INTRODUCTION
Obsessive-compulsive
disorder is one of anxiety disorders, which is characterized by obsessive
thoughts in addition to the compulsive acts to reduce tension and produce
anxiety if resisted. Compulsive act is repeated continuously, and can be
alienating and time-consuming to patient. The patient is aware of the
ridiculousness of the idea and the oddness of the compulsive act. One of the
main causes of this disorder is the biological factors; such as lack of
organization of the neurotransmitter Serotonin in brain cortex, as well as
irregular blood flow in some areas of the brain with strong hereditary factors,
in addition to the psychological and social factors that might lead to
affection with obsessive-compulsive disorder. Freud described the presence of
three defense mechanisms to determine the form of obsessive-compulsive
disorder, which are isolation, undoing and reaction formation.1
Multiple
methods used to manage obsessive-compulsive disorder according to severity of
illness and acceptance or resistance of patients to the treatment; as
traditional therapy including drugs like serotonin re-uptake inhibitors (SRIs)
and psychotherapy, including cognitive-behavioral therapy. Recently, surgery
and alert the brain using magnetic fields by repetitive transcrainial
magnetic stimulation
(rTMS) are used. rTMS is similar in action to Electroconvulsive Therapy (ECT),
while minimizing side effects of ECT such as memory loss, the possibility of
brain damage resulting from the convulsions that occur during and after the ECT
and there is no need for anesthesia.2-4
One of the most
important effects of rTMS is its effects on the neurotransmitter Serotonin and
increase the extracellular serotonin (5-HT).5,6
Aim of work: To
examine the effectiveness of repetitive transcranial magnetic stimulation
(rTMS) in the treatment of obsessive-compulsive Egyptians patients, in a
clinical study. Also to identify the better efficacy of using of this treatment
will be individually or combined with drug therapy.
MATERIALS
AND METHODS
Twenty Egyptian patients
diagnosed as obsessive-compulsive patients by DSM IV-TR 20007 and
Yale-Brown of Obsessive Compulsive Scale (Y-BOCS).8 Those Patients
were selected from the Psychiatric outpatient
clinic of Al-Hussein Hospital,
Al-Azhar University, Neuropsychiatry outpatient clinic of students hospital
Al-Azhar University and Neuropsychiatry outpatient clinic of Dar El-Shifa
Hospital. We excluded patients with history of any types of seizures and head
trauma.
Patients
were divided into two groups one for patients never received any type of
treatment before; newly diagnosed, group (A) and the other for patients on
medical treatment during the study group (B). The severity of the illness
before magnetic stimulation was assessed using Yale-Brown scale. In this study,
the selected area to be stimulated was the prefrontal area due to the increase
of metabolic activity and blood flow in the frontal lobes of the brain and
basal ganglia, especially the caudate and cingulum, the prefrontal area
considered as the closest area on the scalp to alert them magnetically.
Magnetic stimulation was directed to the left prefrontal area of the brain for
these patients, according to a study assumes that the use of magnetic
stimulation to the left side individually gives an impact on both sides of the
brain depending on the intensity of the alert was measured by functional
magnetic resonance (Interleaved BOLD fMRI).9
The transcranial
magnetic stimulation device used in the study is
MAGSTIM Rapid. It is located in the outpatient clinic of Neurology and
Psychiatry at the Al Doa’ah Hospital, and we used the 8-shaped or
butterfly-shape coil.
The
8-shaped coil placed on the left prefrontal area of the patient’s head, which
is determined by a 5 cm
forward and 2 cm
to the below the center of the head (Midline). In this study, repetitive
transcranial magnetic stimulation adjusted for all patients including motor
threshold (MT) 90%; 20Hz stimulation every 2 seconds for 20 minutes in 8
sessions every 48 hours. All patients signed a written consent to conduct
magnetic stimulation after being informed that the results of magnetic
stimulation on patients with obsessive-compulsive disorder may not lead to any
improvement in the medical condition.
We started with a
comprehensive medical history, medical examination and full psychological
history. All patients were diagnosed by DSM-IV TR 20007 criteria of
OCD and Yale-Brown Obsessive Compulsive scale8 before magnetic
stimulation to measure obsessive-compulsive symptoms and to determine the
severity of illness. The next step was applying repetitive transcranial
magnetic stimulation (rTMS) for eight sessions, then we re-evaluated the
patients again by Yale-Brown Obsessive Compulsive scale, together with clinical
interview.
Statistical
Analysis
The
collected data were computerized and statistically analyzed using SPSS program
(Statistical Package for Social Science) version 15.0. Qualitative data were
expressed as frequencies and percentages.
P-Value <0.05 was considered significant
RESULTS
The mean age of group (A) was 26.2±4.7 years, and 28.0±5.6
years in Group (B), with 70% in the third decade and 30% in the fourth decade.
