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Brazilian Journal of Psychiatry

Print version ISSN 1516-4446On-line version ISSN 1809-452X

Rev. Bras. Psiquiatr. vol.37 no.2 São Paulo Apr./June 2015

https://doi.org/10.1590/1516-4446-2014-1581 

Letters to the Editors

New-onset panic attacks after deep brain stimulation of the nucleus accumbens in a patient with refractory obsessive-compulsive and bipolar disorders: a case report

Marcelo B. Sousa1 

Telmo Reis2 

Alexandre Reis2 

Paulo Belmonte-de-Abreu1  2  3 

1Psychiatry Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil

2Neurosurgery Service, Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil

3Department of Psychiatry, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil


New-onset panic attacks (PA) have been described in patients with obsessive-compulsive disorder (OCD) receiving deep brain stimulation (DBS), mostly during the intraoperative period or a few weeks after device implantation.1,2 We report the case of a 39-year-old, right-handed man with severe treatment-refractory OCD and bipolar disorder type I (BD-I), beginning at age 17 (without any other psychiatric disorder), who developed late-onset PA after DBS implant placement.

The patient presented with obsessions of doubt, cleaning, and disgusting thoughts accompanied by checking and cleaning compulsions, with an intense need for reassurance and avoidance. Due to poor response to multiple drugs and to cognitive-behavioral therapy (Table 1), the patient underwent surgical evaluation for DBS. Implantation was performed after the patient and relatives had signed an informed consent form and following authorization from the Federal Council of Medicine. At baseline, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 363 and the Beck Depression Inventory (BDI) score was 35.4

Table 1 Medications previously taken by the patient 

Medication Maximum dose (mg) Duration
Clozapine 400 15 years
Fluoxetine 80 14 years
Valproate 2000 3 years
Lithium 1200 16 years
Clomipramine 250 3 years
Sertraline 200 2 years
Paroxetine 80 1 year
Fluvoxamine 300 6 years
Citalopram 60 7 months
Haloperidol 5 6 months
Risperidone 6 3 years

Bilateral DBS electrodes were inserted through the anterior limb of the internal capsule into the nucleus accumbens (NAcc) near the anterior commissure (Figure 1). Intraoperative evaluation of the DBS electrodes was carried out using bipolar stimulation at each contact. Pulse width and stimulation frequency ranged from 90 to 210 µs and 100 to 180 Hz, respectively. Voltage varied between 0 and 4 V, while bilateral stimulation was 3+/0-, 3+/1-, 3+/2-, and 0+/3-. The patient did not notice any change in mood or anxiety during stimulation. Testing occurred for approximately 2 to 4 minutes at each setting and the voltage was turned off before testing each contact. The patient was discharged from the hospital with the DBS regulated at 4.2 V, 150 µs, 150 Hz both sides, LL 3+, zero and 1 Neg, RR 7+, 4 and 5 Neg. Final adjustment was performed after several trials with on-off checking. Five months after surgery, the patient had experienced significant improvement of both OCD (Y-BOCS = 17) and depression (BDI = 9). Suddenly, within 12 hours of a follow-up visit involving a parameter adjustment for better control of OCD symptoms (4 V, 180 µs, 120 Hz both sides, LL C+, zero and 1 [-], RR C+, 4 and 5 [-]), the patient began to have severe panic attacks, which were controlled after new adjustments in association with clonazepam 1 mg/day. The adjustments involved more ventral connectivity with bipolar stimulation, instead of a dorsal stimulation, and were performed because they elicited better OCD control, but possibly triggered PA. The device was turned off; however, due to patient request, it was immediately reset to the previous settings, thus limiting conclusions of causality.

Figure 1 Magnetic resonance imaging scan showing the deep brain stimulation electrodes (Medtronic model 3387) inserted bilaterally through the anterior limb of the internal capsule into the nucleus accumbens near the anterior commissure. Cartesian coordinates of the distal end of the deepest contact relative to the mid-commissural point were: left and right: 6 mm lateral to midline, 3 mm anterior to mid-commissural point, and in the anterior commissure-posterior commissure plane. 

Shapira et al. and Okun et al. only observed the occurrence of panic attacks by activating the most ventral contact that is located next to the NAcc.1,2 When this region was stimulated at contact zero, it probably caused amygdala activation, thus evoking the experience of panic.1,2 This may have occurred because of the role of the NAcc as an interface for limbic projections from the amygdala, hippocampus, and cingulate cortex, which receives input from dopaminergic-containing nuclei, while mediating the behavioral and affective changes induced by DBS.2,5 Additionally, the patient’s comorbid BD-I could have facilitated affective side effects with NAcc stimulation.

Disclosure

The authors report no conflicts of interest.

References

1. Shapira NA, Okun MS, Wint D, Foote KD, Byars JA, Bowers D, et al. Panic and fear induced by deep brain stimulation. J Neurol Neurosurg Psychiatry. 2006;77:410-2. [ Links ]

2. Okun MS, Mann G, Foote KD, Shapira NA, Bowers D, Springer U, et al. Deep brain stimulation in the internal capsule and nucleus accumbens region: responses observed during active and sham programming. J Neurol Neurosurg Psychiatry. 2007;78:310-4. [ Links ]

3. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46:1006-11. [ Links ]

4. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-71. [ Links ]

5. Gorman JM, Kent JM, Sullivan GM, Coplan JD. Neuroanatomical hypothesis of panic disorder, revised. Am J Psychiatry. 2000;157:493-505. [ Links ]

Received: October 10, 2014; Accepted: January 29, 2015

Corresponding author: MarceloB. Sousa, E-mail: mbasso@cpovo.net

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited.