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Obsessive-CompulsiveDisorder

OutlineofOCDLecture

•  Day1– WhatisOCD?– WhatcausesOCD?– HowdoyoutreatiteffecGvely?

•  Day2– WhatdoestypicalcourseofCBTlooklike?– Whatspecificskillswillyouuse?

WhatisObsessive-CompulsiveDisorder?

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ABriefHistory

•  ReportsofO/Csymptomsandcasestudiesdatethroughoutrecordedhistory– Michelangelo,MarGnLuther,Beethoven,NikolaTesla,HowardHughes,andothers

•  DSMconceptualizaGonisthemostinfluenGalatthisGme– Majorchangesfrom4thto5thediGon

DSM-5OperaGonalDefiniGonA.  Presenceofobsessions,compulsions,orboth:

•  Obsessionsasdefinedby(1)and(2):1.  Recurrentandpersistentthoughts,urges,orimages

thatareexperienced,atsomeGmeduringthedisturbance,asintrusiveandunwantedandthatinmostindividualscausemarkedanxietyordistress

2.  Thepersona\emptstoignoreorsuppresssuchthoughts,urges,orimages,ortoneutralizethemwithsomeotherthoughtoracGon(i.e.,byperformingacompulsion)

DSM-5OperaGonalDefiniGon

•  Compulsionsasdefinedby(1)and(2):1.  RepeGGvebehaviorsormentalactsthatthe

personfeelsdriventoperforminresponsetoanobsession,oraccordingtorulesthatmustbeappliedrigidly

2.  ThebehaviorsormentalactsareaimedatprevenGngorreducinganxietyordistress,orprevenGngsomedreadedeventorsituaGon;however,thesebehaviorsormentalactseitherarenotconnectedinarealisGcwaywithwhattheyaredesignedtoneutralizeorprevent,orareclearlyexcessive

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OperaGonalDefiniGon

B.  TheO/CareGmeconsuming(forexample,takemorethan1houraday)orcauseclinicallysignificantdistressorimpairmentinfuncGoning.

C.  TheO/CsymptomsarenotduetothedirectphysiologicaleffectsofasubstanceoraGMC

D.  Thecontentoftheobsessionsorcompulsionsisnotrestrictedtothesymptomsofanothermentaldisorder

OCDSpecifiers•  Goodorfairinsight:RecognizesthatOCDbeliefsaredefinitelyorprobablynottrue,orthattheymayormaynotbetrue

•  Poorinsight:ThinksOCDbeliefsareprobablytrue

•  Absentinsight/delusionalbeliefs:CompletelyconvincedOCDbeliefsaretrue

•  Tic-relatedOCD:TheindividualhasalifeGmehistoryofachronicGcdisorder

MostCommonObsessions

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CommonCompulsions

OCDSubtypes

•  Tic-relatedOCD– Mayaccountforupto40%ofpediatriccases– Oaenmale-dominated– Highincidenceofsymmetry/exactness/ordering– Lowercleaning/contaminaGon– HighratesoftrichoGllomaniaandDBDs

Leckmanetal.(2010)

OCDSubtypes

•  Early-onsetOCD– Pre-pubertalonsetofOCsymptoms– SimilarnatureofOCsymptoms– Dominatedbymales– SubstanGalporGonwillremitbyadulthood–  IncreasedriskofGcsandtrich– Confounded/overlappingwithGc-relatedOCD

Leckmanetal.(2010)

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OCDSymptomDimensions

•  Somedisagreementoverhowmanydimensionsarepresent

•  FactoranalyGcandlatentclassanalysismodelshavecomeupwithdifferentdimensions

•  Dimensionsappeartobetemporallystable

Abramowitzetal.(2009);Leckmanetal.(2010)

4-factor

• Hoarding• ContaminaGon/cleaning

• Symmetry/ordering• Forbiddenthoughts

5-factor

• Hoarding• ContaminaGon/cleaning

• Symmetry/ordering• Forbiddenthoughts• Over-responsibility

LCA

• Singlespectrumbasedonseverityornumberofendorsedsymptoms

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OCDPrevalence

•  Around1%inpediatricpopulaGon

•  Between2-3%intheadultpopulaGon– Largenumberof“sub-clinical”cases(5%)

•  96%+ofpaGentshavebothOandC

Abramowitzetal.(2009);Leckmanetal.(2010)

