UPMC procedure offers hope for severe OCD cases

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Doctors at UPMC are now offering surgical brain stimulation for people with severe obsessive-compulsive disorder, or OCD.

The procedure, known as deep brain stimulation, or DBS, sends signals to parts of the brain using electrodes inserted through the skull and connected to controllers under the chest. It has been used for years to treat people with Parkinson’s disease and other movement disorders and is also being tried experimentally for people with severe depression.

Mark Richardson, director of epilepsy and movement disorder surgery at UPMC, said his department will offer the surgery under a “humanitarian device exemption,” and it will be limited to adults with such severe OCD that they haven’t responded to psychotherapy or medication.

“There are a lot of people with OCD, but when you whittle it down to the people who would qualify, it’s a smaller number,” said Dr. Richardson. He anticipated that at most he might do one to five surgeries a year. In a national trial of DBS for OCD, doctors have assembled about 20 people for the surgery over the past six years, said lead investigator Benjamin Greenberg of Brown University in Rhode Island.

OCD affects an estimated 2 million adults in the United States.

Intrusive thoughts that lead to compulsive, ritualistic behaviors characterize the disorder. Some OCD patients fear germs and wash their hands and bodies excessively. Others are paranoid about safety issues and continually check to see if they have turned off the stove or locked the door.

For reasons doctors still don’t entirely understand, stimulating certain deeper parts of the brain can re-tune brain circuits to function more normally.

The federal Food and Drug Administration has approved DBS as a routine surgery for Parkinson’s, essential tremor, dystonia and other movement disorders. In those cases, doctors thread the electrodes to a part of the brain that governs the tremors or contortions those ailments cause.

Experimental trials of DBS for depression have targeted two different areas: one that seems to dampen negative feelings and another that tries to boost positive emotions.

With OCD, the target area is at the border of deep brain regions known as the ventral capsule and ventral striatum, said Dr. Richardson.

In healthy people, that area is part of circuits that are active when people worry, when they make decisions and when they form habits, so it makes sense that abnormal functioning could lead to the excessive anxiety and compulsive actions of OCD, said Dr. Greenberg.

Scientists aren’t sure why the pulses from the DBS electrodes normalize those circuits in some people, but they already knew that surgery to remove that part of the brain sometimes had the same effect, said Dr. Greenberg.

Brain imaging studies on OCD patients whose symptoms improve after any kind of treatment also show changes in those same circuits, he said.

In Pittsburgh, researchers plan to use a special kind of brain imaging known as magnetoencephalography, which detects the magnetic fields the brain creates, to measure the before-and-after effect of DBS.

In the DBS operation, surgeons drill holes through the skull using local anesthetic and then thread thin electrodes to the target areas on each side of the brain. They then test the effect of the current when the patient is awake to see if it relieves the obsessive feelings.

After that, they put the patient under general anesthetic to thread wires from the electrodes beneath the scalp and down to controllers implanted under the chest.

Doctors can then adjust the current with a remote control device.

One advantage of DBS is that it can be turned off if there are unwanted side effects, and the electrodes even can be removed if necessary.

Previous studies with small groups of patients have shown that about half of them have significant relief of OCD symptoms after the DBS surgery.

Some of those patients were virtually locked inside their homes because of their obsessions.

“To have even one or two people be able to return to a life they have been locked out of is a significant outcome,” said Dr. Richardson.

Under the humanitarian device exemption procedure, patients’ insurance will usually cover the surgery if they qualify otherwise.

Patients who are at least 18 and have not responded to psychotherapy or drug treatment may qualify for the operation; they also can’t have had any previous brain injuries or surgery.

Families interested in the DBS option can contact Dr. Richardson’s clinic at 412-864-3420.

■ Tomorrow: An OCD patients talks about how therapy turned her life around

Mark Roth: mroth@post-gazette.com, 412-263-1130 or on Twitter @markomar.

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