Barcelona snapshots

Prof. Eileen M. Joyce

Eileen M. Joyce psychiatrist Controversias Psiquiatry Barcelona
University College London, United Kingdom
Talk Treatment-resistance OCD
Date Saturday, April 27th, 2019
Time 9:45 to 10:30


Eileen Joyce is a Professor of Neuropsychiatry at The Institute of Neurology, University College London. Her current research focuses on interventions for neuropsychiatric disorders such as schizophrenia, OCD and Tourette's syndrome and their mechanisms of action. Her clinic work includes the management of complex neuropsychiatric disorders such as conversion disorder, Parkinson's disease and Tourette's syndrome. She is involved in clinical studies of deep brain stimulation and neurosurgical ablation for severe mental illness.

Professor Joyce obtained her first degree in experimental psychology and PhD in dopamine psychopharmacology from the University of Cambridge. She then went on to study medicine also at Cambridge. She trained in psychiatry at the Bethlem and Maudsley Hospitals and spent several years as a research worker at the Institute of Psychiatry, where she was a Wellcome Trust Lecturer in Mental Health. This was followed by time at the USA National Institutes of Health. Before moving to UCL/UCLH, she was Professor of Neuropsychiatry at Imperial College London before to moving to UCL.

She is Chairman of the Faculty of Neuropsychiatry, Royal College of Psychiatrists.


OCD is a common mental illness with a lifetime prevalence estimated as 1-2%, making it more common than schizophrenia and bipolar disorder. It can be extremely disabling and is the 11th world leading cause of nonfatal burden (WHO). There are effective pharmacological and psychological treatments, but 10-20% of patients do not respond in a meaningful way despite optimal management. Somatic treatments have been developed as alternatives when standard interventions have failed.

Ablative neurosurgery for severe OCD has been practiced internationally in specialist centres since the 1950's. The two main procedures are anterior cingulotomy and anterior capsulotomy. There are few outcome studies and participant numbers are inevitably low. The response rate is approximately 33-50% with anterior capsulotomy showing a marginal advantage for efficacy but a disadvantage for adverse effects. Anterior capsulotomy has been refined over the years and recently, non-operative techniques using radiofrequency or ultrasound to create lesions are showing promise.

As an alternative to ablation, deep brain stimulation (DBS) for OCD was proposed in 1999 on the grounds that it is adjustable and reversible. The first target studied was the same as that for anterior capsulotomy and the second was the subthalamic nucleus (STN). There have been several randomised controlled trials of DBS for OCD with variable results but an overall response rate of 50-66%. A recent study comparing DBS at these two targets in the same patients suggests that they are equivalent in efficacy for alleviating OCD symptoms but have different mechanistic actions because they influence separate abnormal OCD circuits. DBS of the anterior capsule has a greater effect on mood whereas that of the STN improves cognitive flexibility.

Ablative neurosurgery and DBS are reserved for the most severe intractable patients. Less invasive interventions, suitable for more patients with less severe but nevertheless disabling symptoms is required. Repetitive transcranial magnetic stimulation (rTMS) has proved successful for the treatment of patients with persistent depression who have not responded to medication or psychological therapy and this is now a focus of study in OCD. However, there are complications with this technique for OCD. One is whether high or low frequency rTMS is optimal. Another is because the cortical areas which form the nidus of neural circuits know to be abnormal in OCD are deep seated and therefore difficult to modulate with external stimulation. Nevertheless, electromagnetic coils have been designed to overcome this problem and the early results are promising.


[web] Rasmussen SA et al (2018). Gamma Ventral Capsulotomy in Intractable Obsessive-Compulsive Disorder. Biol Psychiatry. 2018 Sep 1;84(5):355-364..

[PDF] Kim SJ et al (2018). A study of novel bilateral thermal capsulotomy with focused ultrasound for treatment-refractory obsessive-compulsive disorder: 2-year follow-up. J Psychiatry Neurosci. 2018 Aug;43(5):327-337.

[web] Tyagi H et al (2019). A Randomized Trial Directly Comparing Ventral Capsule and Anteromedial Subthalamic Nucleus Stimulation in Obsessive-Compulsive Disorder: Clinical and Imaging Evidence for Dissociable Effects.. Biol Psychiatry. 2019 Jan 30. pii: S0006-3223(19)30063-0. doi: 10.1016/j.biopsych.2019.01.017.

[web] Carmi L et al (2018). Clinical and electrophysiological outcomes of deep TMS over the medial prefrontal and anterior cingulate cortices in OCD patients. Brain Stimul. 2018 Jan - Feb;11(1):158-165..