L9 - OCD Flashcards
(88 cards)
1
Q
OCD DSM-5 criteria
A
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2): see next slide
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder
Specify if (measured with a scale):
- With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
- With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
- With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true. (very difficult to treat)
Specify if:
- Tic-related: The individual has a current or past history of a tic disorder (comorbid; lot of patients have motoric/verbal tics, poor outcomes if tics present)
2
Q
Background info
What are obsessions according to the DSM-V + examples?
A
Recurrent, persistent, intrusive, and unwanted thoughts, impulses or images that cause anxiety or distress
Examples:
- being afraid to make others sick
- thinking that certain numbers, colors or words bring good luck
- worrying about sticky food scraps
- being afraid of saying strange things to others
- images of something violent or terrible
- unpleasant thoughts about sexuality
- worrying about one’s appearance
- worrying about bacteria and viruses
- fearing that you will give in to impulses (e.g. kill someone or steal)
3
Q
What are compulsions according to the DSM-V?
A
- Repetitive behaviors or thoughts (mental acts) that the person feels compelled to respond to in reaction to an obsession or according to rules that must be rigidly applied
- They are aimed at preventing/reducing fear or suffering, or preventing a certain dreaded event or situation
- Compulsions have no real connection with what needs to be neutralized or prevented by them, or are clearly excessive
- They do decrease the anxiety and distress that obsessions cause
4
Q
Examples of compulsions
A
- frequent or excessive washing of hands
- excessive cleaning
- checking locks
- checking gas
- checking things so that nothing dangerous can happen
- touching or skipping certain pavement tiles or
- walking only on curb edges
- tapping things, making things equal, setting things straight
- the need to tell things
5
Q
What is phenomenology and what is its goal?
A
- study of experiences, perceptions, thoughts, feelings, memories, and fantasies
- goal: to describe reality as it appears to a person
6
Q
What cognitive biases occur in OCD?
A
- intolerance of uncertainty
- thought-action fusion
- exaggerated sense of responsibility
- overestimation of danger
- perfectionism
7
Q
Is it O-C-D or C-O-D?
A
- Traditionally we think OCD: compulsions are a response to obsessive thoughts
- According to the C-O-D view: obsessions are a form of post-hoc rationalization that can reduce the cognitive dissonance which occurs as a result of excessive compulsions
8
Q
What are the barriers to seeking treatment for OCD and why is it detrimental?
A
- Only 3% of the general population is affected by OCD and only few enter treatment
- Barriers: shame and lack of knowledge (e.g., that these psychological problems constitute mental disorders)
- Causes a long delay in receiving treatment (est. 15 years)
- This is detrimental because the duration of untreated illness is one of the principal determinants of clinical and health outcomes - early detection crucial (especially with child and adolescent OCD)!
9
Q
What treatment for OCD are there?
A
- CBT - important part of it is Exposure Response Prevention (ERP)
- Medication (SSRIs and dopaminergic, i.e. anti-psychotics)
- Deep Brain Stimulation (DBS) - electrode implanted in the brain on the basal ganglia (performed also at UMC to severe, refractory compulsive patients)
10
Q
Lecture
What are the four most important themes patients describe
A
- 400-500 compulsions or obsessions known
- Within one theme, the specific content can change but not really to another category
- Contamination & cleaning
- Responsibility for causing or not preventing harm & checking/ reassurance seeking
- Taboo thoughts about sexual activity, violence and blasphemy & checking
- Need for order and symmetry & ordering/ counting
11
Q
Example of a case
A
A 35-year old female patient has given birth to her firstborn baby. Since, she is preoccupied with fever-blister/ herpes labialis, she checks every person she meets for having a fever-blister at the grocery store or at the birthdays of family and friends. She disallows anyone to pick up or hug her child. After returning from a family gathering, she repeatedly washed her cheeks with soap and recently also with bleach. She also has to wash all the clothes. She regularly checks with her husband if he has seen anyone with e fever-blister.
12
Q
What role does family/close ones play in recovery of the patient?
A
- Often the family members are part of the compulsion/obsession (like in the previous case)
- Family members want to help the patient and they feel like they can help by engaging in the compulsions with the patient but that is not the case, it worsens the likelihood of the person improving
- Especially in child psychiatry, they have specific programme for parents and siblings of OCD patients to teach them how to handle the compulsions to not contribute to the disorder - very positive results, the child improves way quicker when family members undergo this
13
Q
Another example of a case
A
A 38-year old male patient, working as an account manager, is being hindered by the constant thought of finding his 3-year old daughter sexually attractive. When she sits on his lap, or when he was changing her diaper, he would see images, or think of him sexually assaulting the child. Subsequently, he continuously tries to check his emotional and physical reaction in regard to these thoughts and images, afraid of truly becoming sexually aroused. The impact on his social and family live is enormous. As it resulted in keeping distance to his daughter, never changing diapers, bathing the child or giving hugs. Furthermore he’s constantly doubting whether or not he already has assaulted his daughter. As he’s afraid of being a pedophile he does not dare to share this with his wife.
