Module 9: OCD: symptomatology, mechanisms and treatment Flashcards

Question

# Treatment 1) cognitive behavioral therapy: cognitive behavioral model of OCD

Answer 1

obsesisons -> anxiety / distress (or other bad feelings) -> compulsions -> (temporary) relief and reduction in distress BUT over time compulsions increase (due to negative reinforcement) & the brain becomes more dependent on these compulsions to manage anxiety --> this can increase overall stress and anxiety in the long run

Answer 2

Normalize intrusive thoughts and ideas because intrusive thoughts are in themselves very normal BUT The problem with OCD is that intrusive thoughts become obsessions · Obsessions may become and obsession when they appraise the intrusion as a real threat, personally significant or pvovoking high level of uncertainty

Answer 3

1. inflated responsibility: belief that one has the special power to cause and/or the duty to prevent negative outcomes 2. overimportance of thoughts (thought-action-fusion) -- belief that the mere presence of a thought makes it important -- thought has ethical or moral ramifications -- Thinking the thought increases the likelihood of performing corresponding behavior 3. Overestimation of threat: belief that negative events are especially likely 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 do not occur

Answer 4

A) Estimation of catastrophe: If i dont completely put down my cig my house fill burn down * As a clinician, calculate the probability of the catastrophe * Then identify the intermediate steps that lead to the house burning down * Calculate the chance of each and add together B) Estimation of responsibility: (e.g., when client: I am alone responsible if my bike causes an accident) * Pie technique: making a pie that includes all possible factors that could contribute to a specific catastrophe

Answer 5

* most important part of evidence based treatments for OCD exposure: overcoming avoidance by suggesting which situations trigger anxiety and doing it * Touch the inside of the toilet (flooding: exposing them to a really fearful thing) * Order things asymmetrical on your desk * Actively think of yur gruesome intrusions response prevention: reducing compulsions * Do NOT clean your hands after toilet exposure * Do not order your desk before starting work --> both lead to extinction: feared outcome is not happening -> anxiety and stress go down

Answer 6

important to go from mild to severe anxiety-provoking situations

Answer 7

Behavioral nurses say that Supported exposure is important for the patient: * Helpful to have a person who supports exposure like a behavioral nurse specialized in CBT

Answer 8

* 70% responder ! Responder defined as a 35% decrease of Y-BOCS is classified as a responder * Avg. Symptom decrease of 60-70% Although OCD still remains. Patient tell that although they are happier with their life with fewer symptoms, their OCD is still there * Patients are scared that symptoms will come back when triggered by stress

Answer 9

* 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

Answer 10

* male gender * single * lower socioeconomic status * lower educational level

Answer 11

* family history of OCD * poor therapeutic alliance * greater family accomodation * absence eatly response to SSRIs

Answer 12

have not yet been replicated again and again -> we couldn't find a good predictor of treatment outcome

Answer 13

Focus specifically on pathological doubt induced by a patient who is not able to trust their own senses - e.g., locking a door but then doubting whether you actually did - instead of exposure which is hard for patients due to increasing anxiety and fear --> quite new 2000-2005

Answer 14

* serotonergic medication * SSRIs or tricyclic medication do work in OCD * 50-60% respond to SSRIs in general the problem is that: * patient-doctor delay due to shame and fear * fear of side effects side effects of antidepressants: tricyclic vs SSRIs - you can explain to patients that some side effects relate to dose and sometimes they are only there in the start

Answer 15

used worldwide for OCD 1. start with a SSRI, max dosage, min 3 months (serotonin) 2. switch to a different SSRI, max dosage, min 3 months (serotonin) 3. switch to clomipramine (tricyclic antidepressant), maximum dosage, min of 3 months, possibility of measuring blood-levels (serotonin) 4. add a low dosage of an antipsychotic, min of 1 month (dopamine) = extra 30% responder rate

Answer 16

to find out if patients are treatment refractory or not (treatment resistant or not) --> those with a high comorbidity with depression or anxiety may benefit from medication because they are more ready to start with CBT - A combination of CBT and medication is most effective and what is seen in practice (also in meta-analyses) - Medication helps the efficacy of CBT

Answer 17

* 1-2 years continuation if there are still symptoms, because after CBT, there is stress, problems and there is no therapist --> important to continue medication --> then 1-2 years observation and decrease if no symptoms * No lowering of dosage, only after 6 months you start lowering * Gradually loweing dosage in case of prolonged remission -- If you don't do it gradually there is a HIGH relapse risk (80% after complete discontinuation) -- Lecturer advises to take medicine life long

