Interoceptive Exposure: An Overlooked Modality in the Cognitive-Behavioral Treatment of OCD

Identifying subgroups of urge suppression in Obsessive-Compulsive Disorder using machine learning

Obsessive-compulsive disorder (OCD) is phenomenologically heterogeneous. While predominant models suggest fear and harm prevention drive compulsions, many patients also experience uncomfortable sensory-based urges ("sensory phenomena") that may be associated with heightened interoceptive sensitivity. Using an urge-to-blink eyeblink suppression paradigm to model sensory-based urges, we previously found that OCD patients as a group had more eyeblink suppression failures and greater activation of sensorimotor-interoceptive regions than controls. However, conventional approaches assuming OCD homogeneity may obscure important within-group variability, impeding precision treatment development. This study investigated the heterogeneity of urge suppression failure in OCD and examined relationships with clinical characteristics and neural activation. Eighty-two patients with OCD and 38 controls underwent an fMRI task presenting 60-s blocks of eyeblink suppression alternating with free-blinking blocks. Latent profile analysis identified OCD subgroups based on number of erroneous blinks during suppression. Subgroups were compared on behavior, clinical characteristics, and brain activation during task. Three patient subgroups were identified. Despite similar overall OCD severity, the subgroup with the most erroneous eyeblinks had the highest sensory phenomena severity, interoceptive sensitivity, and subjective urge intensity. Compared to other subgroups, this subgroup exhibited more neural activity in somatosensory and interoceptive regions during the early phase (first 30 s) of blink suppression and reduced activity in the middle frontal gyrus during the late phase (second 30 s) as the suppression period elapsed. Heterogeneity of urge suppression in OCD was associated with clinical characteristics and brain function. Our results reveal potential treatment targets that could inform personalized medicine.

Differential posttraumatic stress disorder symptom cluster response to stellate ganglion block: secondary analysis of a randomized controlled trial

Empirically supported treatments for posttraumatic stress disorder (PTSD) exist, but research suggests these therapies are less effective, acceptable, and feasible to deliver to active duty service members (SMs) compared to civilians. Stellate ganglion block (SGB) procedure, in which a local anesthetic is injected around the cervical sympathetic chain or stellate ganglion to temporarily inhibit sympathetic nervous activity, is gaining popularity as an alternative PTSD treatment in military settings. However, it is unknown whether certain PTSD symptoms are more responsive to SGB than others. The current study involved a secondary analysis of data collected from a previous randomized controlled trial of SGB compared to sham (normal saline) injection (N = 113 SMs). PTSD symptoms were assessed via clinical interview and self-report at baseline and 8 weeks post-SGB or sham. Logistic regression analyses showed that the marked alterations in arousal and reactivity PTSD symptom cluster demonstrated the greatest symptom severity reductions after SGB, relative to sham. The reexperiencing cluster also showed pronounced response to SGB in clinician-rated but not self-reported outcomes. Post-hoc item-level analyses suggested that arousal and reactivity cluster findings were driven by reductions in hypervigilance, concentration difficulties, and sleep disturbance, whereas clinician-rated reexperiencing cluster findings were driven by reductions in physiological reactions to trauma cues, emotional reactions to trauma cues, and intrusions. Our findings align with a burgeoning literature positioning SGB as a potential novel or adjunctive PTSD treatment. Results could guide future hypothesis-driven research on mediators of therapeutic change during SGB for PTSD symptoms in SMs.

Relationships between interoceptive sensibility and resting-state functional connectivity of the insula in obsessive-compulsive disorder

Patients with obsessive-compulsive disorder (OCD) exhibit abnormality in their subjective perception of internal sensation, a process known as interoceptive sensibility (IS), as well as altered functioning of the insula, a key neural structure for interoception. We investigated the multivariate structure of IS in 77 OCD patients and 53 controls and examined associations of IS with resting-state functional connectivity (FC) of the insula within the OCD group. For each group, principal component analysis was performed on 8 subscales of the Multidimensional Assessment of Interoceptive Awareness assessing putatively "adaptive" and "maladaptive" aspects of IS. Associations between IS components and insula FC in the OCD group were evaluated using seed regions placed in each of 3 subdivisions of the insula (posterior, anterior dorsal, and anterior ventral). Behaviorally, controls showed a 2-component solution broadly categorized into "adaptive" and "maladaptive" IS, while OCD patients exhibited a 3-component solution. The general tendency to notice or be aware of sensation loaded onto an "adaptive" IS component in controls but loaded onto both "adaptive" and "maladaptive" IS components in OCD. Within OCD, insula FC was differentially associated with distinct aspects of IS, identifying network connections that could serve as future targets for the modulation of IS in OCD.

