Belmonte-de-Abreu, Paulo Silva

Reis, Alexandre Macdonald

Reis, Telmo

Sousa, Marcelo Basso de

Brazilian Journal of Psychiatry

English

Lume 5.8

DisclosureThe authors report no conflicts of interest.References1 Neves FS, Malloy-Diniz LF, Romano-Silva MA, Aguiar GC, de MatosLO, Correa H. Is the serotonin transporter polymorphism (5-HTTLPR)a potential marker for suicidal behavior in bipolar disorder patients?J Affect Disord. 2010;125:98-102.2 Neves FS, Malloy-Diniz LF, Barbosa IG, Brasil PM, Corrêa H. Bipolar dis-order first episode and suicidal behavior: are there differences accordingto type of suicide attempt? Rev Bras Psiquiatr. 2009;31:114-8.3 Leverich GS, Post RM. Course of bipolar illness after history ofchildhood trauma. Lancet. 2006;367:1040-2.4 Grassi-Oliveira R, Stein LM, Pezzi JC. [Translation and contentvalidation of the Childhood Trauma Questionnaire into Portugueselanguage]. Rev Saude Publica. 2006;40:249-55.5 Labonté B, Turecki G. Epigenetic effects of childhood adversity inthe brain and suicide risk. In: Dwivedi Y, editor.The neurobiologicalbasis of suicide. Boca Raton: CRC Press; 2012. p.256-84.New-onset panic attacksafter deep brain stimulationof the nucleus accumbensin a patient with refractoryobsessive-compulsive andbipolar disorders: a casereportRev Bras Psiquiatr. 2015;37:182–183doi:10.1590/1516-4446-2014-1581New-onset panic attacks (PA) have been describedin patients with obsessive-compulsive disorder (OCD)receiving deep brain stimulation (DBS), mostly duringthe intraoperative period or a few weeks after deviceimplantation.1,2 We report the case of a 39-year-old, right-handed man with severe treatment-refractory OCD andbipolar disorder type I (BD-I), beginning at age 17 (withoutany other psychiatric disorder), who developed late-onsetPA after DBS implant placement.The patient presented with obsessions of doubt, cleaning,and disgusting thoughts accompanied by checking andcleaning compulsions, with an intense need for reassuranceand avoidance. Due to poor response to multiple drugsand to cognitive-behavioral therapy (Table 1), the patientunderwent surgical evaluation for DBS. Implantation wasperformed after the patient and relatives had signed aninformed consent form and following authorization from theFederal Council of Medicine. At baseline, the Yale-BrownObsessive Compulsive Scale (Y-BOCS) score was 363 andthe Beck Depression Inventory (BDI) score was 35.4Bilateral DBS electrodes were inserted through theanterior limb of the internal capsule into the nucleusaccumbens (NAcc) near the anterior commissure (Figure 1).Intraoperative evaluation of the DBS electrodes was carriedout using bipolar stimulation at each contact. Pulse widthand stimulation frequency ranged from 90 to 210 ms and100 to 180 Hz, respectively. Voltage varied between 0 and4 V, while bilateral stimulation was 3+/0-, 3+/1-, 3+/2-,and 0+/3-. The patient did not notice any change in moodor anxiety during stimulation. Testing occurred for approxi-mately 2 to 4 minutes at each setting and the voltage wasturned off before testing each contact. The patient wasdischarged from the hospital with the DBS regulated at4.2 V, 150 ms, 150 Hz both sides, LL 3+, zero and 1 Neg,RR 7+, 4 and 5 Neg. Final adjustment was performed afterseveral trials with on-off checking. Five months aftersurgery, the patient had experienced significant improve-ment of both OCD (Y-BOCS = 17) and depression(BDI = 9). Suddenly, within 12 hours of a follow-up visitinvolving a parameter adjustment for better control of OCDsymptoms (4 V, 180 ms, 120 Hz both sides, LL C+, zeroand 1 [-], RR C+, 4 and 5 [-]), the patient began to haveFigure 1 Magnetic resonance imaging scan showing the deepbrain stimulation electrodes (Medtronic model 3387) insertedbilaterally through the anterior limb of the internal capsule intothe nucleus accumbens near the anterior commissure.Cartesian coordinates of the distal end of the deepest contactrelative to the mid-commissural point were: left and right: 6 mmlateral to midline, 3 mm anterior to mid-commissural point, andin the anterior commissure-posterior commissure plane.Table 1 Medications previously taken by the patientMedication Maximum dose (mg) DurationClozapine 400 15 yearsFluoxetine 80 14 yearsValproate 2000 3 yearsLithium 1200 16 yearsClomipramine 250 3 yearsSertraline 200 2 yearsParoxetine 80 1 yearFluvoxamine 300 6 yearsCitalopram 60 7 monthsHaloperidol 5 6 monthsRisperidone 6 3 yearsRev Bras Psiquiatr. 2015;37(2)182 Letters to the Editorssevere panic attacks, which were controlled after newadjustments in association with clonazepam 1 mg/day. Theadjustments involved more ventral connectivity with bipolarstimulation, instead of a dorsal stimulation, and wereperformed because they elicited better OCD control, butpossibly triggered PA. The device was turned off; however,due to patient request, it was immediately reset to theprevious settings, thus limiting conclusions of causality.Shapira et al. and Okun et al. only observed theoccurrence of panic attacks by activating the most ventralcontact that is located next to the NAcc.1,2 When this regionwas stimulated at contact zero, it probably caused amygdalaactivation, thus evoking the experience of panic.1,2 This mayhave occurred because of the role of the NAcc asan interface for limbic projections from the amygdala,hippocampus, and cingulate cortex, which receives inputfrom dopaminergic-containing nuclei, while mediating thebehavioral and affective changes induced by DBS.2,5Additionally, the patient’s comorbid BD-I could havefacilitated affective side effects with NAcc stimulation.Marcelo B. Sousa,1 Telmo Reis,2 Alexandre Reis,2Paulo Belmonte-de-Abreu1,2,31Psychiatry Service, Hospital de Clı́nicas de Porto Alegre (HCPA),Porto Alegre, RS, Brazil. 2Neurosurgery Service, Hospital Moinhosde Vento (HMV), Porto Alegre, RS, Brazil.3Department of Psychiatry, School of Medicine, UniversidadeFederal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, BrazilSubmitted Oct 10 2014, accepted Jan 29 2015.DisclosureThe authors report no conflicts of interest.References1 Shapira NA, Okun MS, Wint D, Foote KD, Byars JA, Bowers D, et al.Panic and fear induced by deep brain stimulation. J Neurol NeurosurgPsychiatry. 2006;77:410-2.2 Okun MS, Mann G, Foote KD, Shapira NA, Bowers D, Springer U,et al. Deep brain stimulation in the internal capsule andnucleus accumbens region: responses observed during active andsham programming. J Neurol Neurosurg Psychiatry. 2007;78:310-4.3 Goodman WK, Price LH, Rasmussen SA, Mazure C, FleischmannRL, Hill CL, et al. The Yale-Brown Obsessive Compulsive Scale. I.Development, use, and reliability. Arch Gen Psychiatry. 1989;46:1006-11.4 Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventoryfor measuring depression. Arch Gen Psychiatry. 1961;4:561-71.5 Gorman JM, Kent JM, Sullivan GM, Coplan JD. Neuroanatomicalhypothesis of panic disorder, revised. Am J Psychiatry. 2000;157:493-505.Rev Bras Psiquiatr. 2015;37(2)Letters to the Editors 183

New-onset panic attacks after deep brain stimulation of the nucleus accumbens in a patient with refractory obsessive-compulsive and bipolar disorders : a case report

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New-onset panic attacks after deep brain stimulation of the nucleus accumbens in a patient with refractory obsessive-compulsive and bipolar disorders : a case report

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