[Show abstract][Hide abstract] ABSTRACT: Background
Obsessive-compulsive disorder is one of the most disabling of all psychiatric illnesses. Despite available pharmacological and psychotherapeutic treatments about 10% of patients remain severely affected and are considered treatment-refractory. For some of these patients deep brain stimulation offers an appropriate treatment method. The scope of this article is to review the published data and to compare different target structures and their effectiveness.Methods
PubMed search, last update June 2013, was conducted using the terms ¿deep brain stimulation¿ and ¿obsessive compulsive disorder¿.ResultsIn total 25 studies were found that reported five deep brain stimulation target structures to treat obsessive-compulsive disorder: the anterior limb of the internal capsule (five studies including 14 patients), nucleus accumbens (eight studies including 37 patients), ventral capsule/ventral striatum (four studies including 29 patients), subthalamic nucleus (five studies including 23 patients) and inferior thalamic peduncle (two studies including 6 patients). Despite the anatomical diversity, deep brain stimulation treatment results in similar response rates for the first four target structures. Inferior thalamic peduncle deep brain stimulation results in higher response rates but these results have to be interpreted with caution due to a very small number of cases. Procedure and device related adverse events are relatively low, as well as stimulation or therapy related side effects. Most stimulation related side effects are transient and decline after stimulation parameters have been changed.Conclusion
Deep brain stimulation in treatment-refractory obsessive-compulsive disorder seems to be a relatively safe and promising treatment option. However, based on these studies no superior target structure could be identified. More research is needed to better understand mechanisms of action and response predictors that may help to develop a more personalized approach for these severely affected obsessive compulsive patients.
[Show abstract][Hide abstract] ABSTRACT: Deep brain stimulation (DBS) has been shown to be an efficacious treatment for many neurological conditions and has thus been expanded to psychiatric diseases as well. Following an introduction on the history of DBS in psychiatry, this review summarizes commonly raised ethical concerns and questions on clinical trial design, selection of patients, informed consent and concerns about the possible impact of DBS on an individual's personality. Finally, it highlights the fact that critique on DBS in psychiatry is probably not selectively based on scientific concerns about potential risks; instead, the neurobiological origin of specific psychiatric disorders has been questioned.
[Show abstract][Hide abstract] ABSTRACT: Postmortem and positron emission tomography studies have indicated the pathophysiological involvement of microglial cells in schizophrenia. We hypothesized that the microglial production of quinolinic acid (QUIN), an endogenous N-methyl-D-aspartate receptor (NMDAR) agonist, may be linked to the previously described glutamatergic deficits in the hippocampus of schizophrenia patients. We performed a semi-quantitative assessment of QUIN-immunoreactive microglial cells in schizophrenia patients and matched controls in the CA1, CA2/3, and dentate gyrus (DG) area of the posterior hippocampal formation. Complementary immunostaining of the commonly used microglial surface marker HLA-DR was performed in adjacent histological sections. Fewer QUIN-immunoreactive microglial cells were observed in the CA1 hippocampal subregion of schizophrenia patients compared to controls (left p = 0.028, right p = 0.018). No significant diagnosis-dependent changes were observed in the CA2/3 and DG regions. These results were controlled for potential confounds by age, duration of disease, autolysis time, psychotropic medication, and hippocampal volume. No diagnosis-related differences were observed for the overall density of microglial cells (HLA-DR expression). Our findings suggest that reduced microglial QUIN content in the hippocampal CA1 region is associated with schizophrenia. We hypothesize that this association may contribute to impaired glutamatergic neurotransmission in the hippocampus of schizophrenia patients.
Brain Behavior and Immunity 05/2014; · 5.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Increased S100B serum levels have been considered as a marker of glial pathology, brain damage, and blood–brain-barrier impairment. However, S100B expression has also been detected outside the nervous system, suggesting that altered S100B serum levels may not exclusively reflect brain-specific pathologies. Notably, S100B secretion in adipocytes seems to be down-regulated by insulin, and up-regulated by stress and fasting. Therefore, we assumed that dynamic changes of S100B could be observed by challenging healthy subjects with an oral glucose tolerance test (OGTT).
