A Clinical Staging Model for Obsessive-Compulsive Disorder: Is It Ready for Prime Time?

Obsessive-compulsive disorder and suicide: a longitudinal study in Taiwan

AIMS

Research evidence has established an association of obsessive-compulsive disorder (OCD) with suicidal thoughts and suicide attempts. However, further investigation is required to determine whether individuals with OCD have higher risk of death by suicide compared with those without OCD.

METHODS

Of the entire Taiwanese population, between 2003 and 2017, 56,977 individuals with OCD were identified; they were then matched at a 1:4 ratio with 227,908 non-OCD individuals on the basis of their birth year and sex. Suicide mortality was assessed between 2003 and 2017 for both groups. Time-dependent Cox regression models were used to investigate the difference in suicide risk between individuals with versus without OCD.

RESULTS

After adjustment for major psychiatric comorbidities (i.e., schizophrenia, bipolar disorder and major depressive disorder), the OCD group had higher risk of suicide (hazard ratio: 1.97, 95% confidence interval: 1.57-2.48) during the follow-up compared with the comparison group. Furthermore, OCD severity, as indicated by psychiatric hospitalizations due to OCD, was positively correlated with suicide risk.

CONCLUSIONS

Regardless of the existence of major psychiatric comorbidities, OCD was found to be an independent risk factor for death by suicide. A suicide prevention program specific to individuals with OCD may be developed in clinical practice in the future.

Internet-based acceptance and commitment therapy for obsessive-compulsive symptoms: A randomized controlled trial

Subthreshold obsessive-compulsive symptoms (OCS) are associated with increased distress, help seeking behaviours, and functional problems, and may predict progression into further mental health problems. This study investigated the effectiveness of a four-module internet-based acceptance and commitment therapy (iACT) for adults with OCS compared to internet-based progressive relaxation training (iPRT). Eighty-nine adults with OCS participated in a single-blinded randomised controlled trial of iACT or iPRT. Self-report assessments of OCS, psychological flexibility, and quality of life, among others, were measured at baseline, post-treatment, and at three-month follow-up. Both iACT and iPRT showed large pre-post improvements in OCS (b = 6.32, p < 0.001, d = 0.8) and medium improvements in psychological flexibility (b = -0.38, p = 0.011, d = 0.47) and quality of life (b = -5.26, p = 0.008, d = 0.58), with no significant differences in effects between groups. All improvements were maintained at follow-up. There were no differences in attrition or adherence between groups. iACT was rated more favourably by participants at post-treatment, and there were some differences in qualitative feedback across groups. These findings suggest both iPRT and iACT may be helpful in improving mental health in adults with OCS, but that iACT may be more acceptable.

Obsessive-compulsive existential type: a dialectical-phenomenological approach

The clinical presentation of obsessive-compulsive patients is characterized by unwanted, intrusive, nonsensical, self-related, and recurrent ideas, thoughts, images, or impulses associated with active compulsive compensations. Under the operational diagnostic criteria adopted by the biological- and cognitive-oriented neopositivist medical paradigm, it is known as "obsessive-compulsive disorder." However, this paradigm has been criticized for its controversial assumptions, limited methodologies, theoretic biases, and inconsistency in producing practical outcomes. To bypass some of these issues, we propose a complementary approach that draws on and further develops existing psychopathological studies of the obsessive-compulsive anthropological condition based on dialectical phenomenological psychopathology. As such, we refer to the global clinical configuration as the "obsessive-compulsive existential type." Our theoretical inspiration comes from the classical phenomenological work on obsessions undertaken by Straus and Gebsattel, which identified the negative transformation of the obsessive-compulsive life-world or the endogenous emergence of the anti-eidos (diluting existential force). We then propose to broaden the concept of anti-eidos, especially in its dialectical correlation with eidos (unifying existential force), representing the existential dialectic between transformation and permanence. Next, we detail the dynamics of anthropological disproportions in obsessive-compulsive existential type, essentially the supremacy of the anti-eidos over the eidos. This primary imbalance modifies the obsessive-compulsive existential structure, consisting of polymorphic temporality; weakened intentionality; maladjusted calibration of distance with the world and others; an integral, isolated, besieged self with dwindling self-agency, and tense and over-protecting embodiment. We also analyze compensatory hyperreflexivity and compulsive rituals as expressions of structural counterbalancing designed to contain the primary structural disproportions and derangements. The heterogeneous obsessive-compulsive clinical manifestations are the complex result of the primary structural alteration and subsequent phenomenological compensations. They tend to be variable in temporal span and rarely assume a fixed form, hindering diagnosis. We correlate structural frameworks with multiple clinical examples. Finally, we raise some insights on how our study may contribute to scientific research and therapeutic proposals.