14
Q
Differential diagnosis
A
Big overlap with lot of different kind of disorders/diseases:
- Medical disorders: dementia, TBI, PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections)
- Medication/ drugs: clozapine, amphetamines, cocaine
- Excessive worries in GAD or MDD
- Preoccupation with appearance in body dysmorphic disorder
- Difficulty discarding or parting with possession in hoarding disorder
- Repetitive and stereotyped behavior in autism spectrum disorder, Tourette syndrome, mental retardation, frontal lobe lesion, Parkinson, schizophrenia
- Ritualized eating behavior (eating disorders)
- Preoccupation with substances or gambling (substance-related and addictive disorders)
- Sexual urges or fantasies (paraphilic disorders)
- Thought insertion or delusional ideas (schizophrenia spectrum and psychotic disorders)
15
Q
Comorbidity of OCD
A
- 90% have another disorder
- Also personality disorders (25%) - especially OCPD (23%)
- Anxiety disorders 76% (social or specific phobia 43%) > mood disorders 65% (bipolar 22%) > impulse control disorders 60% ( ODD 30%) > substance-related disorders 40% (alcohol 40%)
Picture 1
16
Q
What are the differences between OCD and OCPD?
A
OCD:
- obsessive-compulsive and related disorders (DSM-5)
- obsessions and/or compulsions
- anxiety
- egodystonic (thoughts, impulses, or behaviors that are perceived as being at odds with one’s self-perception, values, and beliefs, causing distress)
- one/few domains
OCPD:
- personality disorders (DSM-5)
- rigidity, need for control, perfectionism
- tension
- egosyntonic (thoughts and behaviors align with one’s sense of self - this is who I am)
- multiple domains
17
Q
Epidemiology OCD
A
- 12-month prevalence 1.2%
- Age of onset: childhood or early adulthood
- Detection of OCD occurs late (lot don’t seek help due to shame/stigma)
- Only aroud 30% of patients receives the right treatment (big gap between diagnosing and treatment)
- Longer duration of untreated illness leads to poorer outcomes and prognosis
18
Q
Gender differences in the onset
A
- Age of onset → M: before age of 10, F later but in adolescence
- Peak of onset → M: 20yrs, F: increases more steadily but peak also mostly aroudn 20yrs
- Generally, more females than males but not by much but females are more motivated to seek treatment
- picture 2
19
Q
Course of OCD
A
- Chronic course
- Three patterns that can be observed during a lifetime of a patient (differs per patient):
↪ relapsing/remitting course
↪ stable chronic, severe course
↪ increase of symptoms over the years - Overall partial remission at least for a short time
- Periods of waxing and waning of symptoms
- However, relatively few studies have actually examined the course of the disorder
- Stress is the “fertilizer”of OCD symptoms… - that’s why you should prepare them what to do in stressful events
20
Q
Measuring scale of OCD
A
Yale-Brown Obsessions and Compulsions Scale (Y-BOCS)
- a 10-item, clinician-administered scale - takes time to learn it
- Most widely used rating scale for OCD - worldwidely validated
- Provides five rating dimensions for obsessions and
compulsions:
1. time spent or occupied (broad category - Problem with the scale that you would give a 4 to a client who spents more than 8 hrs a day preoccupied by their symptoms but there are patients who have very severe OCD, such as 12 or 18 hrs per day but then you don’t distinguish between these (despite the fact that it differs a lot) because the scale only goes up to 8hrs)
2. interference with functioning or relationships
3. degree of distress
4. resistance to obsessions/ccompulsions
5. degree of control - The 10 Y-BOCS items are each scored on a scale from
0 = “no symptoms” to 4 = “extreme symptoms” - Max = 40 points, 20 (obsessions) + 20 (compulsions)
21
Q
Four treatment options of OCD?
A
- Cognitive-behavioral therapy (CBT)
↪ Cognitive therapy
↪ Exposure and Respons prevention (ERP) - Inference Based Approach (IBA)
- Medication
- Neuromodulation (rTMS, DBS)
22
Q
What is the Inference Based Approach (IBA)
A
- new approach
- not focusing on exposure (very difficutl for patients - increases anxiety so lot of dropout)
- focuses on the specific pathological doubt that is induced by the patient who is not able to trust his senses anymore
- IBA says that patients will often rather trust fantasy possibilities than their own reasoning
- E.g. patients locks the door and leaves but then they don’t trust it anymore so they have to go back and check
23
Q
Cognitive behavioural model of OCD
A
- Starts with obsessions that induce anxiety/distress (or other bad feelings) so to decrease this feeling, they engage in compulsions which provide relief (temporary reduction in distress)
- However, the repetitive behaviours or mental acts will again strengthen the anxiety
- The relief negatively reinforces the compulsions
- All based on the model of fear aqcuisition and fear extinction
24
Q
What is cognitive therapy about?
