Update on neurosurgical treatment for obsessive compulsive disorder

Responses to pharmacotherapy and psychotherapy in obsessive-compulsive disorder (OCD) range from 60 to 80% of cases. However, a subset of OCD patients do not respond to adequately conducted treatment trials, leading to severe psychosocial impairment. Stereotactic surgery can be indicated then as the last resource. Five surgical techniques are available, with the following rates of global post-operative improvement: anterior capsulotomy (38-100%); anterior cingulotomy (27-57%); subcaudate tractotomy (33-67%); limbic leucotomy (61-69%), and central lateral thalamotomy/anterior medial pallidotomy (62.5%). The first technique can be conducted as a standard neurosurgery, as radiosurgery or as deep brain stimulation. In the standard neurosurgery neural circuits are interrupted by radiofrequency. In radiosurgery, an actinic lesion is provoked without opening the brain. Deep brain stimulation consists on implanting electrodes which are activated by stimulators. Literature reports a relatively low prevalence of adverse events and complications. Neuropsychological and personality changes are rarely reported. However, there is a lack of randomized controlled trials to prove efficacy and adverse events/complication issues among these surgical procedures. Concluding, there is a recent development in the neurosurgeries for severe psychiatric disorders in the direction of making them more efficacious and safer. These surgeries, when correctly indicated, can profoundly alleviate the suffering of severe OCD patients.O transtorno obsessivo-compulsivo (TOC) responde aos tratamentos habituais (fármacos e psicoterapia) em cerca de 60 a 80% dos casos. Existe, assim, uma parcela de pacientes resistente aos tratamentos usuais, mesmo que adequadamente conduzidos, com grave prejuízo psicossocial. Nestas situações, a neurocirurgia pode ser indicada. Existem cinco técnicas cirúrgicas disponíveis, com as seguintes taxas de melhora global pós-operatória: capsulotomia anterior (38 a 100%); cingulotomia anterior (27 a 57%); tractotomia subcaudado (33 a 67%); leucotomia límbica (61 a 69%) e talamotomia central lateral com palidotomia anteromedial (62,5%). A capsulotomia anterior pode ser realizada através de diferentes técnicas: neurocirurgia padrão, radiocirurgia ou estimulação cerebral profunda. Na neurocirurgia padrão, circuitos neurais são interrompidos por radiofreqüência via trepanação no crânio. Na radiocirurgia, uma lesão actínica é induzida sem a necessidade de abertura do crânio. A estimulação cerebral profunda consiste na implantação de eletrodos ativados a partir de estimuladores. A literatura indica taxas relativamente baixas de eventos adversos e complicações, sendo raramente descritas alterações neuropsicológicas e de personalidade. Cumpre ressaltar, no entanto, a falta de ensaios clínicos randomizados que comprovem a eficácia e investiguem os eventos adversos ou complicações dos procedimentos cirúrgicos acima mencionados. Concluindo, há um recente aprimoramento das neurocirurgias dos transtornos psiquiátricos graves no sentido de torná-las cada vez mais eficazes e seguras. Estas cirurgias, quando adequadamente indicadas, podem trazer alívio substancial ao sofrimento de pacientes com TOC grave.Universidade de São Paulo Faculdade de Medicina Departamento de PsiquiatriaInstituto de Radiocirurgia NeurológicaUniversidade Federal de São Paulo (UNIFESP) Departamento de PsiquiatriaUNIFESP, Depto. de PsiquiatriaSciEL

Cross validation with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Brazil: the 32 item hypomania symptom check-list, first Revision (HCI-32-R-1)