Closing the Gap for Children with OCD: A Staged-Care Model of Cognitive Behavioural Therapy with Exposure and Response Prevention

Childhood obsessive-compulsive disorder (OCD) is among the most prevalent and disabling mental health conditions affecting children and adolescents. Although the distress and burden associated with childhood OCD are well documented and empirically supported treatments are available, there remains an unacceptable "treatment gap" and "quality gap" in the provision of services for youth suffering from OCD. The treatment gap represents the large number of children who never receive mental health services for OCD, while the quality gap refers to the children and young people who do access services, but do not receive evidence-based, cognitive behavioural therapy with exposure and response prevention (CBT-ERP). We propose a novel staged-care model of CBT-ERP that aims to improve the treatment access to high-quality CBT-ERP, as well as enhance the treatment outcomes for youth. In staged care, patients receive hierarchically arranged service packages that vary according to the intensity, duration, and mix of treatment options, with provision of care from prevention, early intervention, through to first and second-line treatments. Based on a comprehensive review of the literature on treatment outcomes and predictors of treatments response, we propose a preliminary staging algorithm to determine the level of clinical care, informed by three key determinants: severity of illness, comorbidity, and prior treatment history. The proposed clinical staging model for paediatric OCD prioritises high-quality care for children at all stages and levels of illness, utilising empirically supported CBT-ERP, across multiple modalities, combined with evidence-informed, clinical decision-making heuristics. While informed by evidence, the proposed staging model requires empirical validation before it is ready for prime time.

Early Identification and Intervention in Pediatric Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by persistent thoughts with subsequent repetitive behaviors. Interventions that are effective for adult OCD cannot simply be generalized to pediatric OCD, since OCD in children and adolescents usually has a different clinical presentation, etiology and course from adult OCD. Delayed and inadequate treatment is associated with a worse prognosis, making the need for early identification and intervention in pediatric OCD very urgent. In this paper, we reflected on the current constraints that make early interventions for pediatric OCD unpromoted and reviewed the approaches with potential application for early identification and early intervention in pediatric OCD, categorized by three-level prevention stages corresponding to a clinical staging model. Since the etiology of pediatric OCD is still unclear, primary prevention is most lacking, and early interventions for pediatric OCD are currently focused on the secondary prevention stage, which aims to prevent the conversion of obsessive-compulsive symptoms into full-blown OCD; tertiary prevention mostly focuses on the alleviation of mild to moderate OCD, while interventions for co-morbidities are still in their infancy. We closed by considering the important research questions on this topic.

Early intervention in obsessive-compulsive disorder: From theory to practice

Obsessive-compulsive disorder (OCD) is frequent and often disabling. Yet, correct diagnosis and appropriate treatment implementation are usually delayed, with undesirable consequences. In this paper we review the rationale for early intervention in OCD and provide recommendations for early intervention services. Two scenarios are discussed, i.e., subclinical (prodromal) obsessive-compulsive symptoms (OCS) and full-blown OCD. Although the typical patient with OCD reports a long history of subclinical OCS, longitudinal studies suggest most individuals with OCS in the community do not convert to full-blown OCD. Thus, research on "at risk" phenotypes for OCD and how they should incorporate different risk factors (e.g., polygenic risk scores) are badly needed. For this specific scenario, preventative treatments that are cheap, well tolerated and highly scalable (e.g., lifestyle interventions) are of major interest. On the other hand, increasing evidence suggests OCD to be a progressive disorder and the severity and duration of illness to be associated with both biological changes and increased clinical complexity, including greater number of physical and psychiatric comorbidities, increased family accommodation and worse treatment response. Therefore, prompt identification and early treatment implementation for full-blown OCD are also critical for ethical, clinical and therapeutic reasons. Based on the existing findings, we argue that, regardless of focusing on subclinical OCS or clinical OCD, early intervention services need to target a childhood age group. In addition to delivering well established treatments to people with full-blown OCD early on their illness, early intervention services also need to provide psychoeducation for patients, families and teachers.