A
- Normalization of Intrusive Thoughts - intrusive thoughts completely normal, everyone has them - psychoeducation
- Intrusions may become an obsession when one appraises the intrusion as a real threat, personally significant or provoking high level uncertainty (make them very personal)
- Several cognitive dysfunctions / biases lead to appraisal of the intrusions
- Cognitive therapy focusses on repairing the dysfunctional beliefs
25
Dysfunctional beliefs associated with obsessions
1. **Inflated responsibility**: belief that one has the special power to cause and/or the duty to prevent negative outcome.
2. **Overimportance of thoughts** (**thought-action-fusion** - thinking about something already means you're doing it):
I) Belief that the mere presence of a thought makes the thought important
II) Thought has ethical or moral ramifications
III) Thinking the thought increases the likelihood of performing corresponding behavior
3. **Overestimation of threat**: belief that negative events are especially likely and awful
4. **Perfectionism**: belief that mistakes and imperfection are intolerable
5. **Intolerance for uncertainty**: belief that it is necessary and possible to be completely certain that negative outcomes will not occur
26
# Find the cognitive biases in OCD
One of our patients was doubting if her child, after giving birth, had been accidentally swapped in the hospital. She got fixed at gaining absolute certainty and she asked for a genetic test. The test-result indicated that the child was biologically hers. The reliability of the test was 99.99%. She remained obsessed with this idea for years.
Intolerance of uncertainty - there is not a complete certainty from the genetic test and she is not able to tolerate that
27
# Find the cognitive biases in OCD
One patient mentioned that when he walked on the street, he was continuously focused on sharp objectsl ike nails. He had to pick up all sharp objects because someone else could hurt himself by stepping in the nail and than he would be guilty.
Inflated responsibility
28
# Find the cognitive biases in OCD
“The mere thought of acting violently to my partner
makes me a horrible person.”
Thought – Action fusion
29
Cognitive techniques for overcoming dysfunctional beliefs
1. Estimation of the catastrophe
2. Estimation of responsibility: pie technique
30
Estimation of the catastrophe
- The patient describes the situation he is worried about “If I do not extinguish my cigarette my house will burn down.” And then the therapist asks ''How big is the chance that your house burns down.'' → *Calculation of the probability of the catastrophe* with the patient
- You split the real danger in little things that can be done before it comes down to it:
- How big is the chanage if:
1. I did not extinguish my cigarette 1/10
2. A little spark falls on the floor covering 1/10
3. The wall-to-wall carpet will catch fire 1/10
4. The carpet starts to burn and I do not immediately notice the fire 1/100
5. I notice the fire too late, so I cannot do anything about it 1/100
- Then you accumulate the chance abd you see that the chance is very low (e.g. 1/1000000)
31
Estimation of responsibility: pie technique
- Helps patients get the insight into the idea of the obsessions
- “The patient thought that he alone would be responsible if his bicycle fell on the street and the driver of a car would neither be able to brake nor to get out of the way of the bicycle.”
- Factors were listed which contributed to a car crash: driver, weather, approaching traffic
- Making a pie including realistic percentages
32
What are the two parts of Exposure and Response Prevention (ERP)?
1) **Exposure**: overcoming avoidance - suggest all kinds of situations that are gonna trigger the anxiety and obsessions of the patient
- Dirty the countertop of your kitchen
- Touch the inside of the toilet (flooding)
- Order things asymmetrical on your desk
- Actively think of your gruesome intrusions
2) **Response Prevention**: Reducing compulsions - very important!!
- Do not clean the countertop before starting to cook
- Do not wash your hands following your toilet exposure
- Do not order your desk before starting work
**Extinction** is going to happen so the feared outcome will not be there and the patient experiences that the anxiety is gradually decreasing (picture 3)
33
What are an important elements of exposure to maximize the efficacy?
- Create a fear hierarchy: mild to severe anxiety-provoking situations - important so that the client earns trust in the exposure therapy
- Supported exposure - think with the patient what situations are most fearful, be present during the exposure to support the patient
↪ These really help the patient to overcome the fear and keep working on exposure therapy
34
Efficacy of CBT for OCD
* 70% of patients respond to CBT
* Responder defined as a 35% decrease of the Y-BOCS
* Average symptom decrease of 60-80% - but they are not completely cured and often come back especially in periods of stress (also when scared of another relapse which can even increase the chances of relapsing)
35
Factors associated with poor treatment outcome in OCD
**Clinical**
- More severe OCD
- Greater functional impairment
- Sexual, religious and hoarding symptoms
- Poor insight
- Higher number of comorbidities
- Greater resistance to change
- Lower adherence to treatment
**Demographic**
- Male gender
- Single
- Lower SES
- Lower educational level
**Other**
- Family history OCD
- Poor therapeutic alliance
- Greater family accommodation
- Absence early response to SSRIs
In meta-analysis, these were not replicated so it's not clear what exactly predicts poor outcome
36
What medication is used and what are the problems with it?