OCDCourse

•  Usuallygradualonset

•  Chronic,unremikngcourseifuntreated

•  SymptomscanchangeacrossGme,butwillrarelydisappear

Abramowitzetal.(2009);

GenderDifferences

•  Manymoremaleyoutharediagnosed,butnosexdifferencesinadults

•  Amongmen,hoardingassociatedwithGADandGcdisorders,butinwomenwithSAD,PTSD,BDD,nailbiGng,andskinpicking

Vesaga-Lopezetal.(2008)

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Comorbidity

•  Upto75%presentwithcomorbiddisorders

•  MostcommoninpediatricsareADHD,DBDs,depression,andotheranxietydisorders

•  PresenceofcomorbidspredictQoL,moresothanOCDseverity

Lacketal.(2009)

Comorbidity

•  DifferentprimaryO/Careassociatedwithcertainpa\ernsofcomorbidity– Symmetry/ordering:Tics,bipolar,OCPD,panic,agoraphobia

– ContaminaGon/cleaning:EaGngdisorder– Hoarding:Personalitydisorders,especiallyClusterC

•  MostprevalentadultcomorbidsareSAD,MDD,alcoholabuse

Leckmanetal.(2010)

ImpactofOCD

•  AlmostalladultsandchildrenwithOCDreportobsessionscausingsignificantdistress

•  PervasivedecreaseinQoLcomparedtocontrols

•  YouthshowproblemaGcpeerrelaGons,academicdifficulGes,andparGcipateinfewerrecreaGonalacGviGes

Lacketal.(2009);Fontenelleetal.(2010)

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ImpactofOCD

•  LowerQoLinpediatricfemales

•  Comparedtootheranxiety/unipolarmood:– Lesslikelytobemarried– Morelikelytobeunemployed– MorelikelytoreportimpairedsocialandoccupaGonalfuncGoning

Lacketal.(2009);Abramowitzetal.(2009)

CulturalAspectsofOCD

•  Similarepidemiologicalratescross-culturally

0%

1%

2%

3%

4%

5%

Hunga

ry

Puerto

Rico

United

States

Canad

a

New Zeal

and

German

y (Mun

ich)

Icelan

d

Caribb

ean

Korea

Iran

African

American

s

Hong K

ong

The N

etherl

ands

Taiwan

Ind

ia

German

y

Brazil

CulturalAspectsofOCD

•  Typesofsymptomsreportedinvariousculturesvariesli\le,butprevalencedoes– USBlacksmorelikelytoshowcontaminaGonissues,especiallyconcerninganimals

– MorereligiousChrisGansandMuslimsplacemoreimportanceoncontrollingtheirthoughts

– HighlevelsofscrupulosityinJewishpopulaGons

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WhatCausesOCD?AnEvoluGonarilyInformedBiopsychosocialModel

EGology

•  ThreeprimaryperspecGves– Psychological– Biological– EvoluGonarily

•  Thereisaneedtointegratetheseintoaevo-bio-psycho-socialmodel,tohelpwithamulG-levelunderstandingofOCD

PsychologicalCauses

•  Manynon-empiricalexplanaGonsputforthhistorically(demonpossession,psychoanalyGc)

•  Threeheavilyevidence-basedpsychtheories– Behavioral– CogniGve– CogniGve-behavioral

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Behavioral

•  BasedonMowrer’stwo-stagetheoryoffear

•  IndividualsfirstlearnanxietyviaaclassicalcondiGoningprocess,andthenitismaintainedviaoperantcondiGoning

•  NeutralsGmulusbecomesacondiGonedfearsGmulus,andthisfearisthenmaintainedvianegaGvereinforcement

NeutralsGmulus Noresponse

NeutralsGmulus

UncondiGonedfearresponse

UncondiGonedfearsGmulus

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NeutralsGmulus

NegaGvelyreinforcedbehavior

CondiGonedfearsGmulus

CogniGve

•  Obsessionsbeginwithanormalintrusivethought,whicheveryoneexperiences

•  Thisinteractswithapre-formedbeliefsystemcenteredaroundexaggeratedconcernsandhighexpectaGonsofnegaGveconsequences

•  Thisthenleadstomarkeddistressandanxiety

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CogniGve-Behavioral

•  Focusesonabi-direcGonalviewofbehaviorandcogniGons,bothofwhichinfluenceemoGon

•  ObsessionsiniGallyarisefromdysfuncGonalbeliefsthatsomeonehas

•  Causesunwantedintrusivethoughts(whicharenormal)tobeappraisedasthreateningorunacceptable,causingdistress