Medical status of outpatients with obsessive-compulsive disorder in psychiatric department and its influencing factors

OBJECTIVES

Obsessive-compulsive disorder (OCD) is a chronic and refractory mental disorder with early onset, low response rate, and poor prognosis. Studies have shown that the age of onset, severity, course of disease, and untreated course of disease may affect its clinical efficacy. At present, there are few studies on the duration of untreated illness (DUI) of OCD patients. The current medical status and untreated course of OCD patients in China are still unclear. This study aims to investigate the current medical status of OCD patients in psychiatric outpatients of a general hospital, including the course of disease and DUI as well as its influencing factors.

METHODS

A total of 310 outpatients with OCD who visited the Department of Mental Health, Guangdong Provincial People's Hospital for the first time, were recruited and interviewed. The information including age, gender, years of education, marital status, work status, age of onset, comorbid mental disorders, age of first treatment, course of disease, and DUI were collected. We also calculated the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Global Assessment Function (GAF) scores for total sample to analyze the demographic characteristics and clinical data of patients with OCT. The median DUI was used as the cut-off value, and the patients were divided into a short DUI group and a long DUI group. The differences in demographic characteristics and clinical data between the 2 groups were compared, and the factors affecting the DUI were analyzed.

RESULTS

There were 158 males (51%) and 152 females (49%). The age of onset was (19.48±7.97) years. The years of education were 13.49±3.13; 215 (69.4%) were single and 95 (30.6%) were married; 103 (33.2%) were employed and 207 (66.8%) were unemployed. The median course of OCD was 4 years and the median DUI was 3 years. There were 177 cases in the short DUI (≤3 years) group and 133 cases in the long DUI (>3 years) group. Compared with the long DUI group, the patients in the short DUI group were younger (P<0.01); they had mild obsessive-compulsive symptoms (P<0.05) and a shorter education period and course of disease (P<0.01 and P<0.001, respectively); and they were more unemployed and single (both P<0.001). Correlation analysis showed that DUI was positively correlated with age, course of disease, years of education, and Y-BOCS score (r=0.45, P<0.001; r=0.74, P<0.001; r=0.27, P<0.001; r=0.17, P<0.01). When the DUI of OCD patients was used as the dependent variable, Y-BOCS, age, course of disease, whether to work, marital status, and years of education were used as the independent variables for binary logistic regression analysis, which showed that the duration of illness could predict the short and long DUI of OCD [Wald χ2=49.78, Exp(B)=1.34, P<0.001].

CONCLUSIONS

Investigation for the medical status of OCD patients in the psychiatric outpatients of a general hospital in Guangdong, China shows that the duration of illness of OCD patients in the psychiatric outpatients and the DUI of OCD patients are generally shorter than previous foreign reports. The DUI of OCD patients is affected by the course of disease, age, severity of symptoms, and other factors. In the future, large sample, multi-center, and follow-up studies could be considered to further explore the influencing factors for the DUI of OCD and the impact on the prognosis of the disease, to help improve the status of delayed treatment for OCD and improve the effective rate of OCD treatment.

Along the fringes of Agency: neurodevelopmental account of the obsessive mind

The experiential core of the obsessive mind rests on subtle, primary mental phenomena (such as obsessions and so called "sensory phenomena") which precede and trigger behavioral compulsions. Converging evidence supports a possible pathophysiological role for altered corollary discharge (phenotypically expressed in sensorimotor symptoms and contributing to a reduced Sense of Agency [SoA]), in the neurodevelopment of obsessions and "sensory phenomena." In phenomenological terms, "sensory phenomena" may represent the subjective experiential resonance of an individual history of persistent inaccurate sensory predictions, whereas accompanying manifestations, such as the obsessive need for order and symmetry, may represent a compensatory attempt to mitigate "sensory phenomena" (eg, by increasing the sensory predictability of the surrounding world). Since disturbances of both SoA and Sense of Ownership have been thematized as potential pathogenetic factors in the neurodevelopment of the psychotic mind, a dimensional account of altered sensorimotor prediction may partly explain the affinities (and high comorbidity) between obsessive-compulsive disorder and schizophrenia spectrum disorders.

