Somatic Therapies in

Treatment-Resistant OCD:
TMS and DBS

Robert Hudak, M.D.

Associate Professor of Psychiatry
University of Pittsburgh School of Medicine
 Transcranial Magnetic Stimulation: FDA Approved

Superior to sham Well tolerated, mild

treatments in headaches, and
resistant patients local irritation

High frequency Targets medial

daily treatments prefrontal cortex
for 6 weeks and ACG*

*Anterior cingulate gyrus

Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D. M., Daskalakis, J., ... & Feifel, D. (2019). Efficacy and
safety of deep transcranial magnetic stimulation for obsessive-compulsive disorder: a prospective multicenter randomized
double-blind placebo-controlled trial. American Journal of Psychiatry, 176(11), 931-938.
 Transcranial Magnetic Stimulation

Specific coil and machine There are no guidelines as

to when to use TMS (yet)

Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D. M., Daskalakis, J., ... & Feifel, D. (2019). Efficacy and
safety of deep transcranial magnetic stimulation for obsessive-compulsive disorder: a prospective multicenter randomized
double-blind placebo-controlled trial. American Journal of Psychiatry, 176(11), 931-938.
 Deep Brain Stimulation: FDA Approved

Can be safe No neuropsychiatric May improve

during pregnancy deficits after surgery verbal memory

Dougherty, D. D., & Greenberg, B. D. (2011). Neurobiology and neurocircuitry of obsessive-compulsive disorder

and relevance to its surgical treatment (pp. 20-29). Cambridge University Press, New York, NY, USA.
 DBS: Criteria for Treatment
1. Y-BOCS* ≥ 28 for at least 5 years. GAF*: ≤ 45

2. Failed adequate trial of 2 SSRIs + clomipramine

3. Failed augmentation with clomipramine, glutamatergic

agent, and antipsychotics for at least 1 month.

4. Failed at least 20 adequate ERP sessions

*Yale-Brown Obsessive Compulsive Scale

*Global Assessment of Functioning

Dougherty, D. D., & Greenberg, B. D. (2011). Neurobiology and neurocircuitry of obsessive-compulsive disorder

and relevance to its surgical treatment (pp. 20-29). Cambridge University Press, New York, NY, USA.
 DBS: Exclusion Criteria

Psychosis Bipolar disorder

Body dysmorphic
Current SUD
disorder

Greenberg, B. D., Malone, D. A., Friehs, G. M., Rezai, A. R., Kubu, C. S., Malloy, P. F., ... & Rasmussen, S. A. (2006). Three-year
outcomes in deep brain stimulation for highly resistant obsessive–compulsive disorder. Neuropsychopharmacology, 31(11), 2384-2393
 DBS: Initial Study of 10 Subjects
• 6 of 8 subjects experienced 25% reduction in Y-BOCS
at 36 months

• 4 of 8 subjects experienced 35% reduction in Y-BOCS at

36 months

• Depression and anxiety scores improved significantly

at 3 months

Greenberg, B. D., Malone, D. A., Friehs, G. M., Rezai, A. R., Kubu, C. S., Malloy, P. F., ... & Rasmussen, S. A. (2006). Three-year
outcomes in deep brain stimulation for highly resistant obsessive–compulsive disorder. Neuropsychopharmacology, 31(11), 2384-2393
 DBS: Adverse Effects

Transient Epigastric
elevated mood sensations

Olfactory and Asymptomatic brain

gustatory sensations hemorrhage (1 patient)

Greenberg, B. D., Malone, D. A., Friehs, G. M., Rezai, A. R., Kubu, C. S., Malloy, P. F., ... & Rasmussen, S. A. (2006). Three-year
outcomes in deep brain stimulation for highly resistant obsessive–compulsive disorder. Neuropsychopharmacology, 31(11), 2384-2393
Key Points

• Transcranial magnetic stimulation was approved for OCD in 2019.

• The machine used for TMS in OCD is different than the one used
for MDD.

• Ablative procedures and deep brain stimulation are used in the

most severe and treatment-resistant cases. 
Next Presentation

Surgical Treatment for OCD: Procedures,

Effectiveness, and Indications