Bilateral deep brain stimulation for the treatment of body dysmorphic disorder and obsessive-compulsive disorder

Abstract

Background:

Body dysmorphic disorder (BDD) is classified under obsessive-compulsive and related disorders. BDD is characterized by intense preoccupation with the perception of deficits or flaws in appearance, with repetitive behaviors manifested by altered self-perception. These symptoms bring about significant distress, making normal functioning difficult. Patients tend to respond to a combination of cognitive and pharmacologic therapies, similar to the treatment responses of patients with other obsessive-compulsive spectrum disorders. However, in severe cases of intractable BDD when multiple modalities of therapy have failed, other treatments such as deep brain stimulation (DBS) could be considered.

Case Description:

A 23-year-old Caucasian male presents with a 5-year history of worsening BDD, OCD, and social phobia. A combination of cognitive behavioral therapy and standard pharmacological treatment was attempted, but symptoms progressed, leading to suicidal ideation. Ultimately, the patient elected to undergo placement of a DBS device bilaterally targeting the region bound by the ventral striatum, nucleus accumbens, and subgenual cingulate. The patient was evaluated using both the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist and the Hamilton Rating Scale for Depression, both pre and postoperatively over the course of 21.5 months.

Conclusion:

Following DBS treatment, this patient demonstrated marked improvements in BDD-associated symptoms previously resistant to both cognitive behavioral and pharmacological therapy. This case highlights how DBS treatment can effectively improve symptoms in treatment-refractory BDD when first-line modalities have been exhausted and thus may be a potential consideration for clinical use.

INTRODUCTION

Deep brain stimulation (DBS) has been widely used in the treatment of Parkinson’s disease and is valued for its reversibility and adjustability, characteristics that have encouraged investigation of its utility in other treatment-refractory neuropsychiatric disorders, including Tourette’s syndrome, dystonia, intractable depression, and obsessive-compulsive disorder (OCD).[7,13,17,19] Previous studies applying DBS to patients with severe, treatment-resistant OCD have demonstrated substantial improvement across a range of clinical presentations.[1,2,12,14,17]

More recently, body dysmorphic disorder (BDD) has been reclassified within the “Obsessive-Compulsive Spectrum” rather than among the somatoform disorders.[3-5] This shift reflects the significant overlap between BDD and OCD, including intrusive, anxiety-provoking thoughts and ritualized or habitual behaviors used to mitigate distress. BDD preoccupations share notable similarity with OCD obsessions, and patients with both BDD and OCD exhibit elevated rates of bulimia, social phobia, bipolar disorder, substance-related problems, major depression, and a meaningful association with anorexia nervosa.[6,8,13,16]

Standard treatment for BDD commonly involves a combination of cognitive behavioral interventions and pharmacotherapy.[3] Although controlled trials are limited, available data suggest that serotonin reuptake inhibitors and behavioral therapy may produce moderate symptom reduction.[11,13] Surgical or cosmetic interventions, despite being frequently pursued, rarely provide benefit; in one study, 109 of 131 patients who underwent dermatologic or plastic surgery experienced no improvement or a worsening of symptoms.[15] These findings underscore the need for alternative therapeutic strategies in severe, refractory cases. DBS has been previously reported once as a treatment modality for BDD.[3]

Pharmacologic treatment for OCD and related disorders, such as BDD, is effective in only a portion of patients, with approximately 40–60% demonstrating meaningful clinical improvement, leaving a substantial group who remain symptomatic despite adequate therapy.[17] An estimated 10% progress to treatment-refractory illness.[17] For these individuals, surgical interventions may be considered, including neuromodulation approaches such as DBS or, less commonly, ablative procedures. Ablative surgeries, including subcaudate tractotomy, anterior capsulotomy, and anterior cingulotomy, aim to disrupt hyperactivity within the cortico-striato-thalamo-cortical (CSTC) circuits that underlie OCD pathophysiology.[17] Key nodes in this network include the orbitofrontal cortex, anterior cingulate cortex, and basal ganglia structures such as the caudate nucleus, which together facilitate reward processing, motivation, decision-making, and integration of cognitive and emotional signals.[17] Within the basal ganglia, the nucleus accumbens and ventral caudate play central roles in converting emotional and motivational input into behavioral output.[17]

Neuromodulation offers a non-ablative alternative aimed at adjusting, rather than permanently interrupting, these dysfunctional circuits. DBS is particularly advantageous due to its ability to be titrated and modified over time, allowing stimulation settings to be adjusted in accordance with symptom fluctuations, functional goals, and treatment response.[17] These characteristics make DBS a compelling option for severe OCD and BDD. First implemented for OCD in 1999, DBS subsequently received a Humanitarian Device Exemption from the U.S. Food and Drug Administration in 2009 for treatment-refractory cases.[17] Despite substantial progress, the optimal stimulation target remains an area of active investigation, though several regions within the CSTC network have consistently shown therapeutic promise.[17]

Here, we present a case of bilateral DBS lead placement in the region between the nucleus accumbens and ventral caudate [Figure 1], which is an established target selected for its critical role in regulating affective, motivational, and behavioral processes to offer therapeutic relief in a patient with severe OCD and comorbid BDD.