Application of a staging model in patients with obsessive-compulsive disorder: cross-sectional and follow-up results

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a prevalent and disabling condition with frequent chronic course. Staging models applied to psychiatric disorders seek to define their extent of progression at a particular time-point and differentiate early, milder clinical phenomena from those characterizing illness progression and chronicity. In OCD patients, a staging model has been recently proposed but not tested yet. This was the aim of the present study.

METHODS

From an overall sample of 198 OCD patients, recruited across two psychiatric clinics in Northern Italy, 70 patients on stable treatment completed a follow-up assessment ranging from 12 to 24 months. At follow-up initiation, patients had been divided into four staging groups, according to the model proposed by Fontenelle and Yucel. At the end of the follow-up, patients were subdivided into three groups (no stage change, improved stage, or worsened stage) compared with statistical analyses.

RESULTS

At the end of the follow-up, 67.1% patients showed no stage changes, 24.3% a stage improvement, and 8.6% a stage progression. Worsened patients showed higher rates of comorbid disorders and higher rates of unfavorable employment characteristics compared to the other subgroups (P < .05). Patients with worsened stage showed higher prevalence of somatic obsessions (P < .05), while patients with improved stage showed higher rates of magical thinking and violence/harm obsessions compared to other groups (P < .05).

DISCUSSION

The present results provide epidemiologic and clinical correlates of the first application of a staging model in a sample of OCD patients, encouraging further studies to assess the utility of this approach in the field.

Through the prism of comorbidity: A strategic rethinking of early intervention in obsessive-compulsive disorder

The diagnostic criteria for obsessive-compulsive disorder (OCD) have undergone minor changes in DSM-5 yet a major turnaround intervened in the overarching categorical allocation. OCD indeed has been separated from the anxiety disorders and included in an autonomous class of OCD-related disorders. Converging factors, i.e., the specificity of the clinical phenotype, the robust evidence for familial aggregation, the availability of effective treatments, and the increasing awareness of the role of environmental factors in its onset and course make OCD a suited target for tailored early intervention programs. However, studies on the topic are still scarce and OCD remains marginally conceptualized within an overdue early detection/intervention framework. Starting from the consolidated clinical evidence of OCD extensive comorbidity with schizophrenia-spectrum and bipolar disorders, we articulate a strategic proposal for a more integral incorporation of OCD within early detection and intervention paradigm.

Predictors for 12-month long-term outcome in patients with obsessive-compulsive disorder: The influence of duration of untreated illness and age at onset

BACKGROUND

It remains unknown whether the duration of untreated illness (DUI) may play a critical role in clinical improvement of patients with obsessive-compulsive disorder (OCD). Using a relatively large sample of subjects with OCD, this study investigated the potential impact of the DUI on patients' clinical course and long-term treatment response.

METHODS

Two hundred and seven patients with OCD recruited by the OCD outpatient clinic of our university hospital participated in the study. The sample was divided into two groups according to the median DUI (DUI≤3 years and DUI >3 years). Patients were treated with selective serotonin reuptake inhibitors or venlafaxine for 48 weeks in open-label conditions. Treatment response and other clinical variables were analysed.

RESULTS

The total sample showed a mean (SD) DUI of 4.07 (3.5) years, and the mean (SD) illness duration was 6.27 (6.5) years. More than half of the patients had not been treated before (56.5% for OCD). With a median of 3 years as cutoff DUI, response rates were found to be significantly higher in subjects with a short DUI (p < 0.001). Regression analyses showed that a short (≤3 years) DUI and later age at onset predicted better response and higher Y-BOCS scores percentage changes at the endpoint of 48 weeks (β = -1.11, p = 0.003). In addition, there was no correlation between DUI and age of onset in the total patients (r = -0.13, p＞0.05).

CONCLUSIONS

This preliminary study suggests associations between a shorter duration of untreated OCD and favourable long-term outcomes, and a longer DUI with a worse clinical course.

Short communication: A report of the first twelve months of an early intervention service for obsessive-compulsive disorder (OCD)

OBJECTIVES

To present a report on the first twelve months of an early intervention service for patients with obsessive-compulsive and related disorders.

