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Obsessive-compulsive disorder (OCD) is a common psychiatric disorder with a lifetime prevalence of 1–3% and is associated with significant morbidity. Pharmacotherapy and Cognitive behavior therapy form the first line of treatment. However, around half of the patients with OCD do not respond to the above first-line treatments, necessitating the need for various augmentation strategies [
] and newer treatment modalities. Neuromodulation techniques such as transcranial direct current stimulation (tDCS) have shown promise as an add-on treatment for alleviating symptoms in various psychiatric disorders, including OCD [
The Cortico-striato-thalamo-cortical (CSTC) circuits are implicated in the pathophysiology of OCD; specific brain regions related to this circuit have been targeted for symptom amelioration. One such region is pre-SMA (supplementary motor area) [
Efficacy of pre-supplementary motor area transcranial direct current stimulation for treatment resistant obsessive compulsive disorder: a randomized, double blinded, sham controlled trial.
]. Pre-SMA is involved in response inhibition function. Hypoactivity of this region can lead to striatal hyperactivity due to disinhibition contributing to OC symptoms [
Efficacy of pre-supplementary motor area transcranial direct current stimulation for treatment resistant obsessive compulsive disorder: a randomized, double blinded, sham controlled trial.
In conventional tDCS, the larger electrodes (35 cm2 size) may lead to modulation of a wider cortical area. High definition tDCS (HD-tDCS) uses smaller ring electrodes (around 12 mm diameter) and can provide more focal with a dominant unipolar stimulation [
Utility of pre-supplementary motor area anodal high definition transcranial direct current stimulation for treatment resistant obsessive compulsive disorder.
]. Recently, an accelerated protocol for tDCS has been attempted for treating symptoms of Schizophrenia with an intersession interval of fewer than 30 minutes and 5 sessions in a day, showing promising results [
]. The accelerated protocol for conventional tDCS, along with the benefit of being less time-consuming has been suggested to have rapid and longer-lasting effects. We are unaware of any published report on the feasibility & clinical utility of accelerated protocol using high-definition tDCS. In this background, we describe the administration of accelerated HD-tDCS to a patient with treatment-resistant OCD that led to a rapid improvement in symptoms.
Mr. S. 29-year-old gentleman presented with OC symptoms with a total illness duration of 17 years. He had repetitive, intrusive unwanted thoughts of contamination, pathological doubts, blasphemy, and images associated with repetitive hand washing, checking, and counting. At the time of presentation, pathological doubts with rechecking and counting compulsions were the major distressing symptoms leading to significant socio-occupational dysfunction. The patient had previously failed adequate trials of fluvoxamine 600 mg/d, fluoxetine 60 mg/d, sertraline 200mg/d, and augmentation with risperidone 2mg/d. He had also received adequate sessions of exposure and response prevention therapy with moderate benefits. In view of persistent symptoms despite all these treatments, he was diagnosed to have treatment-resistant OCD.
Due to compelling personal circumstances, the patient requested for any new intervention that might help him to improve faster. Hence, an accelerated HD-tDCS therapeutic protocol was planned alongside (2-days prior to starting HD-tDCS) initiation of clomipramine 50mg/d and ondansetron 8mg/d with tapering doses of sertraline. HD-tDCS was delivered using central electrode over pre-SMA (FCz) [anode; +2mA] and 4 return electrodes over Fz, FC3, FC4 and CPz [cathode; −0.5 mA] for 2 days [Soterix 1x1 device with 4x1 HD-tDCS adaptor (https://soterixmedical.com/research)]. Five sessions were provided each day, each lasting 20 minutes with an intersession interval of 20 minutes. He tolerated the sessions very well with no adverse effects as assessed by a structured questionnaire [
]. There was a 50% reduction in the severity of OC symptoms as measured using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), with further improvement noted at 10th-day tele-follow-up (Fig. 1). This improvement persisted at 30th-day tele-follow-up.
Fig. 1Change in Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores following 2 days of accelerated HD-tDCS (at Baseline, Post-stimulation and at 10th day follow-up to the end of stimulation). (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)
We describe the first-time application to support the feasibility and clinical utility of an accelerated protocol using HD-tDCS as an add-on treatment leading to rapid and substantial clinical improvement in a patient with treatment-resistant OCD; furthermore, the clinical benefits were sustained during a short-term follow-up. Additionally, a briefer number of treatment days in this accelerated protocol avoids the logistic issues associated with longer treatment [
]. Further, the protocol was well tolerated without any adverse effects. While the recent change in medication may be considered a potential confounder in attributing the improvement to HD-tDCS, such rapid amelioration of symptoms is unlikely to be due to medications alone. Given the faster clinical improvement and good tolerance without any significant adverse effects, this single case observation encourages further systematic studies examining accelerated HD-tDCS in OCD.
Financial support
This study is supported by Department of Biotechnology (DBT) - Wellcome Trust India Alliance (IA/CRC/19/1/610005).
Contributions
VSS, SV & GV conceptualized the study. HP, SBN, LK, and HG were involved in clinical assessment and HD-tDCS administration. HP and SBN prepared the first draft. All authors reviewed and contributed to the final draft of the manuscript.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Declaration of competing interest
There are no potential conflicts of interest to report.
Acknowledgement
HP is supported by Department of Biotechnology(DBT) - Wellcome Trust India Alliance (IA/CRC/19/1/610005). SBN is supported by Indian Council of Medical Research (ICMR). VSS acknowledges the support of the India-Korea joint program cooperation of science and technology by the National Research Foundation (NRF) Korea (2020K1A3A1A68093469), the Ministry of Science and ICT (MSIT) Korea, and the Department of Biotechnology (India) (DBT/IC-12031(22)-ICD-DBT). SV is the recipient of a current Department of Biotechnology (DBT) -Wellcome Trust India Alliance Intermediate Clinical Fellowship (Grant number IA/CPHI/15/1/502026). GV acknowledges the support of the Department of Biotechnology (DBT) - Wellcome Trust India Alliance (IA/CRC/19/1/610005) and the Department of Biotechnology, Government of India (BT/HRD-NBA-NWB/38/2019-20(6)).
References
Arumugham S.S.
Reddy J.Y.C.
Augmentation strategies in obsessive–compulsive disorder.
Efficacy of pre-supplementary motor area transcranial direct current stimulation for treatment resistant obsessive compulsive disorder: a randomized, double blinded, sham controlled trial.
Utility of pre-supplementary motor area anodal high definition transcranial direct current stimulation for treatment resistant obsessive compulsive disorder.
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