OGTT was performed in 17 healthy adult test persons (9 male and 8 female). Apart from S100B, glucose, free fatty acids, insulin, C-peptide, and cortisol were determined in all samples after an overnight fast (0 h), as well as 1 h and 2 h after ingestion of 75 g glucose.
Mean S100B concentrations decreased about 20% during the first hour after glucose ingestion (P < 0.001). This decrease of S100B levels was not related to the declining morning peak of cortisol. However, the decrease of serum-S100B 1 h after glucose ingestion correlated inversely with the respective changes of serum-insulin (r = −0.484, P = 0.049) and serum-C-peptide (r = −0.570, P = 0.017).
Our study suggests an inverse correlation between insulin secretion and S100B release after a standardized OGTT. Additional experiments, including the administration of insulin and the measurement of other food intake-related factors are important to ascertain an insulin-regulated S100B release in vivo. To improve comparability between clinical studies assessing conditions with rather mild changes of serum S100B, blood should be taken in a more standardized way (e.g., after fasting overnight).
[Show abstract][Hide abstract] ABSTRACT: Increased S100B serum levels have been considered as a marker of glial pathology, brain damage, and blood-brain-barrier impairment. However, S100B expression has also been detected outside the nervous system, suggesting that altered S100B serum levels may not exclusively reflect brain-specific pathologies. Notably, S100B secretion in adipocytes seems to be down-regulated by insulin, and up-regulated by stress and fasting. Therefore, we assumed that dynamic changes of S100B could be observed by challenging healthy subjects with an oral glucose tolerance test (OGTT). OGTT was performed in 17 healthy adult test persons (9 male and 8 female). Apart from S100B, glucose, free fatty acids, insulin, C-peptide, and cortisol were determined in all samples after an overnight fast (0h), as well as 1h and 2h after ingestion of 75g glucose. Mean S100B concentrations decreased about 20% during the first hour after glucose ingestion (P<0.001). This decrease of S100B levels was not related to the declining morning peak of cortisol. However, the decrease of serum-S100B 1h after glucose ingestion correlated inversely with the respective changes of serum-insulin (r=-0.484, P=0.049) and serum-C-peptide (r=-0.570, P=0.017). Our study suggests an inverse correlation between insulin secretion and S100B release after a standardized OGTT. Additional experiments, including the administration of insulin and the measurement of other food intake-related factors are important to ascertain an insulin-regulated S100B release in vivo. To improve comparability between clinical studies assessing conditions with rather mild changes of serum S100B, blood should be taken in a more standardized way (e.g., after fasting overnight).
[Show abstract][Hide abstract] ABSTRACT: Despite novel medications and other therapeutic strategies, addiction to psychotropic substances remains one of the most serious public health problems worldwide. In this review, beginning with an introduction of deep brain stimulation (DBS), we highlight the importance of the nucleus accumbens (NAc) in the context of the reward circuitry and addictive behavior. We will provide a short historic overview of other neurosurgical approaches to treat addiction and describe the experimental and preclinical data on DBS in addiction. Finally, we call attention to key ethical issues related to using DBS to treat addiction that are important for future research and the design of clinical trials.
Annals of the New York Academy of Sciences 12/2012; · 4.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Impaired glucose metabolism and the development of metabolic syndrome contribute to a reduction in the average life expectancy of individuals with schizophrenia. It is unclear whether this association simply reflects an unhealthy lifestyle or whether weight gain and impaired glucose tolerance in patients with schizophrenia are directly attributable to the side effects of atypical antipsychotic medications or disease-inherent derangements. In addition, numerous previous studies have highlighted alterations in the immune system of patients with schizophrenia. Increased concentrations of interleukin (IL)-1, IL-6, and transforming growth factor-beta (TGF-β) appear to be state markers, whereas IL-12, interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), and soluble IL-2 receptor (sIL-2R) appear to be trait markers of schizophrenia. Moreover, the mononuclear phagocyte system (MPS) and microglial activation are involved in the early course of the disease. This review illustrates a "chicken-egg dilemma", as it is currently unclear whether impaired cerebral glucose utilization leads to secondary disturbances in peripheral glucose metabolism, an increased risk of cardiovascular complications, and accompanying proinflammatory changes in patients with schizophrenia or whether immune mechanisms may be involved in the initial pathogenesis of schizophrenia, which leads to disturbances in glucose metabolism such as metabolic syndrome. Alternatively, shared underlying factors may be responsible for the co-occurrence of immune system and glucose metabolism disturbances in schizophrenia.