Delivering Transdiagnostic Treatment Over Telehealth During the COVID-19 Pandemic: Application of the Unified Protocol

The COVID-19 pandemic has necessitated an abrupt transition to remote delivery of psychology services at a time when patients and practicing clinicians are experiencing an increase in life stressors (e.g., job loss, social isolation, need to adapt to telehealth practice), which can exacerbate mental health concerns and contribute to clinician burnout. Because the COVID-19 pandemic is affecting diverse individuals in myriad ways, these circumstances can elicit a wide range of emotions and emotional responses. Thus, treatment during this time must be able to address heterogeneous presenting problems while placing minimal burden on clinicians who are adjusting to continuously changing circumstances. Transdiagnostic, emotion-focused, cognitive behavioral treatments (CBT), such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), may be particularly well suited to address the challenges faced by practicing psychologists, and their patients, in the current COVID-19 pandemic. This paper discusses the applicability and adaptability of transdiagnostic treatments to telehealth, focusing primarily on the UP in the context of the COVID-19 pandemic. Further, while many CBT skills (e.g., mindfulness) can be easily translated to tele-delivery, other skills, such as exposure, can be more difficult to implement remotely, especially in the midst of a pandemic. Thus, this paper also provides practical suggestions for clinicians with regard to implementing the UP remotely.

Interoception and Obsessive-Compulsive Disorder: A Review of Current Evidence and Future Directions

Disrupted interoceptive processes are present in a range of psychiatric conditions, and there is a small but growing body of research on the role of interoception in obsessive-compulsive disorder (OCD). In this review, we outline dimensions of interoception and review current literature on the processing of internal bodily sensations within OCD. Investigations in OCD utilizing objective measures of interoception are limited and results mixed, however, the subjective experience of internal bodily sensations appears to be atypical and relate to specific patterns of symptom dimensions. Further, neuroimaging investigations suggest that interoception is related to core features of OCD, particularly sensory phenomena and disgust. Interoception is discussed in the context of treatment by presenting an overview of existing interventions and suggesting how modifications aimed at better targeting interoceptive processes could serve to optimize outcomes. Interoception represents a promising direction for multi-method research in OCD, which we expect, will prove useful for improving current interventions and identifying new treatment targets.

Dimensions of interoception in obsessive-compulsive disorder

Interoceptive sensibility (IS) refers to the subjective experience of perceiving and being aware of one's internal body sensations, and is typically evaluated using self-report questionnaires or confidence ratings. Here we evaluated IS in 81 patients with OCD and 76 controls using the Multidimensional Scale of Interoceptive Awareness (MAIA), which contains 8 subscales assessing adaptive and maladaptive responses to sensation. Compared to controls, OCD patients showed hyperawareness of body sensations. Patients also demonstrated a more maladaptive profile of IS characterized by greater distraction from and worry about unpleasant sensations, and reduced tendency to experience the body as safe and trustworthy. These findings were independent of medication status and comorbidities in the patient group. Correlational analyses showed that subscales of the MAIA were differentially associated with OCD symptom dimensions. These findings indicate that patients with OCD show abnormality of IS that is independent of confounding factors related to medication and comorbidities and associated with different OCD symptom dimensions. Future work would benefit from examining neural correlates of these effects and evaluating whether dimensions of IS are impacted by treatments for the disorder.

Sexual Arousal in Obsessive-Compulsive Disorder With and Without Contamination/Washing Symptoms: A Moderating Role of Disgust Sensitivity

Different findings would indicate that obsessive-compulsive disorder (OCD), a common psychiatric condition, might significantly impair intimate relationships and sexual well-being. The aim of the present study was to ascertain whether OCD outpatients with contamination/washing symptoms experience a lower sexual arousal than those experiencing other symptoms. In addition, we explored whether a higher disgust propensity/sensitivity might moderate the relation between contamination/washing symptoms and impaired sexual arousal. A total of 72 outpatients (27 with contamination/washing symptoms and 45 with other obsessive-compulsive symptoms) were selected for this study and assessed by a battery of specific rating scales. The results highlighted how OCD patients with contamination/washing symptoms and higher disgust sensitivity showed an increased propensity to inhibition due to threat of sexual performance failure and consequences. It may be speculated that the disgust sensitivity may be a mechanism involved in the impairment of this well-being domain. In conclusion, these findings suggest that the sexual wellbeing should be evaluated during routine clinical evaluation of OCD patients.

Obsessive-compulsive symptoms and their links to depression and anxiety in clinic- and community-based pediatric samples: A network analysis

BACKGROUND

Symptoms of depression and anxiety are common in children with obsessive-compulsive disorder (OCD) and associated with more severe OCD, greater impairment, and worse treatment outcome. Beyond twin studies showing that genetic factors contribute to the high co-occurrence, few studies have examined how OCD, depression, and anxiety are linked in youth, and current studies often fail to account for OCD and anxiety heterogeneity.

METHODS

Network analysis was used to investigate how OCD were linked to depression and anxiety in multinational youth diagnosed with OCD (total n = 419) and in school-recruited, community-based samples of youth (total n = 2 991).

RESULTS

Initial results aligned with earlier work showing that severity of obsession-related symptoms are important in linking OCD to depression in youth with OCD. However, when symptom content of OCD (e.g., washing, ordering) was fully taken into account and when measures of anxiety were included, specific OCD symptom dimensions (primarily obsessing and doubting/checking) were linked to specific anxiety dimensions (primarily panic and generalized anxiety) which in turn were linked to depression. These results were replicated in three separate community-based samples from Chile, Italy, and Spain using different measures of anxiety and depression.

LIMITATIONS

Cross-sectional data were analyzed which precludes causal inference. Self-report measures were used.

CONCLUSIONS

Youth with OCD with symptoms related to doubting/checking and obsessing should be carefully assessed for symptoms of panic and generalized anxiety. Non-responders to standard OCD treatment may benefit from interventions targeting panic and generalized anxiety, but more research is needed to test this hypothesis.

The heterogeneous course of OCD - A scoping review on the variety of definitions

Although effective treatments exist, obsessive-compulsive disorder (OCD) is, according to the views of patients and experts, still associated with chronicity, a term with no clear and consistent definition. To improve patient care and to foster research, a clear distinction between the various concepts of chronicity cited in the literature is crucial. The aim was thus to explicate central concepts related to courses and trajectories in OCD based on an explorative, scoping search of the existing literature. Our review revealed a considerable lack in content validity, as the concepts were operationalized inconsistently. Concepts related to symptom improvement were (complete) recovery, partial/full remission and partial/full response. Terms used in relation with symptom stability or worsening were chronic/continuous, intermittent and episodic course, waxing and waning, relapse, recurrence, deterioration and treatment-refractoriness. All concepts are explained and visualized as a result of the review. Further, based on authors' remarks, we present recommendations on how to enhance care for chronic OCD patients, namely training psychotherapists to apply CBT as intended, managing patient beliefs about disease and treatment, and adapting psychotherapy to OCD subtypes. Finally, we then propose a literature-based definition of treatment-refractory OCD.

The impact of prolonged exposure therapy on social support and PTSD symptoms

BACKGROUND

Posttraumatic stress disorder (PTSD) results in high costs to society, particularly among military personnel. Much is known about PTSD treatments-such as exposure therapies-and their outcomes, but less is known about how treatment might impact social support and PTSD symptoms over the course of treatment.

METHODS

In the current study, soldiers with PTSD (N = 162) were randomized to complete prolonged exposure therapy (either with or without virtual reality) or a waitlist control condition. We examined the impact of treatment on perceived social support as a secondary treatment outcome, as well as the associations between social support and PTSD symptoms over time.

RESULTS

Exposure therapy increased perceived social support at the end of treatment compared to waitlist control, β = 0.43, 95% CI [0.13, 0.73]. Multigroup structural equation modeling using a cross-lagged panel design provided evidence that perceived social support was an antecedent of PTSD symptom improvement for participants engaging in treatment, but not for participants in the waitlist control. Treatment effects on change in PTSD symptoms was mediated by change in perceived social support (B = 1.10, 95% CI [0.20, 3.05]).

LIMITATIONS

The results should be considered in light of limitations, including the characteristics of the sample of active duty soldiers, the measurement of social support, and missingess over the course of the study.

CONCLUSIONS

These results suggest that increased perceived social support is a secondary outcome of exposure therapy and may be one pathway through which treatment reduces PTSD symptoms.

