Visuospatial Memory Improvement after Gamma Ventral Capsulotomy in Treatment Refractory Obsessive-Compulsive Disorder Patients

Evidence Accumulation and Neural Correlates of Uncertainty in Obsessive-Compulsive Disorder

BACKGROUND

Decision making is frequently associated with risk taking under uncertainty. Elevated intolerance of uncertainty is suggested to be a critical feature of obsessive-compulsive disorder (OCD). However, impairments of latent constructs of uncertainty processing and its neural correlates remain unclear in OCD.

METHODS

In 83 participants (24 OCD patients treated with capsulotomy, 28 OCD control participants, and 31 healthy control participants), we performed magnetic resonance imaging using a card gambling task in which participants made decisions whether to bet or not that the next card would be larger than the current one. A hierarchical drift diffusion model was used to dissociate speed and amount of evidence accumulated before a decisional threshold (i.e., betting or no betting) was reached.

RESULTS

High uncertainty was characterized by a smaller amount of evidence accumulation (lower thresholds), thus dissociating uncertainty from conflict tasks and highlighting the specificity of this task to test value-based uncertainty. OCD patients exhibited greater caution with poor performance and greater evidence accumulation overall along with slower speed of accumulation, particularly under low uncertainty. Bilateral dorsal anterior cingulate and anterior insula distinguished high- and low-uncertainty decision processes in healthy control participants but not in the OCD groups, indicating impairments in anticipation of differences in outcome variance and salience network activity. There were no behavioral or imaging differences relating to capsulotomy despite improvements in OCD symptoms.

CONCLUSIONS

Our findings highlight greater impairments particularly in more certain trials in the OCD groups along with impaired neural differentiation of high and low uncertainty and suggest uncertainty processing as a trait cognitive endophenotype rather than a state-specific factor.

Cognitive outcomes following functional neurosurgery in refractory OCD patients: a systematic review

Neurosurgery is a therapeutic option for patients with refractory obsessive-compulsive disorder who do not respond to previous treatments. Although its efficacy in reducing clinical symptomatology has been proven, few studies have analyzed its effects at the cognitive level. The aim of this systematic review was to describe the cognitive outcomes of functional neurosurgery in patients that went through capsulotomies or cingulotomies. PubMed, Medline, Scopus, PsycInfo, PsyArticles, and Web of Knowledge were searched for studies reporting cognitive outcomes in refractory obsessive-compulsive patients after capsulotomies and cingulotomies. The risk of bias was assessed with the Assessment Tool for Before-After (Pre-Post) Studies With No Control Group tool; 13 studies met inclusion criteria, including 205 refractory obsessive-compulsive disorder patients for both surgical procedures. Results showed a substantial number of studies that did report significant cognitive improvement after surgery, being this improvement specially related to memory and executive functions. The second-most frequent finding is the maintenance of cognitive performance (nor improvement or worsening). From a neuropsychological point of view, this outcome might be considered a success, given that it is accompanied by amelioration of obsessive-compulsive symptoms. Subtle cognitive adverse effects have also been reported. Neurosurgery procedures appear to be safe from a cognitive point of view. Methodological issues must be improved to draw clearer conclusions, but capsulotomies and cingulotomies constitute an effective alternative treatment for refractory obsessive-compulsive disorder patients.

Gamma knife capsulotomy for intractable OCD: Neuroimage analysis of lesion size, location, and clinical response