Figure 1:

(a) Coronal, (b) sagittal, and (c) axial views shown on maximum intensity projections at the target of lead placement. (d) Coronal, (e) sagittal, and (f) axial views shown on CT imaging demonstrating the DBS leads. The terminal ends of the leads were placed at the intersection of the Nacc (yellow) and ventral caudate (blue). The 3D laboratory loaded the MRI and CT data sets simultaneously, using TeraRecon’s Aquarius iNtuition software. Then, advanced tools within the software were used to segment the brain, caudate nuclei, and accumbens as separate volumes from the MRI data set. In addition, the CT data were used to segment the leads as an individual volume. With the use of registration between both data sets, effort was aimed toward overlaying the data sets as precisely as possible. Finally, all segmented volumes were selected, creating an overlay of only the segmented portion(s) of the data sets, subsequently allowing still images to be captured in orthogonal views. CT: Computed tomography, MRI: Magnetic resonance imaging.

CASE PRESENTATION

History and physical examination

The study was conducted as an IRB-approved research investigation (IRB #201952) under a Humanitarian Device Exemption (HDE #H050003), in accordance with FDA requirements. The protocol followed a prespecified Medtronic study design and included multidisciplinary oversight.

A 23-year-old Caucasian male presented with a 5-year history of progressively worsening OCD, with comorbid BDD and social phobia. Disease progression was associated with suicidal ideation, including one prior suicide attempt. The patient had failed multiple standard cognitive and pharmacologic interventions, including cognitive behavioral therapy, lorazepam, clonazepam, risperidone, and quetiapine.

Worsening BDD symptoms resulted in marked social isolation and ultimately necessitated a leave of absence from college. His BDD was characterized by intrusive preoccupation with perceived physical imperfections, accompanied by heightened self-consciousness and recurrent comparison with others in public settings. These cognitions intensified fixation on specific body features and resulted in significant anxiety, subjective distress, impaired concentration, and loss of focus. Symptom severity fluctuated over time, with recent worsening noted by family members, including an expansion of preoccupations from the head to additional perceived defects involving the chin, experienced by the patient as severely distressing.

Associated behaviors included excessive eye blinking, repetitive touching and rubbing of perceived defect areas, and persistent reassurance-seeking, consistent with compulsive attempts to alleviate body image-related distress.

Preoperative symptom severity was assessed using the Hamilton Depression Rating Scale (HAM-D) and Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). The patient’s preoperative HAM-D score was 20, and his Y-BOCS score was 32, both indicating clinically severe symptomatology. Symptoms were further characterized using the Y-BOCS Symptom Checklist [Figure 2]. The neurosurgical and psychiatric teams jointly reviewed the case and confirmed diagnoses of OCD with comorbid BDD. Although OCD and BDD are related conditions within the obsessive-compulsive spectrum, they are considered distinct clinical entities. Given the patient’s lack of response to multiple lines of medical therapy, and following extensive discussion with the patient and his family, a decision was made to proceed with bilateral DBS lead implantation.

Figure 2:

Recorded preoperative and postoperative Yale-Brown Obsessive-Compulsive Scale checklist.

Severe, treatment-refractory OCD was identified as the primary indication for surgical intervention, and DBS targeting the anterior capsular region was recommended on this basis. While BDD symptoms were prominent and functionally impairing, they were considered comorbid rather than the primary surgical indication. Accordingly, DBS programming and clinical optimization were directed toward obsessive-compulsive symptom reduction rather than specifically targeting BDD symptoms.

Operation

A preoperative frame-based MRI for target determination was performed before the surgical procedure. Once in the operating room, the patient’s head was secured within a 4-pin head fixation CRW stereotactic frame (Integra Radionics, Inc., Burlington, MA), followed by plane localization and orientation. The targeted region was defined by the convergence of the ventral caudate within the ventral striatum and superior nucleus accumbens by following the internal capsule as determined by Talairach’s atlas [Figure 3].[20] Calculation of lead positioning for anterior capsule stimulation was performed and calibrated within stereotactic frame limitations. The stereotactic target was localized 12 mm anterior to the anterior commissure, 8–12 mm lateral to the anterior commissure–posterior commissure line, and 8 mm inferior to the anterior commissure–posterior commissure plane. The procedure was performed using the frame-based approach under general anesthesia, with implantation of both the leads and pulse generator during the same procedure. Bilateral frontal incisions were made for lead placement, with additional retroauricular and infraclavicular incisions for lead anchoring and pulse generator implantation. Leads were tunneled, connected, and secured, and the pulse generator was placed in the right infraclavicular pocket. Wounds were closed in standard fashion. Estimated blood loss was minimal.

