A case of non-affective psychosis followed by extended response to non-stimulation in deep brain stimulation for obsessive-compulsive disorder

We present a case of acute onset of psychotic symptoms, without signs of hypomania, following DBS for intractable OCD in a patient with no prior history of psychosis or delusional beliefs. The patient was a male in his early 20s with a history of intractable OCD, receiving DBS of the ventral capsule/ventral striatum (VC/VS) implanted as part of a randomized clinical trial of DBS for OCD (NCT00640133). The study sought to investigate effectiveness of DBS as a treatment for intractable OCD, as preliminary data had shown promising therapeutic effects [1,2]. The patient’s OCD symptoms began at age 11, marked by exactness, thoroughness and perfectionism. His obsessions were accompanied by near constant doubt and a “need to know”, as well as, concerns about offending others, leading to excessive reassurance seeking. Prior to seeking DBS for OCD, he had received numerous conventional treatments without substantial symptom improvement, including trials of at least three serotonin reuptake inhibitors (SRI), one of which was clomipramine; all trials exceeded 6 months in length and were augmented with benzodiazepines (e.g., clonazepam). Dopamine antagonist augmentation was also tried. Cognitive behavior therapy, including exposure and response prevention, was tried over a period of many years, both in traditional weekly outpatient sessions as well as in a specialty residential treatment setting. At the time of his initial assessment for DBS, his OCD severity rated in the extreme range on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; baseline score 1⁄4 33). He had a history of depression but was not in a depressive episode at the time of initial evaluation for DBS. The surgery to implant the DBS device was unremarkable, and placement was verified by imaging (Fig. 1). Active stimulation was delivered to contact 2 (left) and contact 3 (right), both monopolar; contact points were chosen following post operative titration for most acute affective effect and stimulus optimization. At the patient’s nine-month follow-up, his OCD symptoms had improved