Progress in Neuro-Psychopharmacology and Biological Psychiatry 10/2012; · 3.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Certain cytokines have been identified in the peripheral blood as trait markers of schizophrenia, while others are considered relapse-related state markers. Furthermore, data from peripheral blood, cerebrospinal fluid (CSF) and nuclear imaging studies suggest that (1) blood-brain barrier (BBB) dysfunction (e.g., immigration of lymphocytes into brain tissue and intrathecal antibody production) correlates with the development of negative symptoms, while (2) the brain's mononuclear phagocyte system (microglial cells) is activated during acute psychosis. Based on these neuroinflammatory hypotheses, we have quantified the numerical density of immunostained CD3+ T-lymphocytes, CD20+ B-lymphocytes, and HLA-DR+ microglial cells in the posterior hippocampus of 17 schizophrenia patients and 11 matched controls. Disease course-related immune alterations were considered by a separate analysis of residual (prevailing negative symptoms, n=7) and paranoid (prominent positive symptoms, n=10) schizophrenia cases. Higher densities of CD3+ and CD20+ lymphocytes were observed in residual versus paranoid schizophrenia (CD 3: left: P=0.047, right: P=0.038; CD20: left: P=0.020, right: P=0.010) and controls (CD3: left: P=0.057, right: P=0.069; CD20: left: P=0.008, right: P=0.006). In contrast, HLA-DR+ microglia were increased in paranoid schizophrenia versus residual schizophrenia (left: P=0.030, right: P=0.012). A similar trend emerged when this group was compared to controls (left: P=0.090, right: P=0.090). BBB impairment and infiltration of T cells and B cells may contribute to the pathophysiology of residual schizophrenia, while microglial activation seems to play a role in paranoid schizophrenia. The identification of diverse immune endophenotypes may facilitate the development of distinct anti-inflammatory schizophrenia therapies to normalize BBB function, (auto)antibody production or microglial activity.
Brain Behavior and Immunity 08/2012; 26(8):1273-9. · 5.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The consequences of chronic alcohol dependence cause important health and economic burdens worldwide. Relapse rates after standard treatment (medication and psychotherapy) are high. There is evidence from in vivo investigations and from studies in patients that the brain's reward system is critically involved in the development and maintenance of addictive behavior, suggesting that modification of this system could significantly improve the prognosis of addictive patients. Motivated by an accidental observation, we used the nucleus accumbens (NAc), which has a central position in the dopaminergic reward system for deep brain stimulation (DBS) of alcohol addiction. METHODS: We report our first experiences with NAc DBS for alcohol dependence and review the literature addressing the mechanisms leading to addiction. RESULTS: Five patients were treated off-label with bilateral NAc DBS for severe alcohol addiction (average follow-up 38 months). All patients experienced significant and ongoing improvement of craving. Two patients remained completely abstinent for more than 4 years. NAc stimulation was tolerated without permanent side effects. Simultaneous recording of local field potentials from the target area and surface electroencephalography while patients performed neuropsychological tasks gave a hint on the pivotal role of the NAc in processing alcohol-related cues. CONCLUSIONS: To our knowledge, the data presented here reflect the first attempt to treat alcohol-addicted patients with NAc DBS. Electrical NAc stimulation probably counterbalances the effect of drug-related stimuli triggering involuntarily drug-seeking behavior. Meanwhile, two prospective clinical studies using randomized, double-blind, and crossover stimulation protocols for DBS are underway to corroborate these preliminary results.