Obsessive-compulsive disorder (OCD) affects 2-3% of the population. One-third of patients are poorly responsive to conventional therapies, and for a subgroup, gamma knife capsulotomy (GKC) is an option. We examined lesion characteristics in patients previously treated with GKC through well-established programs in Providence, RI (Butler Hospital/Rhode Island Hospital/Alpert Medical School of Brown University) and São Paulo, Brazil (University of São Paolo). Lesions were traced on T1 images from 26 patients who had received GKC targeting the ventral half of the anterior limb of the internal capsule (ALIC), and the masks were transformed into MNI space. Voxel-wise lesion-symptom mapping was performed to assess the influence of lesion location on Y-BOCS ratings. General linear models were built to compare the relationship between lesion size/location along different axes of the ALIC and above or below-average change in Y-BOCS ratings. Sixty-nine percent of this sample were full responders (≥35% improvement in OCD). Lesion occurrence anywhere within the targeted region was associated with clinical improvement, but modeling results demonstrated that lesions occurring posteriorly (closer to the anterior commissure) and dorsally (closer to the mid-ALIC) were associated with the greatest Y-BOCS reduction. No association was found between Y-BOCS reduction and overall lesion volume. GKC remains an effective treatment for refractory OCD. Our data suggest that continuing to target the bottom half of the ALIC in the coronal plane is likely to provide the dorsal-ventral height required to achieve optimal outcomes, as it will cover the white matter pathways relevant to change. Further analysis of individual variability will be essential for improving targeting and clinical outcomes, and potentially further reducing the lesion size necessary for beneficial outcomes.

Treatment strategies for serotonin reuptake inhibitor-resistant obsessive-compulsive disorder: A network meta-analysis of randomised controlled trials

OBJECTIVES

Treatment-resistant obsessive-compulsive disorder is a chronic debilitating illness. We conducted a network meta-analysis [NMA] to compare the efficacy of all interventions in SRI-resistant OCD from published Randomised controlled trials [RCT].

METHODS

We performed an NMA of RCTs in SRI resistant OCD from all modalities of treatments; pharmacological, psychological, neuromodulation, neurosurgery including deep brain stimulation. The design-by-treatment interaction inconsistency model within the frequentist framework was adopted with a change in Yale-Brown Obsessive-Compulsive Scale score as the primary outcome. We conducted sensitivity analyses excluding studies examining neurosurgical interventions, deep brain stimulation, studies in the paediatric population, and studies from a single geographical region. We also conducted analyses of interventions categorised into treatment groups.

RESULTS

55 RCTs examining 19 treatments or placebo involving 2011 participants were included in the NMA. Ondansetron [Standardised mean difference -2.01 (95% CI: -3.19, -0.83)], deep TMS [- 1.95 (-3.25, -0.65)], therapist administered Cognitive Behavioural Therapy [CBT-TA] [-1.46 (-2.93, 0.01)] and aripiprazole [-1.36 (-2.56, -0.17)] were ranked as the best four treatments on using the Surface Under the Cumulative Ranking [SUCRA] percentage values (85.4%, 83.2%, 80.3%, 67.9% respectively). While all four interventions had large effect sizes, CBT[TA] narrowly missed statistical significance in our analysis. In sensitivity analyses, deep TMS was ranked as the best treatment strategy for SRI-resistant OCD. The small number of subjects in individual studies, higher confidence interval limits, and wider prediction interval for most agents warrant a cautious interpretation.

CONCLUSIONS

Considering the principal analysis and sensitivity analyses together, deep TMS, ondansetron, CBT[TA], and aripiprazole may be considered a first-line intervention for SRI-resistant OCD in adults.

OTHER

This work was not funded. The NMA has been registered with PROSPERO, [Registration number: CRD42020173589].

Cost-effectiveness analysis of radiosurgical capsulotomy versus treatment as usual for treatment-resistant obsessive-compulsive disorder

OBJECTIVE

Stereotactic radiosurgical capsulotomy (SRS-C) is an effective neurosurgical option for patients with treatment-resistant obsessive-compulsive disorder (TROCD). Unlike other procedures such as deep brain stimulation and radiofrequency ablation, the cost-effectiveness of SRS-C for TROCD has not been investigated. The authors herein report the first cost-effectiveness analysis of SRS-C for TROCD.