- Serotonergic medication (SSRIs) or tricyclic antidepressants
- 50-60% respond to SSRIs
- Problems: Patient-doctor delay due to sshame & fear; fear of side-effects
37
Side effects of antidepressants
Trycyclics:
- tremors
- ingestion
- headache
- dry mouth
- drowsiness
- elevated heart rate
SSRIs:
- sweating
- ingestion & nausea
- headache
- dry mouth
- drowsiness
- sexual side effects
- sleeping problems
38
Medication protocol for OCD
1) Start with a SSRI, maximum dosage (essential to get a good result - MDD low dose is enough even within 2 weeks), minimum of 3 months (serotonin)
2) If doesn't work then switch to a different SSRI, maximum dosage, minimum of 3 months (serotonin) - can have additional 30% response if the first one didn't work
3) Switch to clomipramine (Tricyclic antidepressant), maximum dosage, minimum of 3 months, possibility of measuring blood-levels (serotonin)
4) Add a low dosage of an antipsychotic , minimum of 1 month (dopamine) = extra 30% responder rate
→ All these steps are essential to find out whether the patient is treatment-refractory or not
→ If the patient is experiencing high levels of panic or comorbidity, it's better to start with medication because then the patient is much more able to start with CBT
39
For how long should you continue the medication?
- at least 1 year but better 2 years continuation (especially important to continue upon termination of CBT because there is often more stress in patients since they have to adapt to normal life without the external help)
- No lowering of dosage
- Gradually lowering dosage in case of prolonged “remission'' - take at least half a year or even a year
↪ if not do that, high relapse probability
- 80% of people experience relapse so that's why it's advised to take medication life-long, preferably at a low dose
40
What are criteria often used for treatment-refractoriness in OCD?
- Even after all the medication steps and CBT, there are 10% of patients who don't respond to any of those - option of neuromodulation
- But before that you have to assess whether the client really is not responsive to any kind of traditional treatment
- Criteria:
1) Two trials with an SSRI at the maximum dosage for three to six months
2) One trial with clomipramine at the maximum dosage for three to six months
3) At least one trial of an atypical antipsychotic medication used for three months in conjunction with an SSRI or clomipramine
4) Six months of behavioral therapy that includes exposure under the supervision of a clinical psychologist trained in behavioral techniques
41
What are the two options for neuromodulation?
1. Repetitive Transcranial Magnetic Stimulation (**rTMS**) - using magnetic coil outside of the skull to send very brief magnetic impulses that induces the current in the brain which influences neurotransmittion or cortical excitability
2. Deep-brain stimulation (**DBS**) - UMC specilizes in this
42
Neurobiology of OCD
- Involves cortico-striatal cortical circuit
- Important brain areas in OCD: PFC, orbito-frontal cortex, anterior cingulate cortex, thalamus, basal ganglia (picture 4)
- There are two pathways within this CSC circuit which are responsible for OCD: direct vs indirect (picture 5)
- Direct pathways have excitatory effect on cortical excitability and indirect pathways have inhibitory effect
- What is thought in general pathology of OCD that there is a hypractivity of the direct pathway - generalized model and in reality it's more complicated and there now it's thought that there are more and different circuits within CSC which are involved in OCD (picture 6)
43
How does rTMS work?
- still lot of research needs to be done to confirm how exactly it works with OCD but it is used as additional treatment because it has been shown to be beneficial for some patients
- stimulation focuses on dorsolateral PFC and superior motoric area (SMA)
44
What is the efficacy of rTMs in OCD worldwide?
- Network meta-analysis: 21 studies (n=368/ 294)
- Effective targets:
1) Low frequency preSMA
2) High frequency bilateral dlPFC
3) Low Frequency right dlPFC (highest efficacy)
- Mean Y-BOCS decrease is 4 points compared to sham rTMS (rTMS with no stimulation)
- Also improvement of depression
45
Deep Brain Stimulation
- Neurosurgeon puts two electrodes on both sides of the brain targetted at specific areas and you connect them with a cable to a post-generator that is put on the chest of the patient
- You can give the stimulation full time
- Many posibilities to change the stimualtion within the brain since there are many contact points along the electrode (usually 4-12) and you can change the frequency, pulse width, voltage to change the form and area within the brain you're stimulating
- Overview of possible areas of the brain to be stimulated: picture 7 - but different centers use different areas
- By doing a metaanalysis of these different medical centers, they found out that a more personalised approach is more efficient than stimulation of the general, pre-selected areas
- E.g. Stimulation of the ventral striatal capsule have improved affect symptoms compared to STN where patients have more improvement of cog. flexibility
- DBS normalizes fronto-striatal hyperconnectivity
46
DBS optimization
- Takes a long time to optimze, even a year
* Activation 2 weeks following implantation (easy surgery)
* Optimize parameters every 2 weeks
* Voltage 2-10 Volt / pulswidth / frequency
* 4-8 contactpoints
* Duration optimization phase 3-12 months
47
What sequential symptom improvement of DBS for OCD is observed?