Figure 3:

(a) Axial and (b) coronal views are shown. Neurosurgical atlas illustrating lead placement at the intersection of the ventral caudate (green) and nucleus accumbens (yellow), aligned to postoperative CT using manual Talairach atlas registration. Using the AC-PC line as a horizontal baseline and a proportional grid system, neuroanatomy was manually mapped, warped, and scaled to define precise 3D stereotactic coordinates, with the assistance of a neuroradiologist. AC-PC: Anterior commissure-posterior commissure, CT: Computed tomography.

Postoperative course

The DBS device was initially programmed by a Medtronic representative, with ongoing device management and parameter adjustments overseen by the Loyola neurosurgery team at each followup visit. Psychiatric care included neurological and psychiatric medication management provided by the Loyola neurosurgery team, in collaboration with a psychiatrist at an external institution, as well as regular outpatient psychotherapy. The patient was discharged home following an uneventful postoperative course, and the device was activated 1 week later. At a neurosurgical follow-up visit 2 weeks after activation, the patient reported no appreciable change in obsessive-compulsive symptoms but noted early improvement in body dysmorphic symptoms. The device was subsequently reprogrammed to 4.0 V, 120 μs pulse width, with the stimulation frequency maintained at 185 Hz. Programming parameters were adjusted intermittently over the subsequent 18 months. During this period, the patient experienced intermittent hospitalizations and reported subjective cognitive difficulties, which were felt to be related in part to medication effects. His psychiatric medication regimen was substantially reduced without significant symptom recurrence, and he is currently maintained on fluvoxamine, risperidone, and clonazepam. Device settings have since remained stable. Over time, both the patient and treatment team observed gradual and significant improvement in body dysmorphic symptoms, with more modest improvement in obsessive-compulsive symptoms. Consistent with this course, OCD served as the primary surgical indication and target of stimulation. Improvement in comorbid BDD represented a clinically meaningful secondary benefit, occurring in the context of continued psychiatric management and gradual medication tapering.

RESULTS

We recorded several assessments for the patient, both before and after DBS implantation. The total follow-up time between the first encounter and the last with the patient was 27.6 months. The interval between the preoperative and postoperative assessments was 21.5 months [Figure 4]. The evaluation battery included the Y-BOCS [Figure 5], the Yale Brown Obsessive-Compulsive Scale Symptom Checklist [Figure 2], and the Hamilton Rating Scale for Depression (HAMD) [Figure 6]. Stimulation parameters and medication adjustments were also documented throughout the postoperative period following bilateral DBS implantation [Figure 4].

Figure 4:

Timeline depicting changes in medication regimen and stimulation parameters across all patient encounters. BDD: Body dysmorphic disorder, OCD: Obsessive-compulsive disorder, DBS: Deep brain stimulation, N/A: Not Available

Figure 5:

Recorded preoperative and postoperative Yale-Brown Obsessive-Compulsive Scale scores.

Figure 6:

Recorded preoperative and postoperative Hamilton rating scale for depression. Depressive symptom severity is rated on a 5-point scale: 0 (absent), 1 (mild), 2 (moderate), 3 (severe), and 4 (extreme or disabling). Total scores are interpreted as follows: 0–7, normal range or clinical remission; 8–13, mild depression; 14–18, moderate depression; 19–22, severe depression; and ≥23, very severe depression.

The Y-BOCS scale and corresponding symptom checklist demonstrated measurable changes in obsessive-compulsive symptom severity [Figure 7]. The patient reported a preoperative Y-BOCS score of 32 and a postoperative score of 13. As illustrated in Figure 5, both the prescribing clinician and the patient observed meaningful symptom reduction, particularly regarding checking behaviors, which had previously been present daily. Improvements were noted across nearly all Y-BOCS subcategories following surgery.

Figure 7:

Recorded preoperative and postoperative Yale-Brown Obsessive-Compulsive Scale severity rating.

The HAMD was used to assess mood-related symptoms. The patient had a preoperative HAMD score of 20 and a postoperative score of 16, reflecting mild improvement in depressive symptoms.

