Warren Alpert Medical School of Brown University, Providence, RI, USA; Mental Illness Research Education and Clinical Centers, Veterans Affairs Health Care System, San Francisco, CA, USA; Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA.
Department of Cognitive, Linguistic, and Psychological Sciences, Brown University, Providence, RI, USA.
Neuropsychologia. 2022 Jun 6;170:108211. doi: 10.1016/j.neuropsychologia.2022.108211. Epub 2022 Mar 18.
Obsessive-Compulsive Disorder (OCD) is a debilitating disorder causing marked distress and functional impairment. While advances in behavioral and pharmacotherapies have been effective for a majority of patients with OCD, 10-30% remain treatment refractory and severely impaired. For a subset of treatment-resistant individuals with the most severe and disabling (intractable) illness, gamma ventral capsulotomy (GVC) appears effective in reducing OCD symptoms and functional impairment. However, the effects of the ventral internal capsule lesion via GVC surgery on executive function in everyday life have been minimally investigated. Examining behavioral outcomes of GVC also provides a rare opportunity to probe the functional importance of the ventral prefrontal-subcortical connections of the internal capsule white matter tract in a relatively homogenous sample of patients with comparable white matter lesions. The present study investigated changes in frontally-mediated behaviors, measured by the Frontal Systems Behavior Scale (FrSBe), following GVC in 45 individuals with severe and otherwise intractable OCD, as rated by patients themselves and family members. Linear mixed effects models revealed a significant improvement in patient self-ratings on the FrSBe after surgery, while family ratings did not significantly change. Interestingly, improvement on the FrSBe for both self and family raters was significantly correlated with improvement in OCD symptomatology post-surgery, as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). At the group level, we found no evidence of decline in frontally-mediated behaviors assessed by the FrSBe as a result of focal white matter disconnection via GVC. However, we cannot rule out the possibility that placebo effects or compromised patient self-awareness or insight contributed to the significant improvement in self ratings. Our measures may also have limited sensitivity to more selective impairments that could result from a small lesion to the ventral internal capsule. The present study demonstrates the need for detailed investigation of cognitive and behavioral changes as important factors when considering GVC as a viable treatment option for patients with refractory OCD.
强迫症（OCD）是一种使人衰弱的疾病，会引起明显的痛苦和功能障碍。虽然行为和药物治疗的进步对大多数 OCD 患者有效，但仍有 10-30%的患者对治疗无反应，且病情严重。对于一部分对治疗有抵抗性的、病情最严重和最致残（难治性）的患者，腹侧壳核切开术（GVC）似乎可以有效减轻 OCD 症状和功能障碍。然而，通过 GVC 手术对内囊腹侧的损伤对日常生活中的执行功能的影响却很少被研究。检查 GVC 的行为结果也为研究在一个具有相似的白质损伤的相对同质的患者群体中，内囊白质束的腹侧前额皮质-皮质下连接的功能重要性提供了一个难得的机会。本研究调查了 45 名严重且其他方面难治性强迫症患者接受 GVC 治疗后，通过额叶系统行为量表（FrSBe）测量的额叶介导行为的变化，这些患者的自我和家庭成员都对其进行了评估。线性混合效应模型显示，手术后患者自我评分的 FrSBe 显著改善，而家庭成员评分没有显著变化。有趣的是，自我和家庭成员评分的 FrSBe 改善与手术后 OCD 症状的改善显著相关，如耶鲁-布朗强迫量表（Y-BOCS）所测量的。在群体水平上，我们没有发现由于通过 GVC 导致的焦点白质连接中断而导致的 FrSBe 评估的额叶介导行为下降的证据。然而，我们不能排除安慰剂效应或患者自我意识或洞察力受损导致自我评分显著改善的可能性。我们的测量方法可能也对由于腹侧内囊的小损伤而导致的更选择性的损伤不太敏感。本研究表明，需要详细研究认知和行为变化，将其作为考虑将 GVC 作为难治性 OCD 患者可行治疗选择的重要因素。