CogniGve-Behavioral

•  Distresscausesonetotryandreduceitviasometypeofescapeoravoidancebehavior

•  ThisinturnreinforcesthosemaladapGvebeliefs,perpetuaGngthecycle

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Trigger

IntrusiveThought

ThreateningAppraisal Distress

Compulsion ↓Anxiety

Decreaseinanxietyviacompulsionreinforcescompulsionandmakesobsessionmorelikelytoreoccur

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BiologicalCauses

•  Lotsofresearchoverpast20years,butmiredincontroversy

•  TwinstudiesshowrelaGvelystronginfluenceofgeneGcsonOCDdevelopment– Concordanceratesof50%indizygoGc,80-90%inmonozygoGc

GeneGcsofOCD

•  Molecularwork(viasegregaGon,linkage,andassociaGonstudies)hasbeeninconsistent

•  Recent,largescaleinternaGonalworkfailedtofindanySNPswithagenome-widesignificance

•  Pointstoneedfornewresearchmethods,perhapsexaminingepigeneGcexpression

StructuralBiology

•  Damagetobasalganglia,cingulatedgyrus,andtheprefrontalcortexallappeartohaveacausalinfluenceondevelopmentofOCD

•  DecreasedacGvityincaudatenucleusandorbitofrontalcortex

•  VolumereducGoninplanumpolareregion

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EvoluGonaryCauses

•  BothbiologicalandpsychologicalcomponentsofOCDappeartohaverootsinnormalfuncGoning

•  Assuch,OCDmaybeanexaggeratedversionofnormal,evoluGonarily-adapGvebehaviors

•  Responsesto“threats”areoveresGmated,overwhelminganindividual’sresources

O/CasAdapGveTraits?

•  AdapGvetraitshavefourhallmarks:

a)  HavealackofheritablevariaGonb)  Haveevidenceofgooddesignc)  Beevokedbyappropriatetriggersd)  Fitnessmustbereducedwhenitisabsent

•  OCDfitsallfour

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O/CasAdapGveTraits?

•  Proximally,pathologyshoulddevelopduetogeneGcorbiologicalbraindeficits

•  Basalgangliadamage,forinstance,leadstolackofbehavioralinhibiGon,decreasingexecuGvefuncGoningoverhabitualbehavior

O/CasAdapGveTraits?

•  RelaGvelyhigh,consistentprevalenceratesof1-3%cross-culturallysuggestsaspectsofOCDhavebeenselectedforinourpast

•  Oneproposedmechanisminvolvesourabilitytoimagineconsequencesofriskybehaviorswithouthavingtoengageinthem– Alsocausesustodevelopharmavoidancehabits

OCDacrossSpecies

•  Themostcommoncompulsionsappeartohaveanalogsinothermammalbehavior– HibernaGng– OrganizingandcollecGngfood– Grooming,cleaning– Nestbuilding

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FromFAPstoOCD

•  ThesefixedacGonpa\ernsthencombinedwithouruniquelyhumanmeta-cogniGveskills

•  Thisallowedustomentallyrepresentfutureevents,potenGallyexaggeraGngthemandthenrespondingaccordingly

AComprehensiveEGologicalModel

•  ConsideringnormaGve,adapGvebehaviorsandwhattheywouldlooklikewhendisruptedhelpstounderstandulGmaterootsofOCD

•  UnderstandingbiologicalaspectsgivesinsightintoaparGcularperson’svulnerabilitytodevelopingOCD

AComprehensiveEGologicalModel

•  KnowingthepsychologicalunderpinningsofOCDhelpstoprovidebothexplanatorypowerathigherlevelsandinformsintervenGons

•  CBTusingexposurewithresponseprevenGonandcogniGverestructuring– Causesbehavioral,cogniGve,andbiologicalchangesinpeoplewithOCD

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Trigger

IntrusiveThought

ThreateningAppraisal Distress

Compulsion ↓Anxiety

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Conclusions

•  AlthoughpeoplewantsimpleexplanaGonsforphenomena,realliferarelycooperates

•  WemustembraceamulG-levelexplanaGonofmentaldisordersthatencompassesevoluGonary,biological,andpsychologicalfactors

MediaCriGque#1

Evidence-basedTreatments

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PharmacologyforOCD

•  Overall,pharmacology(SRIs)showslargeeffectsizesinadults(0.91),but…– Mosttreatmentrespondersshowresiduals– Veryhighrelapserate(24-89%)