Improvement of:
* Affective symptoms: minutes to hours
* Obsessions: days
* Compulsions: weeks
→ Rapidity of symptom improvement makes DBS highly interesting for the understanding of the underlying neurobiology of OCD
48
Efficacy of DBS in Amsterdam UMC
- The biggest center for DBS for refractory OCD worldwide
- Study by Denys et al. from the UMC: 70 patients; 25 years suffering from OCD; 12 months follow-up
- Results: 40% ↓ of symptoms: response: 52% (full repsonders) + 18% (partial responders)
- first month sharp decrease in OCD symptoms but it continues going down within the year; same results for anxiety and depression
- Adverse events:
1) hypomanic symptoms 39% (mostly only 48hrs after surgery)
2) Agitation 30% (3% permanent)
3) impulsivity 19%
4) Sleeping problems 46% (7% permanent)
5) 3 suicide attempts, 1 suïcide (non-responding patients)
49
Efficacy of DBS worldwide
Gadot e.a. (2022):
* 34 studies: 9 RCTs (n=97) en 25 non-RCTs (n=255)
* Mean decrease of the Y-BOCS 47% (14.3 points)
* Mean follow-up 24 months: 66% response
* Also decrease of depressive symptoms
* Low risk of bias
* Complications: infections 4.4%, obsession with material < 1% (it will break or stop)
50
Cognitive functioning after DBS
3 meta-analyses:
* Many different instruments and methodology
* No changes in cognitive functioning - so no decreased cognitive functioning what the patients usually expect that it will happen
* Improvement of cognitive flexibility
* safe treatment
51
Patient experiences with DBS
* Qualitative interviews with 18 patients with OCD
* Acute changes/ improvement of mood
* Long-term effects: increase of spontaneous actions, improved social interactions, possibility to enjoy life
* Increase of self-confidence
52
Availability of DBS for OCD
* Very beneficial for refractory OCD patients
* 1999 first case of DBS for OCD
* 500 DBS for OCD vs 300.000 DBS for neurological diseases - what's the problem? There are many factors but mostly that surgery is involved
* Between parkinson's and OCD there are comparable high response rates and comparable low dropout
53
Summary
* OCD is a severe psychiatric disorder, with often a hidden/silent suffering
* CSTC circuits are involved
* Cognitive-behavioral therapy (CBT) has high response rates in OCD
* Medication lowers the experienced fear, which supports exposure therapy
* rTMS & DBS are good options for treatment-refractory OCD
54
Role of Psychologists in Amsterdam UMC
* Psychologists have a prominent role in the psychotherapeutic treatment of OCD
* They make the indication for CBT/ IBA and carry out the psychotherapy
* Perform Psychological examinations for e.g. comorbid personality disorders or autism spectrum disorders
* Are part of a multdisciplinary team at our (outpatient) clinic for OCRDs (psychologists, psychiatrists, specialized nurses and therapists)
55
Stiede et al. (2025): OCD
I only included stuff that wasn't in the lecture
56
# Pathophysiology
Which biological factors have been identified through genetics?
- Relatives higher risk proportionately to degree of genetic relatedness
- Twin studies: higher concordance in monozygotic than dizygotic (Heritability 48%)
- Candidate gene for abnormal neurotransmitter activity: SLC1A1 (glutamate transporter) - may underlie generation of compulsive behaviour (evidence limited)
- Neurobiological alterations:
1) Structural/functional changes in cortico-striato-thalamo-cortical (CSTC) loops (e.g. basal ganglia) which is involved in: EF (e.g. learning and decision-making) and motor responses
2) OCD maybe related to imbalance in direct and indirect pathways (CSTC)
↪ Excessive positive feedback through direct pathway - Hyperactivation of orbitofrontal cortex (OCD symptomatology)
57
What three 3 theoretical models are there for OCD?
1. Cognitive model - already discussed as dysfunctional cognitive
2. Behavioural model
3. Inhibitory model of learning
58
What does the behavioural model of OCD say?