METHODS

Using a decision analytic model, the authors compared the cost-effectiveness of SRS-C to treatment as usual (TAU) for TROCD. Treatment response and complication rates were derived from a review of relevant clinical trials. Published algorithms were used to convert Yale-Brown Obsessive Compulsive Scale scores into utility scores reflecting improvements in quality of life. Costs were approached from the healthcare sector perspective and were drawn from Medicare reimbursement rates and available healthcare economics data. A Monte Carlo simulation and probabilistic sensitivity analysis were performed to estimate the incremental cost-effectiveness ratio.

RESULTS

One hundred fifty-eight TROCD patients across 9 studies who had undergone SRS-C and had at least 36 months of follow-up were included in the model. Compared to TAU, SRS-C was more cost-effective, with an estimated incremental cost-effectiveness ratio of $28,960 per quality-adjusted life year (QALY) gained. Within the 3-year time horizon, net QALYs gained were greater in the SRS-C group than the TAU group by 0.27 (95% CI 0.2698-0.2702, p < 0.0001). At willingness-to-pay thresholds of $50,000 and $100,000 per QALY, the Monte Carlo simulation revealed that SRS-C was more cost-effective than TAU in 83% and 100% of iterations, respectively.

CONCLUSIONS

Compared to TAU, SRS-C for TROCD is more cost-effective under a range of possible cost and effectiveness values.

Treatment Outcomes of Gamma-Knife Radio Surgery in Refractory Obsessive-Compulsive Disorder

Background

Obsessive-compulsive disorder (OCD) is a common disease that has negative effects on functionality, and 10% of the patients do not respond to first-line treatments. Gamma-knife radiosurgery (GKRS) has been used in patients with treatment-resistant OCD, but the data on long-term outcomes are still unsatisfactory.

Methods

In this study, 12 patients who underwent GKRS between 2005 and 2020 were evaluated retrospectively. Anterior capsulotomy was performed using two 4-mm isocenters at the midputaminal point of the anterior limb of the internal capsule on each side with a maximum radiation dose of 140-180 Gy. Patients were followed up with the Yale-Brown Obsession and Compulsion Scale (Y-BOCS), Montgomery-Asberg Depression Rating Scale (MADRS), and Brief Psychiatric Rating Scale (BPRS) on the first, third, and sixth months.

Results

After the procedure, a 35% reduction was observed in the overall Y-BOCS scores, and full response rate was 50%. There was a 49.5% decrease in the MADRS scores and a 57.8% decrease in the BPRS.

Conclusion

GKRS is an effective and non-invasive procedure with favorable side effects in treatment-resistant OCD with selected patients.

Neuropsychological outcome in refractory obsessive-compulsive disorder treated with anterior capsulotomy including repeated surgery

AIM

Anterior capsulotomy (AC) is one of the last therapeutic options for obsessive-compulsive disorder (OCD) refractory to conservative treatments. Several forms of cognitive dysfunction have been identified after assessment of neuropsychological outcomes in OCD patients; however, few studies focused on cognitive changes in OCD patients after surgery. In the present study, we evaluated the effects of AC on cognitive performance and mood status in patients with refractory OCD.

METHODS

A total of 12 patients underwent bilateral AC between 2012 and 2019 at our institution. The patients (n = 12, female : male 5:7; mean age 39.7 years; duration ≥5 years) were assessed before and 6 months after intervention. The diagnosis of treatment-refractory OCD was based on recommended criteria for surgical treatment. Patients were assessed using a neuropsychological battery and questionnaires focused on anxiety-depressive symptomatology. The Yale-Brown Obsessive Compulsive Scale was administered as a measure of severity of OCD symptoms.

RESULTS

We detected a significant decrease of OCD, and anxiety and depressive symptomatology assessed by Yale-Brown Obsessive Compulsive Scale, Beck Depression Inventory, and Beck Anxiety Inventory (P < 0.05) 6 months after AC in eight patients, and a partial decrease in four patients. Four patients underwent repeated AC with more pronounced improvement achieved after the first procedure. We did not detect decline in cognitive performance in any patients, but did find better visual memory performance (P < 0.05).

CONCLUSION

AC reduced OCD and anxiety-depressive symptoms, and did not appear to influence cognitive performance, even after repeated surgery.