•  Onlymoderateeffectsizesinyouth(0.46)

Abramowitzetal.(2009)

PharmacologyforOCD

•  SRIscanbeadjunctedwithanGpsychoGcs,butonly1/3willrespond

•  PresenceofGcsappearstodecreaseSSRIeffectsinchildren,unclearinadults

•  OCDw/Gcsrespondsbe\ertoneurolepGcsthanOCDw/oGcs

Abramowitzetal.(2009);Leckmanetal.(2010)

StrengthofEvidenceforMedsMedica(on Type Adults Children

Clomipramine(Anafranil) TCA A B

Citalopram(Celexa) SSRI B C

Escitalopram(Lexapro) SSRI B D

FluoxeGne(Prozac) SSRI B A

Fluvoxamine(Luvox) SSRI A B

ParoxeGne(Paxil) SSRI A B

Sertraline(Zoloa) SSRI B A

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SSRI Optimize dose and duration

Add CBT Optimize dose and duration

Alternate SSRI Optimize dose and duration

Med Augmentation: SSRI + SGA vs CMI CMI + SGA vs SSRI

CMI Optimize dose and duration

Add DCS Alternate Med Augmentation:

SGA vs CMI vs glutamatergic agent

Monotherapies with less evidence

Med Augmentation with less evidence

rTMS

Continue effective treatment regimen for 1y, then taper

A Suggested Treatment Algorithm Based on Level of Evidence. Boxes indicate treatment option and arrows show suggested flow in the case of treatment failure. SSRI = selective serotonin reuptake inhibitor, CMI = clomipramine, CBT = cognitive behavior therapy, SGA = second generation antipsychotic, DCS = d-cycloserine, rTMS = repetitive transcranial magnetic stimulation.

CBTforOCD

•  Thetreatmentofchoice,forbothadultandchildOCD;superiortomedsalone

•  PrimarilyfocusesonEX/RP,whichhasshowneffectsizesof1.16-1.72(88-95%improve)

•  Low(12%)relapserate,butupto25%willdropoutpriortocompleGonoftreatment

CBTOutcomes

•  Thosewithhoardingsymptomsappeartorespondlesswelltotreatment

•  MayneedtoaddmoGvaGonalenhancementtechniquesforthosewhoarereluctanttoengageinexposures

•  GrouptherapyisaseffecGveasindividual

Abramowitzetal.(2009)

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CBTOutcomes

•  Thosewithcomorbiditypresenthigherseverity,butrespondequallywelltoEX/RP

•  Comorbidanxietyordepressivesymptomstendtoshowimprovementsaswell,evenifnotspecificallytargeted

Storchetal.(2010)

CBTOutcomes

CogniGve-BehavioralTherapyforObsessive-CompulsiveDisorder

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Childrenvs.Adults

•  Theoveralltreatment(course,methodsused,etc.)ishighlysimilar

•  Childrendotendtorequiremoresupportandscaffoldingfromparents

•  Nonetheless,bothyouthandadultsneedtohaveastrongsupportsysteminplacetoassistwiththerapyandhomework

OutlineofCBTTreatment

•  Typicallybetween10-16sessions

•  IncludesidenGfiedclientandandotherfamily/supportpersons(parents,spouse,etc.)

•  Fourprimarycomponents– PsychoeducaGon,developmentofafearhierarchy,exposureswithresponseprevenGon,cogniGvestrategies

Psycho

educaG

on

•  ProvideOCDinformaGon

• Correctmisa\ribuGons

• DifferenGatebetweenOCDandnon-OCD

• Describetreatmentprogram Pa

rent/Sup

portToo

ls • DifferenGala\enGon

• Modeling

•  Scaffolding ClientToo

ls •  LearntoexternalizeOCD

•  Learnhowtorateanxietylevels

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ConsideraGons

•  KeepinformaGonandacGviGesdevelopmentallyappropriate– Foryoungchildren(under8),theymaynotneed/benefitfromtheeducaGonporGon

– Olderchildrenandadolescents,however,shouldbeincluded

•  Delivertreatment“withtheclient”andnot“totheclient”

SessionSequence

•  AniniGalassessmentshouldbeconductedpriortotherapystarGng

•  Completeaclinicalinterviewandsymptommeasures

•  HelpsdeterminedifferenGalorcomorbiddiagnosesandimpactofOCDsymptomsonfuncGoning

