Deep brain stimulation (DBS) is an effective treatment for patients with severe obsessive-compulsive disorder (OCD) who are refractory to therapy and medication. Unlike most conventional psychiatric treatments, DBS is a circuit-selective intervention uniquely influencing cognitive-behavioral symptoms in a personalized way. Implanted DBS leads contain multiple electrode contacts that can be separately activated for selective modulation of connected brain pathways. For OCD, the most often used target for lead placement is the anterior limb of the internal capsule (ALIC). Stimulation in this target allows for modulation of parallel white matter pathways connecting corticostriatal circuits (CSCs) involved in emotional, cognitive, or behavioral aspects of decision making. Personalized ALIC DBS would require measuring outcomes reflecting these circuit-selective decision-making functions that are not typically captured in clinical scales. In the current issue of Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, Schüller et al. (
1) investigated how DBS in the ALIC and nucleus accumbens influences impulsive decision making and related brain pathways in 15 patients with OCD. Patients performed the Cambridge Gambling Task during active and inactive DBS on 2 consecutive days. Active DBS increased impulsive decision making, as indicated by reduced risk adjustment, and increased delay aversion, which did not correlate with the clinical OCD outcomes of DBS. Previous studies have also reported increased decision impulsivity in patients treated with DBS independent of clinical benefits, or problematic impulsive behaviors as side effects of ALIC DBS (
- Schüller T.
- Kohl S.
- Dembek T.
- Tittgemeyer M.
- Huys D.
- Visser-Vandewalle V.
- et al.
Internal capsule/nucleus accumbens deep brain stimulation increases impulsive decision making in obsessive-compulsive disorder.
Biol Psychiatry Cogn Neurosci Neuroimaging. 2023; 8: 281-289
- Grassi G.
- Figee M.
- Ooms P.
- Righi L.
- Nakamae T.
- Pallanti S.
- et al.
Impulsivity and decision-making in obsessive-compulsive disorder after effective deep brain stimulation or treatment as usual.
CNS Spectr. 2018; 23: 333-339
3). This could suggest that ALIC DBS may help some but not all patients with OCD by promoting impulsive decision making. Schüller et al. also performed a structural (normative) connectivity analysis of impulsive decision making. Impulsivity was related to stimulation of a pathway between the medial and lateral prefrontal cortex and a specific set of neural structures, i.e., the subthalamic nucleus (STN), thalamus, and globus pallidus pars externa and interna. These structures are part of limbic and associative CSC pathways involved in inhibitory control and flexibility. Inhibitory high-frequency DBS of the suppressive indirect CSC may reduce inhibitory control and promote behavioral flexibility, which can be beneficial for individuals engaged in rigid compulsive behaviors but can promote problematic impulsivity in others. In line with this, in patients with Parkinson’s disease, ventral (anteromedial) STN DBS, which is also a treatment for OCD and within the same indirect CSC, enhances behavioral flexibility at the cost of impaired self-control when patients are faced with competing choices (
- Graat I.
- Mocking R.
- Figee M.
- Vulink N.
- de Koning P.
- Ooms P.
- et al.
Long-term outcome of deep brain stimulation of the ventral part of the anterior limb of the internal capsule in a cohort of 50 patients with treatment-refractory obsessive-compulsive disorder.
Biol Psychiatry. 2021; 90: 714-720
- Scherrer S.
- Smith A.H.
- Gowatsky J.
- Palmese C.A.
- Jimenez-Shahed J.
- Kopell B.H.
- et al.
Impulsivity and compulsivity after subthalamic deep brain stimulation for Parkinson’s disease.
Front Behav Neurosci. 2020; 14: 47
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- Internal capsule/nucleus accumbens deep brain stimulation increases impulsive decision making in obsessive-compulsive disorder.Biol Psychiatry Cogn Neurosci Neuroimaging. 2023; 8: 281-289
- Impulsivity and decision-making in obsessive-compulsive disorder after effective deep brain stimulation or treatment as usual.CNS Spectr. 2018; 23: 333-339
- Long-term outcome of deep brain stimulation of the ventral part of the anterior limb of the internal capsule in a cohort of 50 patients with treatment-refractory obsessive-compulsive disorder.Biol Psychiatry. 2021; 90: 714-720
- Impulsivity and compulsivity after subthalamic deep brain stimulation for Parkinson’s disease.Front Behav Neurosci. 2020; 14: 47
- Deep brain stimulation restores frontostriatal network activity in obsessive-compulsive disorder.Nat Neurosci. 2013; 16: 386-387
- A unified functional network target for deep brain stimulation in obsessive-compulsive disorder.Biol Psychiatry. 2021; 90: 701-713
- Replicable effects of deep brain stimulation for obsessive-compulsive disorder.Brain Stimul. 2021; 14: 1-3
- Hyperactivity of indirect pathway-projecting spiny projection neurons drives compulsive behavior.bioRxiv. 2022; https://doi.org/10.1101/2022.02.17.480966
- A multilevel computational characterization of endophenotypes in addiction.eNeuro. 2018; 5 (ENEURO.0151–18.2018)
- Changing pattern in the basal ganglia: Motor switching under reduced dopaminergic drive.Sci Rep. 2016; 623327
Accepted: January 12, 2023
Received: January 12, 2023
© 2023 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.
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- Internal Capsule/Nucleus Accumbens Deep Brain Stimulation Increases Impulsive Decision Making in Obsessive-Compulsive DisorderBiological Psychiatry: Cognitive Neuroscience and NeuroimagingVol. 8Issue 3
- PreviewDeep brain stimulation of the anterior limb of the internal capsule (ALIC)/nucleus accumbens is an effective treatment in patients with obsessive-compulsive disorder but may increase impulsive behavior. We aimed to investigate how active stimulation alters subdomains of impulsive decision making and whether respective effects depend on the location of stimulation sites.