Toward Personalized Deep Brain Stimulation for Obsessive-Compulsive Disorder.
Toward Personalized Deep Brain Stimulation for Obsessive-Compulsive Disorder.
复制标题
针对强迫症的个性化深部脑刺激。
DOI：
10.1016/j.bpsc.2023.01.004
复制
发表时间：
2023
期刊：
影响因子：
--
通讯作者：
Figee,Martijn
中科院分区：
文献类型：
--
作者：
Fiore,VincenzoG;Smith,AndrewH;Figee,Martijn
脑深部电刺激（DBS）是治疗和药物治疗难治性严重强迫症（OCD）患者的有效治疗方法。与大多数传统的精神病治疗不同，DBS是一种回路选择性干预，以个性化的方式独特地影响认知行为症状。植入的DBS电极导线包含多个电极触点，可以单独激活，以选择性调节连接的脑通路。对于强迫症，最常用的电极导线放置目标是内囊前肢（ALIC）。在这个目标的刺激允许调制平行的白色物质通路连接皮质纹状体电路（CSC）参与决策的情绪，认知或行为方面。个性化ALIC DBS需要测量反映这些电路选择性决策功能的结局，这些功能通常不会在临床量表中获得。在最新一期的生物精神病学：认知神经科学和神经成像，Schüller等人。(1)研究了15名强迫症患者ALIC和脑桥核中的DBS如何影响冲动决策和相关脑通路。患者在连续2天的活动和非活动DBS期间进行剑桥赌博任务。主动DBS增加了冲动决策，如风险调整减少和延迟厌恶增加所示，这与DBS的临床OCD结局无关。先前的研究也报告了接受DBS治疗的患者的决策冲动性增加，与临床获益无关，或有问题的冲动行为是ALIC DBS的副作用（2，3）。这可能表明ALIC DBS可能通过促进冲动决策来帮助一些但不是所有强迫症患者。Schüller等人还对冲动决策进行了结构（规范）连接分析。冲动性与内侧和外侧前额叶皮质和一组特定的神经结构（即丘脑底核、丘脑和苍白球内外部）之间的通路的刺激有关。这些结构是参与抑制控制和灵活性的边缘系统和联合CSC通路的一部分。抑制性间接CSC的抑制性高频DBS可能会减少抑制性控制并促进行为灵活性，这对从事刚性强迫行为的个体可能是有益的，但可能会促进其他人的问题冲动。与此相一致，在帕金森病患者中，腹侧（前内侧）DBS也是一种治疗强迫症的方法，在相同的间接CSC中，当患者面临竞争性选择时，以自我控制受损为代价增强了行为灵活性（4）。(1)符合对强迫症和相关强迫性障碍的基本假设以及如何最好地研究它们的更广泛的重新评估。DBS因果干扰人类特定脑区的独特能力先前已与功能成像相结合，确定DBS破坏位于更腹侧CSC的脑区之间的功能连接的能力（5）。通过功能成像检测到的区域间相关性反映了多突触回路活动的最终产物，Schüller等人的发现代表了对直接测定这些结构连接的日益重视。最相关的目前的工作，一个大型的最近的研究（N= 50）李等人。(6)定义了一个“反应束”，由DBS在临床上对强迫症有效时受到刺激的纤维组成。然后，这种反应道立即在一个新的患者队列中复制...
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 (2, 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, ie, 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 (4).This new work by Schüller et al.(1) fits into a broader re-evaluation of fundamental assumptions about OCD and related disorders of compulsivity and how they are best studied. The unique ability of DBS to causally perturb specific brain regions in humans has previously been combined with functional imaging, identifying the ability of DBS to disrupt functional connectivity between brain areas located in the more ventral CSC (5). Inter-region correlations detectable by functional imaging reflect the end product of activity in polysynaptic circuits, and the findings by Schüller et al. represent a growing emphasis on directly assaying these structural connections. Most relevant to the present work, a large recent study (N= 50) by Li et al.(6) defined a “response tract” consisting of the fibers that are stimulated when DBS is clinically effective for OCD. This response tract was then immediately replicated in a new patient cohort by …