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]

 

REFERENCES

 

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