Learning From Artemisia's Lucretia: Embodied Suffering and Interoception in Suicide

In the painting "Lucretia," Artemisia Gentileschi, one of the major painters of the 17^th century, depicts Lucretia's suicide. This artwork empathic vision offers the spectator the apprehension of a unique phenomenon where psychological pain is transformed into self-aggression. To understand why the body becomes an object to attack, it is important to study the role of interoception and self-awareness in the suicidal process. This essay discusses how bodily representations are crucial for interacting efficiently and safely with the outside world and for establishing the sense of self. It presents some of the available evidence showing that alterations in the body representation and in the sensations perceived by it contribute to suicide. Indeed, neuroimaging studies show that social environmental factors and their biological consequences in the body (e.g., increased neuroinflammation) can alter the neural networks of suicidal behavior by increasing the sensitivity to psychological pain and the disconnection from self-awareness. Therefore, body image, sensations and awareness as well as psychological pain should be examined to improve the understanding of the dynamic interactions between body, brain, and mind that underly suicidal behavior. This conceptualization brings clinical and therapeutic perspectives in a domain where they are urgently needed.

Interoceptive deficits, non-suicidal self-injury, and suicide risk: a multi-sample study of indirect effects

BACKGROUND

Interoceptive deficits (ID) have been associated with non-suicidal self-injury (NSSI) and suicidal behavior in multiple studies. Many of these studies are limited in scope, and have not fully examined possible mechanisms explaining how ID affect suicidal behavior.

METHODS

This study assesses how self-reported ID relate to suicide ideation and attempts in six distinct and geographically diverse samples of adults (n = 2706) and one sample of adolescents (n = 436). Participants responded to a variety of self-report questionnaires and interviews.

RESULTS

Contrary to our hypothesis, self-reported ID were only associated with suicidal ideation in two samples, one of which was the adolescent sample. Largely consistent with our predictions, self-reported ID exhibited an indirect effect on suicide attempts through versatility of NSSI in four of the five adult samples tested. Finally, the indirect effects of self-reported ID on suicide attempts through NSSI versatility did not act indirectly through behaviorally assessed pain tolerance.

CONCLUSIONS

We found that, in adults, self-reported ID are not associated with suicidal ideation, but are connected with a history of suicide attempts, through an indirect effect via NSSI. Our findings also indicate that the mechanism of action leading from self-reported ID to suicidal behavior may differ between adolescents and adults, and relate to suicidal behavior independent of pain tolerance. Clinical implications and future directions are discussed.

Research priorities set by people with OCD and OCD researchers: Do the commonalities outweigh the differences?

Objective

In contrast to research agendas being predominantly set by scientists or funders, a collaborative approach was used to spot future goals for research on obsessive‐compulsive disorder.

Methods

First, we conducted a meta‐review and then compared the results of two online surveys with OCD professionals and patients on research priorities. The literature search was performed in three comprehensive databases, and ten research goals were extracted. Sixty‐four patients and eight professionals responded to open questions on their five most important goals. Then, they ranked the ten aims extracted from the literature on a 6‐point Likert scale.

Results

For patients and professionals, research on treatment gains that persist long‐term was most important. Concerning the top five goals listed in an open format, for patients, development and maintenance of the disease was as important as psychotherapy and its efficacy. In contrast, for professionals, the efficacy and the optimization of psychotherapy were the far most important research goals.

Conclusions

We proposed one possibility to involve patients in OCD research, and the multitude of answers presents a wealth of research ideas.

Practice Implications

Since consistent research involvement may contribute to its clinical impact, researchers are now invited to translate our findings into empirical studies.

The Brown Incompleteness Scale (BINCS): Measure development and initial evaluation

BACKGROUND

In recent years, incompleteness has received increased clinical attention as a core motivation underlying obsessive-compulsive spectrum disorders. Yet, assessment of incompleteness has relied almost exclusively on self-report and has assumed a unitary conceptualization of this phenomenon. Therefore, we sought to develop and validate a new multi-faceted clinician-administered measure of incompleteness. The Brown Incompleteness Scale (BINCS) consists of 21 items; each rated on a 5-point scale, with higher scores indicating a greater degree of incompleteness. The current study describes the measure's development and preliminary validation.

METHODS

The scale was administered to 100 consecutive participants who were part of a longitudinal follow-up study of OCD. The reliability, validity, and factor analytic structure of the scale were evaluated.

RESULTS

Exploratory factor analysis supported a two-factor solution, which can best be described as representing both behavioral and sensory manifestations of incompleteness.

CONCLUSIONS

The BINCS demonstrated strong internal consistency as well as convergent and divergent validity. This clinician-administered scale will provide a more comprehensive clinical assessment of patients with incompleteness.