- Develops: repeated pairing of neutral and aversive stimuli
- Maintains: operant conditioning - alleviate anxiety, distress
- ERP (exposure response prevention)
↪ Extinguish fear response
↪ Attenuate negative reinforcement
59
# Weblecture
What are the important questions in understanding OCD?
Why do individuals with obsessive compulsive disorder continue compulsive behaviours despite being aware of the disastrous consequences?
Is compulsive behavior mostly a consequence of cognitive biases and a need for extreme (goal-directed) control? Or instead a lack of goal-directed control / extreme habit formation?
60
What is the classical view of OCD (and the DSM view)?
Suggests that compulsions are goal-directed
- Prevent or reduce anxiety
- Irrational beliefs stem from cognitive biases (cognitive theory of OCD)
- Compulsion is a consequence of the obsession
↪ Cognitive theory focuses on addressing obsessions and cognitive biases
* According to the cognitive account, compulsive acts could be goaldirected actions aimed at preventing feared events or neutralizing fear, which arises from the obsessions and cognitive biases
* According this view, the compulsion is a consequence of the obsession. (Cognitive) therapy should therefore focus in the first place on addressing the obsessions and cognitive biases.
61
What does the cognitive theory of OCD suggest?
- Compulsivity develops as a consequence of cognitive biases
- Intrusions -> dysfunctional thoughts -> compulsive behaviors
62
What 3 multipliers does the cognitive theory of compulsive checking by Rachman suggest?
3 multipliers : high perceived responsibility, high perceived probability of harm, high perceived seriousness of harm (picture 8)
- they contribute to the development of obsessive compulsive behaviour
63
What is the habit theory of OCD?
- The temporary relief caused by performing compulsions leads to reinforcement of habitual rituals associated with antecedent triggers (picture 9)
- The relief can be perceieved as a positive event so it strengthens the stimulus response leading to a habit (as Thornidike's law of effect; picture 10)
- According to the habit account of OCD, compulsions are driven by aberrantly strong habits
* In summary, rigid repetition of avoidance behavior in the same context, reinforced by the (temporary) positive experience of relief should, according to the Law of Effect, lead to habit formation
* Thus, strong habit formation could possibly lead to the experience of a compulsive urge in OCD ('I MUST do it (exactly like this)!’)
64
How does the cognitive view relate to the subjective experience of patients with OCD?
## Footnote
Compulsions as a goal-directed behavior
- Patients often report that the purpose of their compulsions is to avoid an aversive/dangerous event or situation
- In other cases, they report doing it to experience relief of anxiety
- But we must be careful in interpreting self-reported motives -> cognitive dissonance theory
65
What does the cognitive dissonance theory say about OCD?
- Cognitive dissonance is the unpleasant tension that arises from conflict between (one's) incompatible beliefs, or from (one's) behavior that conflicts with beliefs
- According to cognitive dissonance theory, people feel a strong urge to reduce dissonance by modifying or rationalizing their beliefs or their behavior
- Indeed, in some cases even ‘obsessions may arise as a post hoc rationalization of otherwise inexplicable compulsive urges' in order to resolve cognitive dissonance’
66
Critiques of seeing compulsions as goal-directed behaviours
- In OCD, the behavior is usually egodystonic, which means that a patient feels that the symptoms do not really belong to them (not consistent with self-perceived beliefs)
- They recognize that the compulsions are irrational and/or excessive: “At the moment I find washing my hands more annoying than the thought itself. It takes a long time."
- Furthermore, the relief they experience upon performing the compulsive act is usually highly transient/temporary so then the compulsions end up creating even more anxiety
67
How does the habit account relate to the subjective experience of patients with OCD?
- In addition, some patients report that they have sometimes 'suddenly'/without realizing it themselves started the compulsion act (this can be a problem in treatment)
- It is also sometimes reported that the symptoms temporarily diminish in a new environment (e.g. on holidays)
68
What does the choice of the process driving the behaviour depend on?
- The extent to which behaviour is driven by goal-directed control or habitual control depends on the balance between these processes
- in case of imparied cognitive capacity, behaviour will result from habitual control or rely more on habit formation
69
What does the relevant research for the goal-directed vs habitual status of compulsions focus on?
1. executive functions
2. the neural basis of OCD
3. direct behavioral assessments of the goal-directed/habitual status of behavior
70
What executive functions relevant for ACD are there?