Case Report: Effect of Electroconvulsive Therapy on Obsessive-Compulsive Disorder Comorbid With Body Dysmorphic Disorder

Obsessive-compulsive disorder (OCD) is a chronic psychiatric condition that is associated with considerable morbidity, and ~90% of individuals with OCD have another psychiatric comorbidity. Patients with comorbid OCD and body dysmorphic disorder (BDD) have limited insight and poor psychosocial function, respond poorly to drug treatment, and have an increased risk of suicide. Modified electroconvulsive therapy (ECT) has been attempted to improve symptoms of OCD when drug treatment does not have a satisfactory effect. This report describes a patient who had OCD comorbid with BDD that was successfully treated with modified ECT. Although the mechanism of its effect is unclear, modified ECT may be an alternative treatment for patients with comorbid OCD and BDD. Its efficacy and mechanism of action require further investigation in a large sample of patients with these comorbid disorders.

Cognitive performance in children and adolescents at high-risk for obsessive-compulsive disorder

BACKGROUND

Cognitive performance has been studied in adults with obsessive-compulsive symptoms (OCS) and in adult relatives of patients with obsessive-compulsive disorder (OCD) Meanwhile, few studies have been conducted with children under the same conditions. This study compared the neurocognitive domains previously associated with dysfunction in OCD, especially visuoconstructive ability, visuospatial memory, executive functions, and intelligence, in children and adolescents at high risk (HR) for OCD (n = 18) and non-OCD controls (NOC) (n = 31).

METHODS

For the HR group, we considered the first-degree relatives of patients with OCD that present OCS, but do not meet diagnostic criteria for OCD. Psychiatric diagnosis was assessed by experienced clinicians using the Structured Clinical Interview for DSM-IV and OCS severity was measured by the Yale-Brown Obsessive-Compulsive Scale. Neurocognitive assessment was performed with a comprehensive neuropsychological battery. Performance on the cognitive domains was compared between groups using Multivariate Analysis of Variance, whereas performance on the neuropsychological variables was compared between groups using independent t-tests in a cognitive subdomain analysis.

RESULTS

The cognitive domain analysis revealed a trend towards significance for impairments in the motor and processing speed domain (p = 0.019; F = 3.12) in the HR group. Moreover, the cognitive subdomain analysis identified a statistically significant underperformance in spatial working memory in the HR group when compared to the NOC group (p = 0.005; t = - 2.94), and a trend towards significance for impairments in non-verbal memory and visuoconstructive tasks in the HR group.

CONCLUSIONS

Our results suggest impairments in spatial working memory and motor and processing speed in a non-clinical sample of HR participants. Considering the preliminary nature of our findings, further studies investigating these neurocognitive domains as potential predictors of pediatric OCD are warranted.

Results of Gamma Knife anterior capsulotomy for refractory obsessive-compulsive disorder: results in a series of 10 consecutive patients

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a severe psychiatric condition. The authors present their experience with Gamma Knife radiosurgery (GKRS) in the treatment of patients with OCD resistant to any medical therapy.

METHODS

Patients with severe OCD resistant to all pharmacological and psychiatric treatments who were treated with anterior GKRS capsulotomy were retrospectively reviewed. These patients were submitted to a physical, neurological, and neuropsychological examination together with structural and functional MRI before and after GKRS treatment. Strict study inclusion criteria were applied. Radiosurgical capsulotomy was performed using two 4-mm isocenters targeted at the midputaminal point of the anterior limb of the capsule. A maximal dose of 120 Gy was prescribed for each side. Clinical global changes were assessed using the Clinical Global Impression (CGI) scale, Global Assessment of Functioning (GAF) scale, EQ-5D, Beck Depression Inventory (BDI), and State-Trait Anxiety Inventory (STAI). OCD symptoms were determined by the Yale–Brown Obsessive Compulsive Scale (Y-BOCS).