Answer 18

What to do when up to 40% of people are not responders? - They do not respond to ANY of these treatment options --> then neuromodulation, but you have to really make sure that all other treatment options are exhausted

Answer 19

* is an additional treatment option * we still need to know for whom and how does it work * changes neurobiology in OCD CTSCC circuit -- direct pathways = excitatory effect on cortical excitability -- indirect pathways activity have an inhibitory effect --> in OCD it is proposed that there is a hyperactivity/increased activity within direct pathways ! generalized model, it could be much more complicated

Answer 20

- Focus on the dorsolateral prefrontal cortex and the superior motoric area --> most used cortical areas we stimulate in OCD

Answer 21

- Two electrodes inserted which keep inducing stimulation (benefit is that stimulation keeps happening) - Connected to a pulse monitor

Answer 22

! Targeting one area affects the whole circuit --> area that you insert in doesn't matter - A better approach may be to make the process more client-centered - Find the right voltage / area for the each patient

Answer 23

patients with focus on ventral striatum areas show improvement in affective symptoms compared to SBN where flexibility improves - Patients come in with specific symptom reduction desires and so it would be nice to be able to somehow target these

Answer 24

normalizes hyperactivity of frontostriatal brain areas in OCD patients - takes up to a year to get positive results

Answer 25

* Improvement of affective symptoms: minutes to hours -- E.g., I see the world more clear, start laughing etc. * Obsessions: days * Compulsions: weeks The rapidity of symptom improvement makes DBS highly interesting for the understanding of the underlying neurobiology of OCD - Works even for those that have been suffering for a long time, 40 years even

Answer 26

anxiety and depression decrease together with Y-BOCS scores of OCD

Answer 27

* 12-months follow-up 40% decrease in symptoms: respnse 54% (full responders) + 18% (partial responders) adverse effects: * hypomanic symptoms * agitation * sleeping problems * 3 suicide attempts, 1 completed

Answer 28

* mean decrease of Y-BOCS 47% (14,3 points) * mean follow-up 24 months: 66% response * decrease of depressive symptoms * low risk of bias * complications: infections 4,4%, obsessions with material <1% (regarding the electrode breaking)

Answer 29

3 meta-analyses on resulting cognitive functioning * Some people are scared that it will have an effect on their cognitive functioning - but - No changes in cognitive functioning * Improvement of cognitive flexibility * Complication: all studies used different instruments and methodology

Answer 30

* Patients desrcibe acute improvement in mood, function better and enjoy life again in the beginning * Long term effects: patients finally able to do spontaneous actions, living and making social contacts again Kiverstein: increase of self confidence OCD patients often overly dependent on their partners and become more independent afterwards (this may cause partners to feel bad)

Answer 31

* 1999 first case of DBS for OCD * 500 DBS for OCD vs 300 000 DBS for neurological diseases * comparable high response rates * comparable low dropout Why is it that OCD patients receive less DBS than neurological diseases?? Even though the high response rates are comparable together with comparable low dropouts

Answer 32

* OCD is a severe psychiatric disorder with often a hidden/silent suffering * CSTC circuits are involved * CBT has high response rates in OCD * medication lowers experienced fear which supports exposure therapy * rTMS & DBS are good options for treatment-refractory OCD

Answer 33

compulsions are seen as goal directed "aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situations" it is in line with the classical view of OCD according to cognitive theories as well

Answer 34

in line with the classical view of OCD according to the DSM-5 (compulsions as goal-directed actions) dysfunctional beliefs and maladaptive appraisals underlie the development of compulsions - thought of harming one's partner is interpreted as evidence that one is a bad person and likely to actually perform this behavior (anxiety and distress) - repetitive compulsions are performed to relieve the resulting anxiety and distress

Answer 35

* compulsions are seen as "rational actions based on irrational beliefs" which come from cognitive biases so, cognitive biases --> compulsivity

Answer 36

3 multipliers play a role in OCD 1. high perceived responsibility 2. high perceived possibility of HARM 3. high perceived seriousness of HARM all these multiply together to produce intense and prolonged checking or the development of compulsive behavior

Answer 37

* compulsive acts could be goal-directed actions aimed at preventing feared events or neutralizing fear that arises from cognitive biases and obsessions * compulsion is a *consequence* of obsession. (Cognitive) therapy should therefore focus on addressing obsessions and cognitive biases first and foremost