1. **Cognitive flexibility**: including set shifting: the ability to shift attention between one task and another: e.g., Wisconsin-Card Sorting Test
2. **Decision making**: basing choices on the advantages/costs/risks associated with behavior: e.g., Iowa Gambling task and Delay Discounting Task
3. **Inhibitory (impulse) control**: the ability to inhibit actions and thoughts: e.g., Go/NoGo task, stop-signal task, Stroop task
71
Cognitive flexibility
Individuals with OCD tend to make more perseverative errors on the Wisconsin card sorting test
(WCST), suggesting that ability to modify responses on the basis of feedback is impaired (simply put, they do more errors than controls when sorting rule is changed)
## Footnote
Picture 11
72
Decision making on the basis of positive vs. negative consequences
- Iowa Gambling Task: OCD patients exhibit an impaired ability to adjust their behaviour on the basis of monetary gains and losses (they choose worse decks)
- Prefer immediate wins despite negative future consequences & don't learn from losses
## Footnote
Picture 12
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Decision making: delay discounting
* Previous studies yielded inconsistent results
* However, a recent large-scale study (268 unmedicated patients vs. 256 healthy controls) suggests that there is NO difference in delay discounting
* Interestingly, a subgroup of participants with OCD who suffered depressive and anxiety symptoms did show a preference for immediate, small rewards over larger, delayed ones, suggesting that DD was more related to a pessimistic outlook on the future than directly to OCD symptoms - relevant because lot of commorbidity with mood disorders which can hamper research
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Impulse control (i.e., response inhibition)
- A meta-analysis of studies with the stop-signal task reported that OCD patients tend to perform poorly compared to controls, suggesting that response inhibition deficits may be a biomarker of OCD
- The evidence is inconsistent with the Go/No-Go task and Stroop Task
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Interim Summary EF in OCD
- Several cognitive control functions are impaired in OCD patients
- Furthermore, executive dysfunction is also found in unaffected relatives of OCD patients, suggesting that it qualifies as an endophenotype candidate for OCD (heritable, disease state-independent marker)
- Therefore, impaired top-down control may contribute to a disrupted balance of goal-directed control versus habits in OCD
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What are the symptom provocation studies?
- Allows to study the compulsive brain
- Very similar to cue reactivity studies
- Show pictures that trigger emotional reactions that are relevant to the person's clinical picture
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Results of the symptom provocation studies in OCD
- The "wash" pictures in this fMRI study caused more anxiety/tension in OCD patients (with fear of contamination) than in healthy controls
- The blocked design of such studies allows one to examine which parts of the brain become active when symptoms are provoked
- The most consistent finding from symptom provocation fMRI studies is HYPERactivity in orbitofrontal cortex (OFC)/ventromedial prefrontal cortex and caudate (goal-directed brain regions) compared to controls - goal-directed pathway becomes more active as a response to symptom provoking stimuli
- Other brain regions that have been implicated are the anterior cingulate cortex (ACC), dorsolateral PFC and parietal cortex… - less consistently than the above
- Based on abnormalities in these corticostriatal circuits in compulsive patients, Graybiel and Rauch (2000) proposed that OCD is a disorder of the balance between goal-directed control and habits in line with the idea of enhanced "habit tendency”
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# Research trying to see goal-directed vs habit control
First habit research: Does habit strength of compulsions correlate with their severity?
- Self-reported habit strength (Self-Report Habit Index; SRHI) of compulsions in 73 OCD patients correlated positively with:
↪ Severity of checking (r=0.27; p=0.02)
↪ Severity of hoarding (r=0.36; p=0.01) - (In the DSM, hoarding is classified separately from OCD)
↪ Severity of ordering symptoms (r=0.29; p=0.13)
- Symptom severity and OCD were predicted by how habitual the individuals experience those behaviours - in line with habitual account
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Evidence from experimental paradigms
- Fabulous fruit game and Slips-of-action test = devaluation-outcome task
- To investigate habit propensity in OCD, we tested 21 individuals with OCD, and 30 age/gender/IQ matched controls
- OCD patients committed more 'slips of action'. This is evidence for generally enhanced 'habit propensity' (since this task is irrelevant to their obsessions and compulsions)
- There was a significant negative relationship between scores on the YaleBrown Obsessive Compulsive Scale (YBOCS) (r=-0.56, p=0.01) and SoAT difference scores (responses for valuable outcomes minus devalued outcomes - the higher the score the better people perform on the task so more goal-directed)
- Thus, the severity of OCD symptoms predicted how vulnerable patients were to slips of action
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Behaviour avoidant task
- reward-learning task- compulsive behaviours usually lead to avoidance behaviour
- 25 OCD patients and 25 controls were trained to press left and right foot pedals to avoid electric shocks to the left and right hand (respectively)
- A red or blue square signaled whether a right or left shock would be delivered
- They learned to press those pedals to avoid shocks
- After a brief training session (3 trials per stimulus), one of the two electrodes was removed, and subjects were told that they could no longer receive a shock to that hand and that their only task thereafter was to continue avoiding shocks. In other words: one of the shocks was "revalued”
- Results: OCD patients were as able as controls to stop pressing to the stimulus that signalled the devalued shock...
- ... but then the electrode was reattached (to both hands) and the subjects were given an additional 30 trials of training before the electrode was removed from the other hand...