Background: Bipolar disorders are frequently diagnosed and treated as unipolar depression initially and accurate diagnosis is often delayed by 8 to 10 years. It has been demonstrated that the bipolar spectrum disorders are associated with notable disability and that the current diagnostic gold standard, the Structured Clinical Interview for DSM-IV (SCID) is not sufficiently sensitive to the diagnosis of hypomania or subthreshold manic states. There is a need for better and simpler ways to identify these conditions.Methods: Hirschfeld et al. (2000) developed and tested a self-report scale for bipolar disorder: the Mood Disorder Questionnaire (MDQ). Recently, another scale has been developed by Angst to assess hypomanic symptoms and to increase the detection of suspected and of manifest, but undertreated, cases of bipolar disorders. in this Brazilian study, 200 patients with the putative diagnosis of depression were interviewed using the Structured Clinical Interview for DSM-IV, Axis I Disorders Clinician Version (SCID-CV; First et al., 1997), as modified by Benazzi and Akiskal (2003) to increase the sensitivity to BP II disorders. Before the interview patients were screened by both HCI-32-R-1 and MDQ and asked to complete them.Results: the HCI-32-R-1 showed a sensitivity of 79.8% and a specificity of 60.5% for the cut-off of 14. A sensitivity of 68.1% and a specificity of 63% were obtained for the Mood Disorder Questionnaire for the cut-off of 7. Limitations: Although not showing a good specificity, the MDQ seems to be a useful instrument for the screening phase, in which it is important that cases are recognized. the HCI-32-R-1 does not distinguish between BP I and BP II disorders. the sample size of patients should be increased in further studies.Conclusions: the HCI-32-R-1 demonstrated two main factors identified as active-elated hypomania and risk-taking/irritable hypomania and showed to be a sensitive instrument for hypomanic symptoms. It is a simple and easy-to-use tool for the self-assessment of hypomanic symptoms and may be a valuable supplement to the clinician's interview. the Mood Disorder Questionnaire is a useful screening instrument for bipolar I, bipolar II disorders and other manifestations of bipolar spectrum. As such, this scale might increase the detection of under-treated cases of bipolar disorders. Further studies are needed to verify the accuracy of these tools in non-psychiatric settings and in the general population. (C) 2011 Elsevier B.V. All rights reserved.Universidade Federal de São Paulo, São Paulo, BrazilMil Hosp, Belo Horizonte, MG, BrazilUniversidade Federal de São Paulo, EPM, São Paulo, BrazilWeb of Scienc

Assessment of obsessive beliefs: Comparing individuals with obsessive-compulsive disorder to a medical sample

Cognitive behavior models for Obsessive-Compulsive Disorder (OCD) are based currently on the presence of specific beliefs associated with the disorder. Among these beliefs are inflated responsibility, concerns over thought-action fusion, and overimportance of thoughts. the aim of this study was to compare scores from the subscales of the Obsessive Beliefs Questionnaire (OBQ-87), developed by the Obsessive-Compulsive Cognitions Working Group (OCCWG, 2001), in 24 patients from an OCD clinic (OCD) and 24 patients from a Medical Clinic (MC) for ambulatory and chronic diseases. All OCD patients were diagnosed using the SCID, and the OCD portion of the SCID was used to rule out patients with OCD from the MC group. the Yale-Brown Obsessive-Compulsive Scale (YBOCS) and Dysfunctional Attitudes Scale (DAS) were also administered. the results indicated that, contrary to predictions, in the domains of Tolerance for Uncertainty, Threat estimation, Responsibility and Perfectionism, the MC group presented higher scores than the OCD group. the same findings occurred with DAS, which was significantly correlated with the OBQ. Possible explanations for these findings are discussed, as well as suggestions for future research with both groups. (C) 2010 Elsevier B.V. All rights reserved.Univ Sao Francisco, Programa Posgrad Strictosensu Psicol, Itatiba São Paulo, BrazilUniv Estadual Campinas, UNICAMP, Dept Genet, Campinas, SP, BrazilFordham Univ, Dept Psychol, Bronx, NY 10458 USAUniversidade Federal de São Paulo UNIFESP, Dept Psiquiatria, São Paulo, BrazilUniversidade Federal de São Paulo UNIFESP, Dept Psiquiatria, São Paulo, BrazilWeb of Scienc