Answer 38

the temporary relief caused by performing compulsions lead to reinforcement of habitual rituals associated with antecedent triggers

Answer 39

According to the habit account of OCD, compulsions are driven by aberrantly strong habits the relief from performing a compulsions is a positive experience -> it can be seen as a form of positive reinforcement

Answer 40

* rigid repetition of avoidance behavior in the same context, reinforced by temporary positive experience of relief should, (according to the law of effect) lead to habit formation * Thus, strong habit formation could possibly lead to experience of a compulsive URGE in OCD (I must do it like this)

Answer 41

* Patients often report that the purpose of their compulsions is to avoid an aversive/dangerous event or situation - Sometimes straightforward: washing hands to prevent contamination - Other times: complex and makes no sense * 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

Answer 42

the unpleasant tension that arises from conflict between one's incompatible beliefs, or from one's behavior that conflicts with beliefs * According to CD theory, people feel a strong urge to reduce this dissonance by modifying or rationalizing their beliefs or 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 * Can also play a role in other disorders like SUD and GD

Answer 43

* In OCD, the behavior is usually egodystonic, meaning that a patient feels the symptoms to not really belong to them * 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 It is temporary, after a few minutes they have to repeat the behavior again --> generates more anxiety

Answer 44

* some patients report that they have sometimes ' suddenly' / without realizing it themselves started the compulsion act (this can be a problem in treatment) - E.g., it is hard to consciously try and suppress a behavior when you start doing it automatically without realizing * It is also sometimes reported that the symptoms temporarily diminish in a new environment (e.g., on holidays)

Answer 45

the extent to which compulsive behavior is driven by goal-directed control or by habits depends on the balance between these processes - E.g., impaired goal-directed control can increase a tendency to rely on habits and vice versa we therefore study both exec functions (goal-directed control), neural basis and direct assessment of goal/habit status of behavior

Answer 46

the ability to shift attention between one task and another * measured with the Wisconsin card sorting task results: OCD patients make more perserverative errors when sorting rule is changed -> ability to modify responses on basis of feedback is impaired

Answer 47

The ability to make choices on the advantages/costs/risks associated with behavior * measured with the Iowa Gambling task and delay discounting task Results: IGT: patients exhibit impaired ability to adjust their behavior on the basis of monetary gains and losses (they choose worse decks) DD: no difference in delay discounting BUT a subgroup who had depressive and anxiety symptoms DID show preference for immediate large rewards over delayed ones --> suggests that DD is more related to a pessimistic outlook on the future than directly to OCD symptoms!!!

Answer 48

the ability to inhibit actions nd thoughts * measured with the Go/No-Go task, stop-signal task, Stroop task) Results: Stop-signal task: OCD patients tend to perform poorly compared to controls-> response inhibition may be a biomarker of OCD Go/No-Go task & Stroop task: inconsistent evidence

Answer 49

* Several cognitive functions are impaired in OCD patients (decision making IGT, response inhibition SST & cognitive flexibility WCST) * Furthermore, executive dysfunction is also found in unaffected relatives of OCD patient, suggesting that it qualifies as an endophenotype candidate for OCD * therefore impaired top-down control may contribute to a disrupted balance of goal-directed control versus habits in OCD

Answer 50

Used to study the compulsive brain Logic is very similar to cue reactivity studies in SUDs and GDs: 1. You show pics or give experiences that trigger emotional responses central to disorder E.g., making someone deliberately act against their obsession like making a desk space messy intentionally

Answer 51

* anxiety inducing stimuli pictures are compared with neutral ones * allows one to examine which parts of the brain become active when symptoms are provoked

Answer 52

being exposed to anxiety inducing and triggering stimuli -> hyperactivity in orbitofrontal cortex (OFC)/ventromedial prefrontal cortex (vmPFC) compared to controls * other brain regions implicated are anterior cingulate cortex, dorsolateral PFC and parietal cortex

Answer 53

the goal-directed pathway seems to become more active during exposure to symptom provoking stimuli * based on abnormalities in these corticostriatal circuits in compulsive patients, OCD is indeed a disorder of the balance between goal-directed control and habits --> this is in line with the idea of enhanced habit propensity

Answer 54

self-reported habit strength of compulsions in 73 OCD patients correlated positively with * severity of cheking * severity of hoarding * severity of ordering symptoms -> symptom severity in OCD was predicted by how habitual they experienced those behaviors in line with the habit account ! this is correlational

