicians because of its application for OCD treatment6. The procedure involves placing electrodes on the brain that produce electrical impulses to counteract abnormal brain activity associated with OCD4. DBS is more commonly used to treat symptoms of Parkinson’s disease, essential tremor, and epilepsy. However, the procedure has been used in the treatment of refractory (i.e., treatment resistant) OCD since the late 1990’s and is FDA approved for this use1,3. Penn State Health has completed four DBS procedures for OCD to date, and there are several more patients under consideration for DBS that are in the preoperative evaluation stages.

Figure 1. Illustration of implanted electrodes following DBS. Image source: https://consultqd.clevelandclinic.org/deep-brain-stimulation-for-neuropsych-disorders-dont-count-it-out-yet/

Our research on DBS for OCD to date is case by case, because so few patients have undergone the surgery. We recently completed a quality analysis with a patient in his 20s that has OCD and underwent DBS to improve his symptoms. Before the surgery, this man experienced severe OCD symptoms and had associated behavior problems, mood swings, social difficulties, and poor financial decision making. His preoperative brain imaging was normal, and his psychiatric evaluation revealed longstanding problems because of his OCD, autism spectrum disorder, and an episode of psychosis. We compared his preoperative and postoperative neuropsychological evaluation results to determine if the surgery resulted in any cognitive changes. Neuropsychological evaluations measure how a person’s brain is working through tests that assess attention, language, visual-spatial skills, memory, executive functioning, mood, personality and other areas.

We compared our patient’s preoperative and postoperative neuropsychological assessment using a reliable change index (RCI). RCI is a statistical method used to determine if scores achieved on the same test at two different time points are statistically and clinically different from each other. Although this may sound boring, the formula is a great way to see if someone is making progress, staying the same, or declining. For our patient, we found that in most areas his test scores stayed the same. This included tests of language (e.g., naming pictures and quickly saying words that begin with a certain letter or belong to a certain category), memory for visual information, and executive functioning (e.g., switching from one task to another, inhibiting an automatic response, and problem solving). The one area where he declined was in his ability to learn and remember a list of words. Before the surgery he remembered about 12 out of 16 words on average, and after, he remembered about 8. Meanwhile, the patient showed significant improvement in his OCD symptoms, to the degree that he could live on his own, maintain competitive employment, and independently manage his daily activities! Because our findings were mixed with the neuropsychological data, it is unclear the extent to which DBS impacted his overall cognitive functioning. Taken together, we need to complete even more research studies to learn about the effects of DBS for OCD patients, with the hope to effectively treat as many people as possible that are suffering from OCD. Through innovate treatments, we hope to help our patients get to a place where talking about organizing, cleaning, and admiring Marie Kondo’s closets is a fun and exciting experience!


References

  1. Alonso, P., Cuadras, D., Gabriëls, L., Denys, D., Goodman, W., Greenberg, B. D., Jimenez-Ponce, F., Kuhn, J., Lenartz, D., Mallet, L., Nuttin, B., Real, E., Segalas, C., Schuurman, R., du Montcel, S. T., & Menchon, J. M. (2015). Deep Brain Stimulation for Obsessive-Compulsive Disorder: A Meta-Analysis of Treatment Outcome and Predictors of Response. PloS one, 10(7), e0133591. https://doi.org/10.1371/journal.pone.0133591
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA.
  3. Borders, C., Hsu, F., Sweidan, A. J., Matei, E. S., & Bota, R. G. (2018). Deep brain stimulation for obsessive compulsive disorder: A review of results by anatomical target. Mental illness, 10(2), 7900. https://doi.org/10.4081/mi.2018.7900
  4. Mantione, M., Nieman, D., Figee, M., van den Munckhof, P., Schuurman, R., & Denys, D. (2015). Cognitive effects of deep brain stimulation in patients with obsessive-compulsive disorder. Journal of psychiatry & neuroscience, 40(6), 378–386. https://doi.org/10.1503/jpn.140210
  5. https://www.mayoclinic.org/diseases-conditions/obsessive-compulsive-disorder/diagnosis-treatment/drc-20354438
  6. https://www.medtronic.com/us-en/healthcare-professionals/therapies-procedures/neurological/deep-brain-stimulation/indications/obsessive-compulsive-disorder.html

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