RESULTS

Ten patients with medically refractory OCD (5 women and 5 men) treated between 2006 and 2015 were included in this study. Median age at diagnosis was 22 years, median duration of illness at the time of radiosurgery was 14.5 years, and median age at treatment was 38.8 years. Before GKRS, the median Y-BOCS score was 34.5 with a median obsession score of 18 and compulsion score of 17. Seven (70%) of 10 patients achieved a full response at their last follow-up, 2 patients were nonresponders, and 1 patient was a partial responder. Evaluation of the Y-BOCS, BDI, STAI-Trait, STAI-State, GAF, and EQ-5D showed statistically significant improvement at the last follow-up after GKRS. Neurological examinations were normal in all patients at each visit. At last follow-up, none of the patients had experienced any significant adverse neuropsychological effects or personality changes.

CONCLUSIONS

GKRS anterior capsulotomy is effective and well tolerated with a maximal dose of 120 Gy. It reduces both obsessions and compulsions, improves quality of life, and diminishes depression and anxiety.

Evolution of gamma knife capsulotomy for intractable obsessive-compulsive disorder

For more than half a century, stereotactic neurosurgical procedures have been available to treat patients with severe, debilitating symptoms of obsessive-compulsive disorder (OCD) that have proven refractory to extensive, appropriate pharmacological, and psychological treatment. Although reliable predictors of outcome remain elusive, the establishment of narrower selection criteria for neurosurgical candidacy, together with a better understanding of the functional neuroanatomy implicated in OCD, has resulted in improved clinical efficacy for an array of ablative and non-ablative intervention techniques targeting the cingulum, internal capsule, and other limbic regions. It was against this backdrop that gamma knife capsulotomy (GKC) for OCD was developed. In this paper, we review the history of this stereotactic radiosurgical procedure, from its inception to recent advances. We perform a systematic review of the existing literature and also provide a narrative account of the evolution of the procedure, detailing how the procedure has changed over time, and has been shaped by forces of evidence and innovation. As the procedure has evolved and adverse events have decreased considerably, favorable response rates have remained attainable for approximately one-half to two-thirds of individuals treated at experienced centers. A reduction in obsessive-compulsive symptom severity may result not only from direct modulation of OCD neural pathways but also from enhanced efficacy of pharmacological and psychological therapies working in a synergistic fashion with GKC. Possible complications include frontal lobe edema and even the rare formation of delayed radionecrotic cysts. These adverse events have become much less common with new radiation dose and targeting strategies. Detailed neuropsychological assessments from recent studies suggest that cognitive function is not impaired, and in some domains may even improve following treatment. We conclude this review with discussions covering topics essential for further progress of this therapy, including suggestions for future trial design given the unique features of GKC therapy, considerations for optimizing stereotactic targeting and dose planning using biophysical models, and the use of advanced imaging techniques to understand circuitry and predict response. GKC, and in particular its modern variant, gamma ventral capsulotomy, continues to be a reliable treatment option for selected cases of otherwise highly refractory OCD.

Obsessive-Compulsive Personality Symptoms Predict Poorer Response to Gamma Ventral Capsulotomy for Intractable OCD

Gamma ventral capsulotomy (GVC) is a radiosurgical procedure which aims to create lesions in the ventral part of the anterior limb of the internal capsule (ALIC). It has been used as a treatment option for patients with intractable obsessive-compulsive disorder (OCD) who do not respond to several first-line treatments attempts. However, changes in personality disorder symptoms after GVC have not been investigated. The aims of this study are to investigate changes in personality disorder symptoms after GVC and to search for baseline personality disorder symptoms that may predict clinical response to GVC. Fourteen treatment-intractable OCD patients who underwent GVC completed the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) at baseline and one year after the procedure. Wilcoxon signed-rank test was performed to investigate personality disorder symptom changes before and after surgery. Linear regression models were utilized to predict treatment response, using baseline personality disorder symptoms as independent variables. We did not observe any quantitative changes in personality disorder symptoms after GVC, compared with baseline. Higher severity of obsessive-compulsive personality disorder symptoms at baseline was correlated with worse treatment response after GVC for OCD (β = -0.085, t-value = -2.52, p-value = 0.027). These findings advocate for the safety of the GVC procedure in this specific population of intractable OCD patients, in terms of personality disorder symptom changes. They also highlight the importance of taking into account the severity of obsessive-compulsive personality disorder symptoms when GVC is indicated for intractable OCD patients.