[Show abstract][Hide abstract] ABSTRACT: Several studies have provided evidence for increased S100B serum concentrations in schizophrenia. The pathophysiological significance of this finding is still uncertain because S100B is involved in many cellular mechanisms and is not astrocyte-specific as was previously assumed. S100B is also expressed by subsets of CD3+ CD8+ T cells and natural killer (NK) cells and may therefore be linked to the immune hypothesis of schizophrenia. We have quantified S100B+ CD3+ CD8+ T cells and NK cells by flow cytometry in the peripheral blood of 26 acutely ill schizophrenia cases and 32 matched controls. In parallel, S100B concentrations and the free cortisol index (FCI), a surrogate marker for stress axis activity, were determined in serum samples from the same blood draw. Psychopathology was monitored using the Positive and Negative Syndrome Scale (PANSS). The patient group had increased S100B+ NK cell counts (P=0.045), which correlated with the FCI (r=0.299, P=0.026) but not with the PANSS or the elevated (P=0.021) S100B serum concentrations. S100B+ CD3+ CD8+ T cell counts were not significantly changed in the patient group and did neither correlate with the FCI and PANSS, nor with S100B serum concentrations. In conclusion, despite the observation of an increase in S100B+ NK cells in schizophrenia patients, the lack of a correlation with serum S100B concentrations suggests that these cells are probably not a major source of S100B in the blood of schizophrenia patients. Notably, elevated S100B+ NK cell counts may be linked with stress axis activation.
Brain Behavior and Immunity 02/2012; 26(4):564-7. · 5.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The influence of bilateral deep brain stimulation (DBS) of the nucleus nucleus (NAcc) on the processing of reward in a gambling paradigm was investigated using H(2)[(15)O]-PET (positron emission tomography) in a 38-year-old man treated for severe alcohol addiction. Behavioral data analysis revealed a less risky, more careful choice behavior under active DBS compared to DBS switched off. PET showed win- and loss-related activations in the paracingulate cortex, temporal poles, precuneus and hippocampus under active DBS, brain areas that have been implicated in action monitoring and behavioral control. Except for the temporal pole these activations were not seen when DBS was deactivated. These findings suggest that DBS of the NAcc may act partially by improving behavioral control.
PLoS ONE 01/2012; 7(5):e36572. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recent meta-analyses showed consistently elevated levels of S100B in serum and cerebrospinal fluid of schizophrenic patients. This finding has been attributed to glial pathology because S100B is produced by astrocytes and oligodendrocytes. However, S100B may be likewise associated with schizophrenia-related disturbances in glial cell as well as adipocyte energy supply and glucose metabolism. The influence of antipsychotic drugs on S100B levels remains unclear, and some studies have suggested that treatment with these drugs may actually contribute to the elevated S100B levels observed in schizophrenic patients. In this study, we explored the effects of the typical antipsychotic haloperidol and the atypical prototype drug clozapine on the release of S100B by astrocytic C6 cells and oligodendrocytic OLN-93 cells. Because of the association between schizophrenia and disturbances in energy metabolism, we assessed the effects of these drugs under basal condition (BC) compared to serum and glucose deprivation (SGD). We found that treatment of C6 and OLN-93 cells with haloperidol and clozapine reduced the release of S100B from C6 and OLN-93 cells under BC and SGD in vitro at a tissue concentration corresponding to the assumed therapeutic dose range of these drugs. These data suggest that elevated levels of S100B in bodily fluids of schizophrenic patients are normalized rather than increased by the effects of antipsychotic drugs on glial cells.
[Show abstract][Hide abstract] ABSTRACT: The ventral striatum/nucleus accumbens (NAcc) has been implicated in the craving for drugs and alcohol which is a major reason for relapse of addicted people. Craving might be induced by drug-related cues. This suggests that disruption of craving-related neural activity in the NAcc may significantly reduce craving in alcohol-dependent patients. Here we report on preliminary clinical and neurophysiological evidence in three male patients who were treated with high frequency deep brain stimulation of the NAcc bilaterally. All three had been alcohol-dependent for many years, unable to abstain from drinking, and had experienced repeated relapses prior to the stimulation. After the operation, craving was greatly reduced and all three patients were able to abstain from drinking for extended periods of time. Immediately after the operation but prior to connection of the stimulation electrodes to the stimulator, local field potentials were obtained from the externalized cables in two patients while they performed cognitive tasks addressing action monitoring and incentive salience of drug-related cues. LFPs in the action monitoring task provided further evidence for a role of the NAcc in goal-directed behaviors. Importantly, alcohol-related cue stimuli in the incentive salience task modulated LFPs even though these cues were presented outside of the attentional focus. This implies that cue-related craving involves the NAcc and is highly automatic.
Frontiers in Human Neuroscience 01/2009; 3:22. · 2.91 Impact Factor