- This time the OCD patients pressed more often to avoid the devalued shock than the healthy controls = more vulnerability to habitual responding
- OCD patients form habits more strongly or faster than controls
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What does the fMRI show on the avoidance task?
- 37 OCD patients and 33 controls were tested on a similar avoidance task inside the scanner (fMRI)
- Again, the OCD patients (after long training) continued to avoid the devalued shock more frequently than healthy controls
- Patients showed HYPERactivation of the orbitofrontal cortex during the learning phase (but this disappeared during the course of training)
- Valued stimulus > devalued stimulus fMRI contrast: Patients who had formed habits (N = 15) showed HYPERactivation of the caudate relative to patients who had not formed habits (N = 22) and controls
- Self-reported urge to avoid the safe stimulus was positively correlated with caudate activation
- Gillan and colleagues interpreted these results as evidence that hyperactivation of the caudate (and perhaps OFC) is related to an imbalance between goal-directed control and habitual control
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So what do the studies show in summary?
- To summarize, taken together, the findings of outcome-revaluation studies support the idea of increased general 'habit propensity’ in OCD, or in other words: a disturbed balance between dual processes (habit formation > goal-directed control)
- The question remains whether this is the result of excessive habit formation or impaired goal-directed, flexible control
- Also, the observation of increased activity in brain regions related to goal-directed control in patients with OCD relative to controls is a bit puzzling in this respect and contrasts with findings from the SUD studies
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What is the clinical relevance of considering these different theoretical perspectives on compulsive behaviour?
- According to the cognitive account, treatment should focus on cognitive biases
- However, exposure Response Prevention (ERP) is currently the most effective treatment for OCD - refraining from compulsions and learning that feared consequences don't occur and anxiety will naturally decrease
- But the problem with this treatment is that acceptability is low and many patients refuse to refrain
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So could the habit account offer an alternative treatment?
- Yes, it could!
- On the basis of the habit account of OCD, Habit Reversal Therapy (HRT) was proposed to offer a promising alternative
- HRT is already well-established as a treatment for individuals with Tourette’s syndrome, trichotillomania and excoriation (skin-picking) disorder
- Based on the idea that when there is a strong habit, it's easier to replace it then try and suppress it
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What two components does HRT have?
1. Awareness training (e.g., daily monitoring of compulsions and identifying the antecedents/triggers)
2. Competing response training (linking the trigger to competing response that is physically, at the motor-level, incompatible, e.g. washing hands -> make a fist)
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Evidence in favour of HRT from a case study
- After 9 sessions of HRT over 11 weeks, all 4 participants showed significant reductions in OCD severity. These gains were largely maintained at follow-up
- All participants rated HRT as a highly acceptable treatment
- Therefore, HRT may offer a promising alternative approach to behavioral treatment of OCD
- However, this has to be said with lot of caution because there has not been enough research yet
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In conclusion...
- More research is needed to shed light on the contributions of habits, cognitive control fcunctions and cognitive biases to compulsive behaviour in OCD...
- ... and to explore the relevance of the habit account of
compulsions for clinical treatment
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Learning objectives
1. List the diagnostic criteria (DSM-V) of OCD [paraphrasing]
1. List common OCD themes (symptom dimensions) [paraphrasing]
1. Explain whether behavior in OCD is ego-dystonic or ego-syntonic [paraphrasing]
1. Describe what are differences/commonalities between OCD and OCPD [paraphrasing]
1. Describe the phenomenology of OCD [paraphrasing]
1. Be able to name, describe and recognize in a case study of OCD: 6 cognitive biases [paraphrasing and evaluating]
1. List and describe evidence-based treatments for OCD, both behavioral and pharmacological, and explain with which mechanisms in OCD they intervene [analyzing] and indicate how these could be applied in the context of a case study [analyzing]
1. Explain how symptom provocation studies can provide insight into the neural basis of OCD [paraphrasing]
1. Demonstrate how studies using the 'outcome revaluation' paradigm show that the balance between habits and goal-directed control is disrupted in OCD [analyzing]
1. Take a critical position on the role of habits in OCD based on behavioral and neuroscientific research [evaluating]
1. Define 'cognitive dissonance' and explain how this could cause obsessions to result from compulsions, rather than the other way around [analyzing]
1. Describe disruptions in cognitive (or éxecutive') control functions in OCD [paraphrasing], and (based on previous literature) indicate to what extent these overlap with substance abuse, gambling disorder, and eating disorders [independent thinking]
1. Explain how Habit Reversal Therapy works [paraphrasing] and indicate how it could be a applied in the context of a case study [analyzing]
1. Describe the neurobiology of OCD [paraphrasing], and explain how it matches and differs from substance abuse and eating disorders [analyzing]