Importantly, the patient’s BDD symptoms, which had been classified within the spectrum of obsessive-compulsive related disorders, were reported to have completely resolved following DBS implantation. The patient demonstrated reduced intensity and frequency of body dysmorphic preoccupations, with diminished distress related to perceived physical defects. This improvement was accompanied by decreased compulsive behaviors, including reassurance-seeking and repetitive touching.

DISCUSSION

BDD is a severe psychiatric condition characterized by a distressing and impairing preoccupation with imagined defects in appearance. Although BDD was formally introduced into the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised in 1987, historical descriptions date back to the 19^th century, when Dr. Enrico Morselli, an Italian psychiatrist, referred to the condition as dysmorphophobia.[4,5] Patients may fixate on a single perceived flaw, multiple features, or their overall appearance, often experiencing intrusive negative self-images and memories. These symptoms are associated with high rates of suicidality. Retrospective studies and one prospective study indicate that 50–60% of individuals with BDD experience suicidal ideation annually, 10 times the rate of the general population, and preliminary evidence suggests that rates of completed suicide attempts are also markedly elevated.[4,6,16,18] The patient experienced a suicide attempt, characterized by an impulsive self-overdose of risperidone and clonazepam following an acute interpersonal conflict related to worsening OCD symptoms and concerns about DBS battery failure. Although the overdose was of relatively low lethality and occurred in a context suggestive of ambivalence, it nonetheless represents suicidal behavior. This finding is consistent with the elevated suicide risk reported in patients with severe, treatment-refractory OCD and related disorders.

In parallel, growing evidence supports the use of DBS for severe, treatment-resistant psychiatric disorders. DBS of the ventral capsule and ventral striatum has shown encouraging results for OCD, with Nuttin et al. reporting reductions in core symptoms following capsular stimulation.[1,2,14,21] Similarly, Mayberg et al. demonstrated that stimulation of the subgenual cingulate region (CG25) can reverse symptoms of refractory depression.[12] Because BDD has been reclassified within the OCD spectrum and shares overlapping pathophysiological circuits, these findings provide a strong rationale for investigating DBS targeting similar regions in severe, intractable BDD.[3] Based on this rationale, the intersection of CG25, the ventral caudate, and the nucleus accumbens was selected as the stimulation target. Layered anatomical maps were constructed and overlaid onto the patient’s imaging to refine trajectory planning and ensure accurate stereotactic coordinate selection. This anatomical convergence zone integrates limbic and striatal pathways involved in affective regulation, reinforcement learning, and motivational salience, processes disrupted in both OCD and BDD.[9,10,14] Modulating this interface allows DBS to influence multiple maladaptive circuits simultaneously by reducing the emotional distress that fuels obsessive thinking, weakening entrenched habitual responses, and diminishing the excessive salience attributed to intrusive thoughts or perceived physical defects. Its dense connectivity with the orbitofrontal cortex, anterior cingulate, and thalamus further positions it as a central node within the CSTC network. Prior DBS work targeting nearby regions, such as the ventral capsule and ventral striatum, has demonstrated meaningful symptom improvement, suggesting that this adjacent intersection may engage a broader integrative affective and cognitive network.[9,10,14]

Optimal management of patients with overlapping neurological and psychiatric disorders requires an individualized, multidisciplinary approach. Advances in functional neurosurgery over the past two decades have refined the understanding of DBS for OCD, including mechanisms, therapeutic potential, and possible adverse effects. For patients with significant psychiatric comorbidity, as in the present case, sustained and coordinated postoperative psychiatric care remains essential for achieving meaningful behavioral and functional outcomes. This includes structured follow-up, frequent medication reconciliation, and systematic monitoring of symptom trajectories and treatment adherence.

Looking forward, several directions warrant continued investigation. First, a deeper delineation of the neurobiological mechanisms underlying OCD and BDD is needed to guide future DBS targeting and parameter optimization. Second, standardized evidence-based models for postoperative psychiatric integration should be developed, particularly for patients with multiple psychiatric comorbidities. Finally, further efforts are required to identify strategies that reduce DBS-associated adverse events and procedure-related complications while preserving or enhancing therapeutic benefits.

CONCLUSION

The use of DBS continues to grow and expand into other areas of treatment for neuropsychiatric disorders. The negative side effects of DBS are minimal because of its adjustability and reversibility, therefore contributing to its broad therapeutic applicability for neurosurgeons. The successful management of our patient’s BDD symptoms by DBS contributes to other studies involving patients with OCD. This case suggests, in select cases when cognitive and pharmacologic therapies have been exhausted, DBS of the region bound by the ventral striatum, nucleus accumbens, and subgenual cingulate may be considered for severe intractable obsessive-compulsive spectrum disorders.

Ethical approval:

Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.