Assessments

•  GoldstandardinassessmentsareclinicianinterviewslikeCY-BOCS&Y-BOCS

•  UsefultoassessimpactofOCDandfamilyaccommodaGonwithFAIS-C,COIS-R,FAS-SR

•  Quickself-reportofsymptomsforscreeningpurposescanuseC-FOCI,LOI-C,orOCI-R

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Session1

•  Resultsofassessment

•  ProvideeducaGonon–  EGologyandcourseofOCD–  Cormorbidity– OCDvsnon-OCDbehaviors

•  Giveoverviewoftreatmentprogram

•  Homework–dailyrecordofOCDsymptoms

Session2

•  Reviewpastsession

•  Startdevelopmentofhierarchy

•  Giveoverviewoftools

•  IntroducedifferenGala\enGonandrewardplan

•  Homework–TracktwoO/Csymptoms,preparerewardsandrewardschart

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Session3

•  Reviewlastweek

•  Introducechildtorewardprogram

•  ReviewOCDsymptomswithchild

•  Introducefeelingthermometer/SUDSandsymptomtracking(clienttools)

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Session3

•  Discusspraise&encouragementwithsupports

•  ReviewleveloffamilyinvolvementinandaccommodaGonofOCDsymptoms

•  Homework–Monitorsymptoms,startrewardchartfordoingso

•  Newhierarchy(bytherapistbetweensessions)

ExposureTechniques

•  ThecommonthreadineffecGveanxietytreatmentsishierarchy-basedexposuretasks

•  Controversyoverexactlywhyexposuretherapyworkssowellforanxiety

•  DoesnotrequireextensivepreparaGontobeeffecGveandlong-lasGng

Rosqvist(2005)

ExposureTechniques

•  BeginbyconstrucGngafearhierarchy1.  GeneratespecificfearedsituaGons2.  RatethemusingSubjecGveUnitsofDistress

•  ConGnuebyactuallydoingtheexposures,workingfromlowertohigherSUDssituaGons

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SampleFearHierarchy

OCRDHomework#2

•  Youwillnowcreateyourownfearhierarchies

•  Shouldincludeawiderangeoffearsand/orsituaGonsthataredistressing

•  UseSUDsraGngtodisGnguishandorderthehierarchy

Session4

•  Reviewlastweek

•  Problemsolvehomeworkorrewardprogram

•  ConGnuehierarchydevelopment

•  IntroducearguingwithOCD

•  Conductin-sessionexposure

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ExposureTypes

•  Imaginalexposuretasks– Oaenusedinthebeginning,orwhenthechildhasabstractworries/fears

– AllowsforpracGcingcopingskillsbeforeconfronGngtherealsituaGon

•  Invivoexposuretasks– Oaenfollowimaginalexposures,usea“liveandinperson”versionofthefearedsituaGon

Exposures•  Exposureoccurbothinandoutofsession

•  RequirescooperaGonofparentstofacilitatesuccessfulhomeworkexposures

•  Shouldbesimilartowhatisbeingdoneinsession,usingahierarchyandSUDsraGngs

•  InternalandexternalrewardsforsuccessfulexposurecompleGonshouldbediscussedbeforehand

Exposures

•  Idealexposuresareprolonged,repeated,andpreventtheuseofdistracGonbehaviors

•  SUDsdecreaseofatleast50%,withmorebeingbe\er

•  MayrequireshapinguptothemoredifficultsituaGons,intermsofbothGmeanduseofdistractors

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TherapistTasks

•  Realizelong-termbenefitsoutweighshort-termdistress,andcommunicatethiseffecGvetothefamily

