Allegheny General Hospital (AGH) has become the first hospital in the region and one of a select few medical centers in the country to offer deep brain stimulation as a treatment for patients with obsessive-compulsive disorder.
Neurosurgeon Donald Whiting, MD, performed the first case on May 21, 2010, implanting a “brain pacemaker” in a 57-year-old Mt. Lebanon woman who has struggled with obsessive-compulsive disorder (OCD) for most of her life.
“At Allegheny General, we’ve had great success using deep brain stimulation (DBS) to treat a variety of neurological symptoms particularly motion disorders such as Parkinson’s disease, essential tremor and dystonia,” said Dr.Whiting, MD, Vice Chairman of the Department of Neurosurgery at AGH and Surgical Director of its Center for Spasticity and Movement Disorders.
“Now that the FDA has approved the use of DBS for patients with severe OCD, we hope to use our expertise to provide relief to patients who truly have exhausted all conservative therapies for OCD.”
DBS uses a battery-operated medical device—similar to a heart pacemaker—to deliver electrical stimulation to targeted areas in the brain that control specific functions, such as movement or, in this case, behavioral impulses.
The DBS system consists of three components: the lead, the extension, and the neurostimulator. The lead, a thin, insulated wire, is inserted through a small opening in the skull and implanted in the anterior limb of the brain’s internal capsule. The extension is an insulated wire passed under the skin of the head, neck, and shoulder to connect the lead to the neurostimulator. The neurostimulator, which is the system’s battery, is implanted under the skin, usually near the collarbone.
Once the system is in place, electrical impulses are sent from the neurostimulator along the extension wire and the lead and into the brain. These impulses interfere with and block the electrical signals that cause OCD symptoms.
Obsessive–compulsive disorder is a mental disorder characterized by intrusive thoughts that produce anxiety (obsessions) and by repetitive behaviors aimed at reducing anxiety (compulsions).
The symptoms of this anxiety disorder may include actions such as repetitive hand-washing and nervous habits, including opening a door and closing it a certain number of times before one enters or leaves a room.
Medications can result in a meaningful change in symptoms for 40 to 60 percent of people with OCD and a significant amount of people respond well to a combination of medications and therapy, said Dr. Alicia Kaplan, a psychiatrist with specialized OCD training who serves on AGH’s multidisciplinary team to identify, treat and manage OCD patients undergoing deep brain stimulation.
“DBS is for patients who have failed multiple adequate treatment trials with medications used for OCD and cognitive behavioral therapy,” Kaplan said. “For these patients, the OCD is so severe that they have not had a meaningful response to such treatments.”
“Treatment-resistant OCD can be very debilitating to the point where the patient is often unable to keep a job or leave their house, which can really impact their overall functioning and social relationships,” Dr. Kaplan said.
Because DBS is intended only for a very specific subset of patients with the most severe cases of OCD, the Food and Drug Administration has permitted the system to be used in just 4,000 OCD patients nationwide.
Drs. Whiting and Kaplan are working with psychiatrist P.V. Nickell, neurosurgeon Michael Oh and Cindy Angle, RN, a DBS programming specialist, to monitor the first local OCD patient to undergo DBS. The team will make adjustments to the patient’s electrical stimulation levels until optimal results are achieved. A variety of electrodes located on the lead wire of the DBS system can be used in hundreds of different combinations to further localize and isolate stimulation of the brain.
Once adjustments yield the best combination for symptom relief – a process that can take months – patients with very severe OCD could see a 50- to 60 percent improvement in their symptoms, according to prior research studies.
“These patients can be stuck all day in their rituals,” Kaplan said. “If you can get a 25 to 30 percent improvement, it could be a great help to them. The main thing is really to see if we can make a change in their quality of life.”