Ablative neurosurgery and deep brain stimulation for obsessive-compulsive disorder

Despite advancements in pharmacotherapeutic and behavioral interventions, a substantial proportion of patients with obsessive-compulsive disorder (OCD) continue to have disabling and treatment-refractory illness. Neurosurgical interventions, including ablative procedures and deep brain stimulation (DBS), have emerged as potential treatment options in this population. We review the recent literature on contemporary surgical options for OCD, focusing on clinical aspects such as patient selection, presurgical assessment, and safety and effectiveness of these procedures. Given the invasiveness and limited evidence, these procedures have been performed in carefully selected patients with severe, chronic, and treatment-refractory illness. Along with informed consent, an independent review by a multidisciplinary team is mandated in many centers. Both ablative procedures and DBS have been found to be helpful in around half the patients, with improvement observed months after the procedure. Various targets have been proposed for either procedure, based on the dominant corticostriatal model of OCD. There is no strong evidence to recommend one procedure over the other. Hence, the choice of procedure is often based on the factors such as affordability, expertise, and reversibility of adverse effects. Surgery is not recommended as a standalone treatment but should be provided as part of a comprehensive package including medications and psychotherapeutic interventions. Available evidence suggest that the benefits of the procedure outweigh the risks in a treatment-refractory population. Advances in neurosurgical techniques and increasing knowledge of neurobiology are likely to bring about further progress in the efficacy, safety, and acceptability of the procedures.

A study of novel bilateral thermal capsulotomy with focused ultrasound for treatment-refractory obsessive-compulsive disorder: 2-year follow-up

BACKGROUND

Recently, a new thermal lesioning approach using magnetic-resonance-guided focused ultrasound (MRgFUS) was introduced for the treatment of neurologic disorders. However, only 2 studies have used this approach for treatment-refractory obsessive-compulsive disorder (OCD), and follow-up was short-term. We investigated the efficacy and safety of bilateral thermal lesioning of the anterior limb of the internal capsule using MRgFUS in patients with treatment-refractory OCD and followed them for 2 years.

METHODS

Eleven patients with treatment-refractory OCD were included in the study. Clinical outcomes were evaluated using the Yale-Brown Obsessive Compulsive Scale, the Clinical Global Impression scale (including improvement and severity), the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Rating Scale for Anxiety (HAM-A) at 1 week and 1, 3, 6, 12 and 24 months following MRgFUS. Neuropsychological functioning, Global Assessment of Functioning and adverse events were also assessed.

RESULTS

After MRgFUS, Yale-Brown Obsessive Compulsive Scale scores decreased significantly across the 24-month follow-up period (mean ± standard deviation, 34.4 ± 2.3 at baseline v. 21.3 ± 6.2 at 24 months, p < 0.001). Scores on the Hamilton rating scales for depression and anxiety also significantly decreased from baseline to 24 months (HAM-D, 19.0 ± 5.3 v. 7.6 ± 5.3, p < 0.001; HAM-A, 22.4 ± 5.9 v. 7.9 ± 3.9, p < 0.001). Global Assessment of Functioning scores improved significantly (35.8 ± 4.9 at baseline v. 56.0 ± 10.3 at 24 months, p < 0.001) and Memory Quotient significantly improved, but other neuropsychological functions were unchanged. The side effects of MRgFUS included headache and vestibular symptoms, but these were mild and transient.

LIMITATIONS

The main limitations of this study were the small sample size and the open-label design.