•  WorkcollaboraGvelywiththechildandfamilytoplanandexecutetheexposures

•  Maintainrapportduringexposuresbybuildinguponpre-establishedrapport

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TherapistTasks

•  Donotallowavoidanceordistracterbehaviorsduringtheexposure

•  Modelinghowtoconductexposuresfortheparents,sothattheycanperformthemathome

•  BeflexibleandcreaGvewhendealingwithlessthanopGmalexposuresandresistance

ObstaclesfortheTherapist

•  I’mmakingmyclientmoreupset/anxious

•  It’sdifficulttoseepeopleindistress

•  CanbeemoGonallydrainingforsometherapists

•  Mayhavetodoexposuresthatyouarenotcomfortablewith

Session4

•  DiscussdifferenGala\enGonagain–especiallyignoring

•  ReviewfamilyinvolvementinOCDsymptoms

•  Problemsolvehomeworkcomplianceobstacles

•  Homework–EX/RPtaskcompleGon;familyuseposiGvea\enGonandignoring

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Session5

•  Reviewlastweek

•  Problemsolvehomeworktasks

•  Revisehierarchyofsymptoms

•  ReviewarguingwithOCD

•  Conductin-sessionexposure

Session5

•  Discussmodeling

•  Homework– Parental/spousemodeling,useofdifferenGala\enGon

– ClientcompletesEX/RPtask(s)eachday

Session6

•  Reviewlastweek

•  Problemsolvehomeworktasks

•  Reviewdisengagementefforts

•  Revisehierarchyofsymptoms&arguing

•  Introducescaffolding/coaching

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Scaffolding

•  Step1–Findoutclientchildfeelsandempathizewiththeclient

•  Step2–BrainstormwithclienthowtoapproachthesituaGon

•  Step3–ChooseopGonfromStep2andactonit

•  Step4–Evaluateandreward

Session6

•  Conductin-sessionexposure

•  Reviewscaffolding/coachingsteps

•  Homework– Parents/spouseusemodeling,DA,scaffolding,conGnuedisengagement,rewardtaskcompleGon

– ClientcompletesERPtask(s)eachday

Session7

•  Reviewpastweek

•  Problemsolvehomework

•  Reviewdisengagement

•  Revisehierarchyofsymptoms&checkarguing

•  Conductin-sessionexposuretocheckscaffolding

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Session7

•  ExpanduseofscaffoldingoutsideofEX/RPpracGcetasks

•  Homework– Encourageuseofallparental/spousetools– HavesupportsapplyscaffoldingoutsideplannedpracGceGmes

– ClientcompleteERPtask(s)eachday

Sessions8-10•  Reviewpastweek

•  Problemsolvehomework

•  Reviewdisengagement

•  Revisehierarchyofsymptoms&arguing

•  Conductin-sessionexposures

•  Homeworkassignments

FurtherSessions

•  Takeplacetwoweeksaaerprevioussessions

•  Similartosessions8-10

•  FocusonhowtohandleOCDfutureproblems– RelapseprevenGonstrategies– Dealingwithsymptomreappearance

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EndingTherapy

•  Sessionsshouldbespacedfurtherapart

•  Someclientsmayneedmoreboostersessionsthanothers

•  Planonhavinglong-termfollow-upvisitstocheckprogressandtroubleshoot

NovelTreatmentsforOCD

GivingTreatmentaBoost

•  CBTusingEX/RPisthegold-standard,followedbyamedicaGonregimen

•  But,some20%+ofpeoplewithOCDmaynotrespondfullytoEX/RP– Numberismuchhigherformeds

•  ThishasledtoaugmentaGonefforts

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VirtualReality

•  Hasbeenusedwheninvivoexposuresaren’tpossibleorfeasible

•  SGllinveryearlystagetreatment,butdevelopmentofcheaperVRandeasierprogrammingmayleadtorapidadvances

MoGvaGonalInterviewing

•  UsedtoenhancedesireforchangeandintrinsicmoGvaGon

•  SomewhatmixedevidencetosupporttheuseofMIinconjuncGonwithCBT– Researchweighsslightlyonthe“yes”sideinthatitseemstoenhanceoutcomes

Self-GuidedTreatment

•  LowlevelsoftreatmentseekingandlowlevelsofEX/RPtrainedprovidersmeanpooraccessinmanyareas

•  Severalcomputer-guidedintervenGonshavebeenfoundtobemoreeffecGvethanplacebos(althoughnotasgoodasinperson)

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NeurosurgicalIntervenGons

•  ThreeprimaryonesforOCD,usuallyasa“lastresort”opGon

•  StereotacGcablaGveneurosurgery– Usuallyananteriorcapsulotomy(alesionintheanteriorlimbofinternalcapsule)

NeurosurgicalIntervenGons

•  DeepbrainsGmulaGon– Delivershigh-frequencycurrenttoanteriorlimbofinternalcapsule,nucleusaccumbens,orsubtalamicnucleus

– Mostprominentandwell-testedopGon

•  RepeGGvetranscranialmagneGcsGmulaGon– Non-invasive,deliversweakelectricalsGmulaGontodorsolateralprefrontalcortexorsupplementarymotorcortex

MediaCriGque#2