The two groups had 55% (n=11) females and 45% (n=9) male. This difference may
be due to random sample, and therefore gender equality was not taken in
consideration. As for the relationship of age with severity of obsessive-compulsive
symptoms, we found that there is no statistical significance among them
(P>0.05). The marital status of the sample was 65% unmarried, 20% married,
10% divorced and 5% widowed, and there was no significant difference between
ratios among both groups (P>0.05). As for the relationship of severity of
the symptoms to marital status; with no statistical significance among groups
(P>0.05).
Family history was positive in 35% of patients either in
first or second-degree relatives. This emphasizes the hypothesis of hereditary
factor as one of the reasons for obsessive compulsive occurrence. As for the
relation of severity of the symptoms, and the family history, there was no
statistical significance between them (P>0.05). Twenty percent of patients
had parents of third-degree relatives’ marriage, and 30% had fourth-degree
relatives’ marriage; which can explained by socio-economic status and being
from areas where marriage within the same family is dramatically high.
By comparing the severity of symptoms (obsessions and
compulsions) between the groups (A) and (B) by Yale-Brown scale before the
magnetic stimulation, we found that there was no statistical significance
difference among them (P>0.05).
After applying rTMS to the two groups, In Group (A) obsessions
(14.4 ± 2.3) and compulsions (14.4 ± 1.6) changed to (13.1 ± 2.4), (10.6± 2.0)
after the stimulation with P-values (p<0.05), (p<0.01) (Table 1). In
Group (B) obsessions (12.3 ± 2.7) and compulsions (13.7 ± 2.5) changed to (10.3
± 2.6), (9.1± 2.4) after the stimulation with P-values (p<0.01), (p<0.01)
as shown in Table (2) That shows the obsessions and compulsions in the two
groups are reduced after the stimulation compared to that before the
stimulation on the Yale-Brown scale and was proved statistically.
Also by comparing the two groups in terms of response of
symptoms (obsessions and compulsions) to the magnetic stimulation, Group (A)
obsessions (13.1 ±2.4) and compulsions (10.6 ± 2.0), Group (B) obsessions (10.3
±2.6) and compulsions (9.10 ± 2.4) we found that the response in the two groups
is great and close as regards
compulsions (p>0.05), while group (B) had responded more than the first
group as regards obsessions (p<0.05). This means that the therapeutic effect
of the magnetic stimulation is better if combined with pharmacological
treatment, even though the effect of pharmacological treatment did not give
positive results before the stimulation (Table 3).
Table 1. he
difference before and after the magnetic stimulation in the obsessions and the
compulsions in group (A).
Variables
|
Group (A) N=10
|
Paired t-test
|
P-value
|
|
Before
|
After
|
|
|
|
Obsessions
|
14.4
± 2.3
|
13.1
± 2.4
|
2.62
|
0.028*
|
|
Compulsions
|
14.4
± 1.6
|
10.6±
2.0
|
6.04
|
0.000**
|
|
|
|
|
|
|
|
|
|
|
*Significant
at P<0.05 **Significant at P<0.01
Table 2. The
difference before and after the magnetic stimulation in the obsessions and the
compulsions in group (B).
Variables
|
Group (B) N=10
|
Paired t-test
|
P-value
|
Before
|
After
|
Obsessions
|
12.3
± 2.7
|
10.3
± 2.6
|
4.74
|
0.001*
|
Compulsions
|
13.7
± 2.5
|
9.1±
2.4
|
6.41
|
0.000*
|
* Significant
at P<0.01
Table 3. The
difference between the two groups in the obsessions and compulsions after the
magnetic stimulation.
Variables
|
Group (A) N=10
|
Group (B) N=10
|
t-test
|
P-value
|
After stimulation
|
Obsessions
|
13.1
±2.4
|
10.3
± 2.6
|
2.45
|
0.024*
|
Compulsions
|
10.6
± 2.0
|
9.10
± 2.4
|
1.50
|
0.149
|
* Significant
at P<0.05
DISCUSSION
In the post-sessions
interviews, most patients informed a decline in the response to compulsive
urge, yet none of them reported a satisfactory response to prevent compulsions
permanently.
By
Yale-Brown scale, we found that 9 cases (4 in group A and 5 in group B) had changed
their symptoms severity from (severe) to (moderate), as well as one patient in
group (B) changed the severity of his symptoms from (moderate) to (mild).
Therefore, half of the sample improved significantly while the other half did
not. The compulsive symptoms are reduced after the stimulation more than the
obsessive symptoms especially in group (B). Therefore, magnetic stimulation may
be useful in treatment of obsessive-compulsive disorder where compulsions
improved in the two groups (A) and (B) more than the obsessions, and it had
more therapeutic effect if pharmacological therapy was added. This is
consistent with the results of Greenberg10, Sachdev11 and
Mantovani12 and theirs colleagues; however, it is not with Alonso13
and Pridmore14 and their colleagues’ results.
In Greenberg and
colleagues study, there was only one session of rTMS, and they found that there
is an improvement in compulsive symptoms for a temporary period of time (eight
hours after the session) with no change obsessive symptoms. They also found
temporary elevation of mood but it did not last for a long time.10
It is clear from this study that the magnetic stimulation has an effect on the
symptoms of obsessive-compulsive disorder, but not enough to be used for only
one session. In this study, we used eight seasons, which is more accurate
statically. Sachdev and colleagues
observed improvement in the obsessions and the compulsions.11
However, there was no control sample through the (Sham arm), and therefore, the
therapeutic effect of rTMS in the study is uncertain.