CONCLUSION

Bilateral thermal lesioning of the anterior limb of the internal capsule using MRgFUS may improve obsessive-compulsive, depressive and anxiety symptoms in patients with treatment-refractory OCD, without serious adverse effects.

Personality measures after gamma ventral capsulotomy in intractable OCD

BACKGROUND

Neurosurgeries such as gamma ventral capsulotomy (GVC) are an option for otherwise intractable obsessive-compulsive disorder (OCD) patients. In general, clinical and neuropsychological status both improve after GVC. However, its consequences on personality traits are not well-studied. The objective of this study was to investigate personality changes after one year of GVC in intractable OCD patients.

METHODS

The personality assessment was conducted using the Revised NEO Personality Inventory (NEO PI-R) and Cloninger's Temperament and Character Inventory (TCI) in 14 intractable OCD patients before and one year after GVC. Comparisons of personality features between treatment responders (n=5) and non-responders (n=9) were performed. Multiple linear regression was also used for predicting changes in clinical and global functioning variables.

RESULTS

Overall, no deleterious effect was found in personality after GVC. Responders had a reduction in neuroticism (p=0.043) and an increase in extraversion (p=0.043). No significant changes were observed in non-responders. Increases in novelty seeking and self-directedness, and decreases in persistence and cooperativiness predicted OCD symptom improvement. Similary, improvement in functioning was also predicted by hgher novelty seeking and self-directedness after GVC, whereas better functioning was also associated with lower reward dependence and cooperativeness after surgery.

CONCLUSIONS

The pattern of changes in personality traits after GVC was generally towards that observed in nonclinical population, and does not raise safety concerns.

Mapping Compulsivity in the DSM-5 Obsessive Compulsive and Related Disorders: Cognitive Domains, Neural Circuitry, and Treatment

Compulsions are repetitive, stereotyped thoughts and behaviors designed to reduce harm. Growing evidence suggests that the neurocognitive mechanisms mediating behavioral inhibition (motor inhibition, cognitive inflexibility) reversal learning and habit formation (shift from goal-directed to habitual responding) contribute toward compulsive activity in a broad range of disorders. In obsessive compulsive disorder, distributed network perturbation appears focused around the prefrontal cortex, caudate, putamen, and associated neuro-circuitry. Obsessive compulsive disorder-related attentional set-shifting deficits correlated with reduced resting state functional connectivity between the dorsal caudate and the ventrolateral prefrontal cortex on neuroimaging. In contrast, experimental provocation of obsessive compulsive disorder symptoms reduced neural activation in brain regions implicated in goal-directed behavioral control (ventromedial prefrontal cortex, caudate) with concordant increased activation in regions implicated in habit learning (presupplementary motor area, putamen). The ventromedial prefrontal cortex plays a multifaceted role, integrating affective evaluative processes, flexible behavior, and fear learning. Findings from a neuroimaging study of Pavlovian fear reversal, in which obsessive compulsive disorder patients failed to flexibly update fear responses despite normal initial fear conditioning, suggest there is an absence of ventromedial prefrontal cortex safety signaling in obsessive compulsive disorder, which potentially undermines explicit contingency knowledge and may help to explain the link between cognitive inflexibility, fear, and anxiety processing in compulsive disorders such as obsessive compulsive disorder.

A register-based 13-year to 43-year follow-up of 70 patients with obsessive-compulsive disorder treated with capsulotomy

OBJECTIVES

Little is known about the long-term medical status of patients with severe obsessive-compulsive disorder (OCD) undergoing capsulotomy, a neurosurgical last-resort treatment. The present study used national registers to identify all operated patients with OCD in Sweden and evaluated their long-term medical status, including mortality, hospital admissions and psychotropic medication after capsulotomy for OCD.

DESIGN

Register-based long-term follow-up cohort study.

PARTICIPANTS

We used the procedural and diagnostic codes in the Swedish National Patient Register to define the study population between 1970 and March 2013. Verification by manual review of medical records of the indication for surgery in those identified by the register yielded the final study cohort of 70 patients, followed 13-43 years after surgery. The sensitivity of the case selection method was 86%.

