Deep Brain Stimulation in Obsessive Compulsive …...• Cognitive deficits have been identified...
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Deep Brain Stimulation in Obsessive Compulsive Disorder: Where are we now? Dr Sarah Farrand Simone Mangelsdorf Neuropsychiatry Unit, Royal Melbourne Hospital
Transcript of Deep Brain Stimulation in Obsessive Compulsive …...• Cognitive deficits have been identified...
Deep Brain Stimulation in Obsessive Compulsive Disorder: Where are we now?
Dr Sarah FarrandSimone Mangelsdorf
Neuropsychiatry Unit, Royal Melbourne Hospital
Acknowledgements and Disclosures• DBS Team
• Professor Dennis Velakoulis• Dr Andrew Evans• Professor Richard Bittar• The Neuropsychiatry Unit MDT
• Disclosures• In 2016, SF received a 0.5FTE fellowship from
Medtronic
Brief overview
• Snapshot of our cohort• New research directions and potential biomarkers• Individualising treatment• Unexpected challenges
DBS for OCD
• First report by Bart Nuttin and colleagues in 1999• Since then approx 200 cases in the literature• Variety of targets: ALIC, NAC, VC/VS, ITP, BNST, STN,
amGPI• Typically 50% response rate• Symptom reduction of 40-60% on average (range is
~0-85%).
Recent History of Psychosurgery in Australia• 1980's – 10-20 surgeries per year, usually anterior
capsulotomies or leucotomies• 1990's – one or two a year• 2001-2006 no operations in Victoria• 2007-2012 – 12 applications in Victoria for DBS (for
depression and OCD) made to the Psychosurgery Review Board
• VIC and QLD only states offering DBS at present
Our Cohort
• 2011-2018: 9 patients completed, 1 pending surgery date, 1 pending assessment.
• Different challenges at different stages• How can we:
• Individualise treatment• Find better ways of illness subtyping, selecting targets,
monitoring response?• Provide recovery-focused follow up.
Current ResultsID Base YBOCS LFU LFU YBOCS % Reduction
1 37 36 21 43.242 37 70 20 45.953 34 71 24 29.414 31 45 22 29.035 29 50 35 -20.696 35 32 32 8.577 28 21 21 25.008 29 11 18 37.939 33 8 16 51.52
Mean 32.56 38.22 23.22 27.77
Reduction in YBOCS is significant, p=0.015Data is an update since published results, Farrand et al, 2018 ANZJP
Emerging research and biomarkers
Use of cognition as a biomarker: Cognition in OCD (1)• Cognitive deficits have been identified in people
with moderate-to-severe OCD symptoms• The profile seems to reflect frontal-striatal
dysfunction and appears to be related to the illness (Purcell, Maruff, Kyrios & Pantelis, 1998)
• Deficits have been identified in areas such as spatial working memory, visual memory, attention and cognitive flexibility across a range of different studies
Use of cognition as a biomarker: Cognition in OCD (2)• In our cohort, we have found evidence to support
the generalised frontal-striatal dysfunction on neuropsychological tests
• There is also a trend of specific impairments which appear to be related to the severity and nature of their individual symptomatology
• Reduced processing speed in those who have predominant 'checking' behaviours
• Meta-memory deficits in those with predominant 'doubting'
Presenter
Presentation Notes
All of our OCD-DBS patients undergo a thorough neuropsychological evaluation prior to their submission to the psychosurgery review board. This is to determine whether there are any marked cognitive deficits which would preclude them from
Use of cognition as a biomarker: Preliminary results
Presenter
Presentation Notes
This is some preliminary data from one patient who was assessed at baseline (prior to stimulation) and 12 weeks after stimulation had been started. There was a set of neuropsychological assessments which were conducted over the sessions - I have selected some of the more sensitive tests (please note that these are scored and interpreted differently, though these are all standardised scores). The first is psychomotor coding – something which is affected in a lot of our OCD patients. She has moved from the average range to the superior range on this task. Her performance on a spatial anticipation task is now at ceiling -(8 is the highest scaled score on this measure) - meaning that her ability to recognise patterns and to flexibly shift her attention has improved. Her design fluency (a visual measure of cognitive flexibility and generativity)has improved from the low average range to the high average range In addition to using the standard neuropsychological assessments, we have also started utilising computerised assessment tools which have been used in other research. The computerised batteries have the advantage of being able to pick up subtle changes in response time and error analysis. What we can see here are SWM (spatial working memory) - looking at errors made – at 12 week follow up she now no longer makes errors. The IED refers to a task which requires a high level of attention to detail and set-shifting, or the ability to think flexibility. Again, she is making less errors on this task, indicating better function in this domain. Overall, on the basis of these results we are seeing evidence of better functionality and connectivity in the frontal-striatal networks which underpin these various cognitive functions.
Use of cognition as a biomarker: preliminary results (2) • Initial results on the cognitive safety of DBS have
been promising• Individuals who have participated in a cognitive
follow up have either shown stability across cognitive domains, or some improvements (e.g. speed of processing) mirroring the improvements in their symptomatology
• These findings are in keeping with other research in this area (e.g. Bergfeld et al, 2013)
Personality and psychopathology in OCD• Very little in the existing literature regarding normal
personality profiles in people with OCD• Most are symptom based (e.g. YBOCS)
• New research project which aims to1. Describe the personality and psychopathology profiles
of our OCD-DBS cohort2. Describe changes in these measures post-DBS
Presenter
Presentation Notes
- one of the advantages of using a personality/psychopathology measure is that we collect different information from the patients that things like the YBOCS does. Often we can see a discrepancy in the clinician rated scales and the self-rated scales - the PAI, or personality assessment inventory, allows us to get a more accurate representation at times of the clinical severity of the areas of interest. The PAI also allows us to gather information on normal personality dimensions – such
Personality Assessment: Pre-DBS
Personality Assessment: Post-DBS
Personality Assessment: a case example
Individualising treatment
DBS post leucotomy: Individualising treatment
Tractography for Surgical Planning
Above: E1- most distal electrode, E4- most proximal
Below: Overlap with anterior thalamic radiations
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OTS Problemssolved on first
choice
OTS Meanchoices to
correct
SWM Betweenerrors
SWM Strategy IED Totalerrors
(adjusted)
IED Stagescompleted
A.
Baseline 6-weeks 12-weeks
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Delay aversionOverall proportion betQuality of decision makingRisk adjustment Risk taking
B.
Baseline 6-weeks 12-weeks
Stimulation planning
Early results, n=2
• n=2 patients where tractography has been utilised to assist DBS planning/programming
• Both have achieved full response in 12 weeks.• Average for the rest of the cohort – 8 months• Other confounding factors – experience, different
programming.
Unexpected challenges
Unexpected Challenges: Overstimulation
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0 1 3 7 8 12 19 23 25 34 35 37 42 44 46 47 53 54 55 56 59 64 66 70Months post DBS
YBOCS over time from 0-70 months
Conclusion
• Many areas for further exploration!• Any questions?• Get in touch:
• Come and find us on twitter at @NWMentalHealth• [email protected]• Neuropsychiatry Unit: Ph. (03) 9342 8750• Fax (03) 9342 8483
