Hoarding symptoms and prediction of poor response to limbic system surgery for treatment-refractory obsessive-compulsive disorder.
OBJECT.: Recent findings have suggested a correlation between obsessive-compulsive disorder (OCD) symptom dimensions and clinical outcome after limbic system surgery for treatment-refractory patients. Based on previous evidence that the hoarding dimension is associated with worse outcome in conventional treatments, and may have a neural substrate distinct from OCD, the authors examined a large sample of patients undergoing limbic surgery (40 with capsulotomy, 37 with cingulotomy) and investigated if symptom dimensions, in particular hoarding, could influence treatment outcome.


METHODS
Data from 77 patients from 3 different research centers at São Paulo (n = 17), Boston (n = 37), and Stockholm (n = 23) were analyzed. Dimensional Yale-Brown Obsessive Compulsive Scale (Y-BOCS; São Paulo) or Y-BOCS Symptom Checklist scores (Boston and Stockholm) were used to code the presence of 4 well-established symptom dimensions: forbidden thoughts, contamination/cleaning, symmetry/order, and hoarding. Reductions in YBOCS scores determined clinical outcome.


RESULTS
Mean Y-BOCS scores decreased 34.2% after surgery (95% CI 27.2%-41.3%), with a mean follow-up of 68.1 months. Patients with hoarding symptoms had a worse response to treatment (mean Y-BOCS decrease of 22.7% ± 25.9% vs 41.6% ± 32.2%, respectively; p = 0.006), with no significant effect of surgical modality (capsulotomy vs cingulotomy). Patients with forbidden thoughts apparently also had a worse response to treatment, but this effect was dependent upon the co-occurrence of the hoarding dimension. Only the negative influence of the hoarding dimension remained when an ANOVA model was performed, which also controlled for preoperative symptom severity.


CONCLUSIONS
The presence of hoarding symptoms prior to surgery was associated with worse clinical outcome after the interventions. Patients with OCD under consideration for ablative surgery should be carefully screened for hoarding symptoms or comorbid hoarding disorder. For these patients, the potentially reduced benefits of surgery need to be carefully considered against potential risks.
Department & Institute of Psychiatry, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil;
Andre F
AF
Gentil
Antonio C
AC
Lopes
Darin D
DD
Dougherty
Christian
C
Rück
David
D
Mataix-Cols
Teagan L
TL
Lukacs
Miguel M
MM
Canteras
Emad N
EN
Eskandar
K Johan
KJ
Larsson
Marcelo Q
MQ
Hoexter
Marcelo C
MC
Batistuzzo
Benjamin D
BD
Greenberg
Euripedes C
EC
Miguel
D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D000067836:Hoarding Disorder / Q000601:surgery*; D006801:Humans; D008032:Limbic System / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009771:Obsessive-Compulsive Disorder / Q000601:surgery*; D011612:Psychosurgery; D012720:Severity of Illness Index; D016896:Treatment Outcome; D055815:Young Adult
DBS = deep-brain stimulation; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition; DY-BOCS = Dimensional Y-BOCS; MGH = Massachusetts General Hospital; OCD = obsessive-compulsive disorder; STOCK = Stockholm; USPMS = University of São Paulo Medical School; Y-BOCS = Yale-Brown Obsessive Compulsive Scale; Y-BOCS-SC = Y-BOCS Symptom Checklist; anterior cingulotomy; capsulotomy; functional neurosurgery; hoarding; obsessive-compulsive disorder; radiosurgery