OUTCOME MEASURES

We studied hospitalisation 5 years before and after surgery. Mortality data were derived from the Causes of Death Register. The Prescribed Drug Register was used to study psychotropic drug utilisation.

RESULTS

By March 2013, 29 of the 70 patients were deceased. Their mean age at the time of death was 68 years (SD=14). Two patients had committed suicide and one had died of suspected suicide. Seventy per cent had been admitted to a psychiatric ward in the 5 years preceding surgery, and 84% in the first five postoperative years. Seventy-five per cent of those alive in 2012 were prescribed at least two psychotropic medications, often at high doses, the most common being antidepressants.

CONCLUSIONS

Malignant OCD has a poor long-term prognosis. Patients who are candidates for surgery should be informed that, while OCD symptoms may be ameliorated with surgery, they should not expect long-term freedom from medication and psychiatric care.

A study of cognitive function in treatment-refractory obsessive-compulsive disorder treated with capsulotomy

OBJECTIVE Anterior capsulotomy (AC) is sometimes used as a last resort for treatment-refractory obsessive-compulsive disorder (OCD). Previous studies assessing neuropsychological outcomes in patients with OCD have identified several forms of cognitive dysfunction that are associated with the disease, but few have focused on changes in cognitive function in OCD patients who have undergone surgery. In the present study, the authors investigated the effects of AC on the cognitive function of patients with treatment-refractory OCD. METHODS The authors selected 14 patients with treatment-refractory OCD who had undergone bilateral AC between 2007 and 2013, 14 nonsurgically treated OCD patients, and 14 healthy control subjects for this study. The 3 groups were matched for sex, age, and education. Several neuropsychological tests, including Similarities and Block Design, which are subsets of the Wechsler Abbreviated Scale of Intelligence; Immediate and Delayed Logical Memory and Immediate and Delayed Visual Reproduction, which are subsets of the Wechsler Memory Scale-Revised; and Corrects, Categories, Perseverative Errors, Nonperseverative Errors, and Errors, subtests of the Wisconsin Card Sorting Test, were conducted in all 42 subjects at baseline and after AC, after nonsurgical treatment, or at 6-month intervals, as appropriate. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was used to measure OCD symptoms in all 28 OCD patients. RESULTS The Y-BOCS scores decreased significantly in both OCD groups during the 12-month follow-up period. Surgical patients showed higher levels of improvement in verbal memory, visual memory, visuospatial skills, and executive function than the nonsurgically treated OCD patients. CONCLUSIONS The findings of this study suggest that AC not only reduces OCD symptoms but also attenuates moderate cognitive deficits.

Association between cognitive impairments and obsessive-compulsive spectrum presentations following traumatic brain injury

This study examined the association between self-reported obsessive-compulsive spectrum symptomatology and cognitive performance in a sample of patients with traumatic brain injury (TBI). Twenty-four adults with a moderate-severe TBI accessing a community brain injury rehabilitation service were recruited. Age ranged between 19 and 69 years. Participants completed a battery of neuropsychological tasks assessing memory, executive functioning, and speed of information processing. Self-report questionnaires assessing obsessive-compulsive (OC) symptoms and obsessive-compulsive personality disorder (OCPD) traits were also completed. Correlational analyses revealed that deficits in cognitive flexibility were associated with greater self-reported OC symptomatology and severity. Greater OC symptom severity was significantly related to poorer performance on a visual memory task. Verbal memory and speed of information processing impairments were unrelated to OC symptoms. Performance on tasks of memory, executive functioning, and speed of information processing were not associated with OCPD traits. Overall, results indicate that greater OC symptomatology and severity were associated with specific neuropsychological functions (i.e., cognitive flexibility, visual memory). OCPD personality traits were unrelated to cognitive performance. Further research is needed to examine the potential causal relationship and longer-term interactions between cognitive sequelae and obsessive-compulsive spectrum presentations post-TBI.