METHODS

Demographic and clinical data including changes in the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Obsessive Compulsive Inventory - Revised (OCI-R) were reported for 48 patients referred to the Western Sydney Obsessive-Compulsive and Related Disorders Service during the first 12 months of its operation.

RESULTS

The service provided education, training and specialised quaternary level assessment and recommendations to patients who have already been assessed by a psychiatrist and/or mental health worker within early intervention teams for psychosis, anxiety clinics and other public psychiatric services. The service failed to reach OCD sufferers early in their course of illness with the mean time from symptom onset being 9.4 years. The use of objective measures such as the Y-BOCS and OCI-R at follow-up was poor and 86.0% (n = 37) remained in treatment at 12 months.

CONCLUSIONS

An early intervention service for OCD is unlikely to be able to assist sufferers early in their course of illness if it is associated with quaternary clinical services or early intervention programmes for psychosis. Efforts might be better focused on providing education and on early screening of young people in non-clinical settings.

Preventive psychiatry: a blueprint for improving the mental health of young people

Preventive approaches have latterly gained traction for improving mental health in young people. In this paper, we first appraise the conceptual foundations of preventive psychiatry, encompassing the public health, Gordon's, US Institute of Medicine, World Health Organization, and good mental health frameworks, and neurodevelopmentally-sensitive clinical staging models. We then review the evidence supporting primary prevention of psychotic, bipolar and common mental disorders and promotion of good mental health as potential transformative strategies to reduce the incidence of these disorders in young people. Within indicated approaches, the clinical high-risk for psychosis paradigm has received the most empirical validation, while clinical high-risk states for bipolar and common mental disorders are increasingly becoming a focus of attention. Selective approaches have mostly targeted familial vulnerability and non-genetic risk exposures. Selective screening and psychological/psychoeducational interventions in vulnerable subgroups may improve anxiety/depressive symptoms, but their efficacy in reducing the incidence of psychotic/bipolar/common mental disorders is unproven. Selective physical exercise may reduce the incidence of anxiety disorders. Universal psychological/psychoeducational interventions may improve anxiety symptoms but not prevent depressive/anxiety disorders, while universal physical exercise may reduce the incidence of anxiety disorders. Universal public health approaches targeting school climate or social determinants (demographic, economic, neighbourhood, environmental, social/cultural) of mental disorders hold the greatest potential for reducing the risk profile of the population as a whole. The approach to promotion of good mental health is currently fragmented. We leverage the knowledge gained from the review to develop a blueprint for future research and practice of preventive psychiatry in young people: integrating universal and targeted frameworks; advancing multivariable, transdiagnostic, multi-endpoint epidemiological knowledge; synergically preventing common and infrequent mental disorders; preventing physical and mental health burden together; implementing stratified/personalized prognosis; establishing evidence-based preventive interventions; developing an ethical framework, improving prevention through education/training; consolidating the cost-effectiveness of preventive psychiatry; and decreasing inequalities. These goals can only be achieved through an urgent individual, societal, and global level response, which promotes a vigorous collaboration across scientific, health care, societal and governmental sectors for implementing preventive psychiatry, as much is at stake for young people with or at risk for emerging mental disorders.

Specialty knowledge and competency standards for pharmacotherapy for adult obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making.

A transdiagnostic perspective of constructs underlying obsessive-compulsive and related disorders: An international Delphi consensus study

BACKGROUND

The Research Domain Criteria seeks to bridge knowledge from neuroscience with clinical practice by promoting research into valid neurocognitive phenotypes and dimensions, irrespective of symptoms and diagnoses as currently conceptualized. While the Research Domain Criteria offers a vision of future research and practice, its 39 functional constructs need refinement to better target new phenotyping efforts. This study aimed to determine which Research Domain Criteria constructs are most relevant to understanding obsessive-compulsive and related disorders, based on a consensus between experts in the field of obsessive-compulsive and related disorders.

METHODS

Based on a modified Delphi method, 46 experts were recruited from Australia, Africa, Asia, Europe and the Americas. Over three rounds, experts had the opportunity to review their opinion in light of feedback from the previous round, which included how their response compared to other experts and a summary of comments given.