Answer 55

* there was a significant negative relationship between scores on the OCD scale (Y-BOCS) and SoAT difference scores --> severity of OCD symptoms predicted how vulnerable patients were to slips of action

Answer 56

1. trained to press left and right foot pedals to avoid electric shocks to the left and right hand respectively 2. a red or blue square signals whether a right or left shock is delivered 3. after a while (brief vs extensive) one of the two electrodes are removed and subjects told that their only task is to continue avoiding shocks results: * after a brief training session: OCD patiens as able as controls to stop pressing to the stimulus that signaled the devalued shock * after an extensive training session: OCD patients press more often to avoid the devalued shock than controls --> there is more vulnerability to habitual perserverative responding in OCD patients & with enough repetition they form habits faster than controls

Answer 57

Patients showed hyperactivation of the orbitofrontal cortex during learning phase * But this disappeared during the course of training (in line with habit theory) Furthermore, valued stimulus > devalued stimulus in fMRI contrasts: patiens who had formed habits showed hyperactivation of the caudate relative to patients who had not formed habits and controls Finally they found that the self-reported urge to avoid the safe stimulus was positively correlated with caudate action -- the more you avoid safe stimuli the more the caudate tries to intervene and change this (hence hyperactivity) but ultimately fails Interpretation of results: evidence that hyperactivation of the caudate (and perhaps the OFC) is related to an imbalance between goal directed control and habitual control (So the study shows not a contradiction, but a malfunctioning balance between the two systems: goal-directed regions light up but don’t stop habits, and habit systems take over rigidly.)

Answer 58

* According to the cognitive account, treatment should focus on cognitive biases * However exposure response prevention is currently the most effective treatment for OCD (learning based) * But the problem with exposure response prevention acceptability is low and many aptients refuse to refrain

Answer 59

It is based on that fundamental idea that when you have a srong habit, its easier to replace it than to simply try and suppress it 2 components: * awareness training: (e.g., daily monitoring of comulsions and antecedents/triggers) * competing response training (physically incompatible response)

Answer 60

established for: * Tourette's syndrome * Trichotillomania * excoriation disorder not much research on OCD other than one case study w/ 4 patients: * after 9 sessions over 11 weeks --> sig. reductions in OCD severity * maintained largely at FU * all participants rated HRT as a highly acceptable treatment!!! This is an example of how adopting a transdiagnostic perspective may increase the development of new treatments

Answer 61

More research is needed to shed light on the contributions of habits, cognitive control functions and cognitive biases to compulsive bahvior in OCD And to explore the relevance of the habit account of compulsions for clinical treatment

Answer 62

Cortico-striato-thalamo-cortical circuit (CSTC) -> the imbalance between direct and indirect pathways within the CSTC is proposed to underlie OCD (in particular the excessive positive feedback through direct pathways in OCD leads to hyperactivation of the OFC)

Answer 63

1. overestimation of threat and inflated responsibility 2. overimportance and control of thoughts 3. perfectionism and intolerance for uncertainty technically there is 6 here

Answer 64

OCD is developed and maintained through learning principles 1. develops through classical conditioning ns(intrusive thought) + us(feared outcome) --> ur(anxiety/distress) --> cs(intrusive thought) --> cr(anxiety/distress) 2. maintained by operant conditioning performing a compulsion when encountering cs --> cr (anxiety/distress) goes down / subsides temporarily --> negative reinforcement important because it is a core element of current psychotherapeutics for OCD (ERP in CBT)

Answer 65

1. Information gathering, psychoeducation, goal setting 2. exposure and response prevention - in vivo & imaginal - fear hierarchy - us SUD scale of distress 3. relapse prevention - homework - situational exposures

Answer 66

SSRIs * dosage differs based on potency, metabolism, and OCD severity Clomipramine * widely replaced by SSRIs due to its more problematic side effect and safety profile with medication, a continuation of its use is a must or decrease should be done slowly to prevent a relapse

Answer 67

that those who were on SSRI medication AND responded well to ERP treatment, did not experience a worse outcome after stopping medication abruptly --> ERP responsiveness can make it possible to discontinue medication without further relapse complications

Module 9: OCD: symptomatology, mechanisms and treatment Flashcards

1. Module background 1-10, 2. Lecture 11-58, 3. Weblecture 59-87, 4. Stiede 88-93 (91 cards)