Mantovani and colleagues
stated a statistically significant reduction of symptoms. Three of five
patients with obsessive-compulsive disorder showed improvement in the symptoms;
40% on a Yale-Brown scale and 60% on Clinical Global Impression scale (CGI) of
the total sample in the follow-up after 3 months.12 It could be
uncertain to use rTMS in conjunction with pharmacological treatment without the use of a
control sample, as this may not illustrates the effect of the magnetic
stimulation.
On
the other hand, Alonso and colleagues stated that there were no significant
difference between pre-and post-magnetic stimulation13, but they did
not use an effective motor threshold and also using the circular coil which
less effective than the 8-shaped coil.
In Pridmore and
colleagues study, there was no significant difference between effective and
Sham stimulations groups14, but there was a necessity to increase
the motor threshold (MT).
Conclusion
We concluded that patients with Obsessive-Compulsive Disorder (OCD) have better response to repetitive
transcranial magnetic stimulation for
obsession symptoms more than compulsions especially those on pharmacological
treatment.
[Disclosure: Authors
report no conflict of interest]
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الملخص العربي
التنبيه المغناطيسي المتكرر
عبر الجمجمة في علاج الوسواس القهري
تم استخدام التنبيه المغناطيسي المتكرر عبر
الجمجمة في علاج الوسواس القهري الذي يشبه الصدمات الكهربائية على المخ ولكن مع
تقليل من الآثار الجانبية. وللتنبيه المغناطيسي تأثير على الناقل العصبي السيروتونين
بزيادة تركيزه خارج الخلية والهدف من هذه الدراسة هو دراسة مدى فاعلية استخدام التنبيه
المغناطيسي المتكرر عبر الجمجمة في علاج مرضى الوسواس القهري وخاصة المصريين في
دراسة إكلينيكية. وكذلك تحديد فاعليته كعلاج لمرضي الوسواس القهري بشكل منفرد أم
مصحوبا بعلاج دوائي.
عينة الدراسة 20 مريضا مصريا (9 ذكور و11 انثي)
تم تشخيصهم بواسطة التشخيص الإحصائي الرابع المراجع 2000 ومقياس يل براون للوسواس القهري وتم تقسيمهم إلى مجموعتين
واحدة منهم تحت العلاج الدوائي أثناء التنبيه والأخرى حديثة التشخيص ولم تتعرض لأي
نوع من العلاج. والإحداثيات المستخدمة في الدراسة: عتبة تحفز ((MT بمقدار 90٪ وتنبيه بمقدار
20 هرتز لكل 2 ثانية لمدة 20
دقيقة وذلك في 8 جلسات منفصلة كل يوم ويوم.
النتائج:
1) بعد
إجراء التنبيه المغناطيسي المتكرر (rTMS) على المجموعتين محل الدراسة وجد أن الوساوس والمقهورات قلت في
المجموعتين بعد إجراء التنبيه عما ما كانت عليه قبل التنبيه على مقياس يل-براون
وتم إثبات ذلك إحصائيا
2) ومن خلال مقارنة المجموعتين من حيث استجابة
الأعراض (الوساوس والقهورات) للتنبيه المغناطيسي المتكرر وجد أن المجموعتين قد
استجابتا بشكل كبير ومتقارب في القهورات ولكن في الوساوس وجد أن المجموعة الثانية
(تحت العلاج الدوائي) قد استجابت بشكل أكبر من المجموعة الأولي وهذا يدل على أن
الأثر العلاجي للتنبيه المغناطيس المتكرر يعطي نتائج أفضل أذا كان مقترنا بالعلاج
الدوائي حتى وأن وكان أثر العلاج الدوائي غير واضح قبل إجراء التنبيه
ومن خلال المقابلات الإكلينيكية لجميع المرضي بعد جراء
التنبيه وجد أن:
1) جميعهم
قد قل لديهم الرغبة في الاستجابة القهورات لفترة تتجوز 4 ساعات تزداد بتكرار.
2) بمراجعة مقياس يل-براون لجميع الحالات قبل
وبعد إجراء التنبيه وجد أن هناك (9) حالات (4) منهم في المجموعة الأولي و (5) في
المجموعة الثانية تغيرت شدة الأعراض لديهم من أعراض شديدة الي متوسطة وحالة واحدة
في المجموعة الثانية تغيرت شدة الأعراض لديها من متوسطة إلى خفيفة وهذا يعني تحسن
نصف أفراد العينة تحسن ملموس.
3) أن أعراض القهورات قلت بشكل عام خلال الدراسة
بعد التنبيه عن الأعراض الوساوسية خاصة في المجموعة الثانية.وأن المجموعة الثانية
للمرضي (تحت العلاج الدوائي) قد استجابت بشكل أكبر للتنبيه المغناطيسي.