RESULTS

Thirty-four experts completed round one, of whom 28 (82%) completed round two and 24 (71%) completed round three. At the final round, four constructs were endorsed by ⩾75% of experts as 'primary constructs' and therefore central to understanding obsessive-compulsive and related disorders. Of these constructs, one came from the Positive Valence System (Habit), two from the Cognitive Control System (Response Selection/Inhibition and Performance Monitoring) and the final construct was an additional item suggested by experts (Compulsivity).

CONCLUSION

This study identified four Research Domain Criteria constructs that, according to experts, cut across different obsessive-compulsive and related disorders. These constructs represent key areas for future investigation, and may have potential implications for clinical practice in terms of diagnostic processes and therapeutic management of obsessive-compulsive and related disorders.

Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders

In this position statement, developed by The International College of Obsessive-Compulsive Spectrum Disorders, a group of international experts responds to recent developments in the evidence-based management of obsessive-compulsive disorder (OCD). The article presents those selected therapeutic advances judged to be of utmost relevance to the treatment of OCD, based on new and emerging evidence from clinical and translational science. Areas covered include refinement in the methods of clinical assessment, the importance of early intervention based on new staging models and the need to provide sustained well-being involving effective relapse prevention. The relative benefits of psychological, pharmacological and somatic treatments are reviewed and novel treatment strategies for difficult to treat OCD, including neurostimulation, as well as new areas for research such as problematic internet use, novel digital interventions, immunological therapies, pharmacogenetics and novel forms of psychotherapy are discussed.

Risk for Pathological Contamination Fears at Coronavirus Time: Proposal of Early Intervention and Prevention Strategies

COVID-19 outbreak represents a stressful life event that might potentially trigger psychopathological symptoms in people with a pre-existing vulnerability. This is particularly relevant for the onset or exacerbation of pathological contamination fears in people with vulnerability to obsessive-compulsive disorder (OCD) or in those individuals with sub-threshold obsessive-compulsive symptoms, or who achieved recovery after a successful treatment. Strict movement restrictions and hygiene habits are essential to limit COVID-19 diffusion and delay its progression. However, the occurrence of dysfunctional, clinically relevant contamination fears may be the downside highlighting the importance of a more comprehensive knowledge on the vulnerability factors of OCD in order to inform policy making and risk communication on one hand, early identification and prevention on the other one. The importance of early identification and prevention of OCD during critical periods, such as the present one, is of paramount importance since this psychiatric condition is associated with a prolonged latency in the correct diagnosis and first professional contact which is in turn associated with worse prognosis and higher resistance to treatment.

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.

Functional Connectivity of the Striatum as a Neural Correlate of Symptom Severity in Patient with Obsessive-Compulsive Disorder

OBJECTIVE

It is well established that the cortico-striato-thalamo-cortical (CSTC) circuit is implicated in the pathophysiology of obsessive- compulsive disorder (OCD). However, reports on corticostriatal functional connectivity (FC) in OCD have been inconsistent due to the structural and functional heterogeneity of the striatum. Therefore, in the present study, we investigated corticostriatal FC using a fine 12-seed striatal parcellation to overcome this heterogeneity and discover the neural correlates of symptoms in OCD patients.

METHODS

We recruited 23 OCD patients and 23 healthy controls (HCs). Whole-brain FC based on striatal seeds was examined using resting-state functional magnetic resonance imaging data and compared across OCD patients and HCs. We conducted correlation analysis between FCs of striatal subregions with significant group differences and symptom severity scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Hamilton Rating Scale for Depression, and Hamilton Rating Scale for Anxiety (HAM-A).

RESULTS

Compared to HCs, patients demonstrated increased FC of the dorsal caudal putamen and ventral rostral putamen (VRP) with several cortical regions, such as the intracalcarine cortex, inferior frontal gyrus, supramarginal/angular gyrus (SMG/AG), and postcentral gyrus (PCG). Furthermore, FC between the VRP and SMG/AG and between the VRP and PCG was negatively correlated with scores on the Y-BOCS compulsive subscale and the HAM-A, respectively.

CONCLUSION

These findings suggest that striatal subregions have strengthened FC with extensive cortical regions, which may reflect neural correlates of compulsive and anxious symptoms in OCD patients. These results contribute to an improved understanding of OCD pathophysiology by complementing the current evidence regarding striatal FC.