Functions of compulsions in obsessive-compulsive disorder

Compulsive rituals in Obsessive-Compulsive Disorder - A qualitative exploration of thoughts, feelings and behavioral patterns

BACKGROUND AND OBJECTIVES

Rituals are common among healthy individuals and across cultures and often serve adaptive purposes. In individuals with obsessive-compulsive disorder (OCD), rituals become compulsive, time-consuming and distressing, and may lead to functional impairment. Previous research has examined the functions and characteristics of compulsive rituals, but there is paucity of in-depth, first-person reports about this topic.

METHOD

We used a qualitative approach to explore thoughts, feelings, and behavioral patterns that characterize OCD rituals. Ten individuals with OCD participated in a semi-structured interview that focused on their most prominent compulsive ritual. The interviews were subjected to a thematic analysis.

RESULTS

Eight themes emerged from the analysis and were organized in two main categories: Micro Level perspective, comprising triggers, attention, emotional changes, and stopping criteria; and Macro Level perspective, comprising feelings and perceptions, change over time, motives, and inhibitors. The findings shed light on the role of fixed rules and feelings of "completeness" in OCD rituals, the nature of emotional and attentional characteristics during rituals performance, and the evolution of compulsive rituals over time.

LIMITATIONS

This study used a qualitative approach based on a small number of participants, which limits the generalizability of the findings.

CONCLUSION

Our results, if replicated, may have clinical implications. The reported patterns of anxiety reduction during ritual performance may contribute to the fine-tuning of CBT for OCD. The findings concerning the nature of attention during ritual performance and the development of rituals over time may be important for understanding the mechanisms that maintain compulsive rituals.

Altered neural anticipation of reward and loss but not receipt in adolescents with obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is characterized by persistent, unwanted thoughts and repetitive actions. Such repetitive thoughts and/or behaviors may be reinforced either by reducing anxiety or by avoiding a potential threat or harm, and thus may be rewarding to the individual. The possible involvement of the reward system in the symptomatology of OCD is supported by studies showing altered reward processing in reward-related regions, such as the ventral striatum (VS) and the orbitofrontal cortex (OFC), in adults with OCD. However, it is not clear whether this also applies to adolescents with OCD.

METHODS

Using functional magnetic resonance imaging, two sessions were conducted focusing on the anticipation and receipt of monetary reward (1) or loss (2), each contrasted to a verbal (control) condition. In each session, adolescents with OCD (n1=31/n2=26) were compared with typically developing (TD) controls (n1=33/ n2=31), all aged 10-19 years, during the anticipation and feedback phase of an adapted Monetary Incentive Delay task.

RESULTS

Data revealed a hyperactivation of the VS, but not the OFC, when anticipating both monetary reward and loss in the OCD compared to the TD group.

CONCLUSIONS

These findings suggest that aberrant neural reward and loss processing in OCD is associated with greater motivation to gain or maintain a reward but not with the actual receipt. The greater degree of reward 'wanting' may contribute to adolescents with OCD repeating certain actions more and more frequently, which then become habits (i.e., OCD symptomatology).

Differential Diagnosis of Autism and Other Neurodevelopmental Disorders

This article discusses the diagnostic criteria for autism spectrum disorder (ASD), as well as other neurodevelopmental disorders that may be confused with or co-occur with ASD. Practitioners involved in diagnostic assessment of ASD must be well versed in the features that differentiate ASD from other conditions and be familiar with how co-occurring conditions may manifest in the context of ASD. ASD symptoms present differently across development, underscoring the need for training about typical developmental expectations for youth. Periodic reevaluations throughout development are also important because support needs for individuals with autism change over time.

Exploring the relationship between context and obsessions in individuals with obsessive-compulsive disorder symptoms: a narrative review

Obsessions in obsessive-compulsive disorder (OCD) have long been proposed to differ from intrusive thoughts in unaffected individuals based on appraisal of the thoughts. However, more recent research indicates that cognitive processes behind obsessions may differ significantly from those in healthy individuals concerning their contextual relationship. This narrative literature review summarizes current evidence for the role of context-relatedness for obsessions in OCD and intrusive thoughts in affected and unaffected individuals. The review encompasses a total of five studies, two of which include individuals diagnosed with OCD (one study also includes a group of unaffected control individuals), while the other three studies investigate the relationship between OCD symptoms and context in unaffected individuals. As assessed by mainly self-reports, the review examines the connection between thoughts and their context, shedding light on how the repetition and automaticity of thoughts, as well as their detachment from context over time contribute to defining obsessions in contrast to intrusive thoughts. However, the link with context depends on the content of the obsessions. We propose the term "decontextualization of thoughts" to describe the phenomenon that obsessions gradually lose their connection with external context during the development of OCD. Future research should investigate whether this hypothesis can be supported by experimental evidence and identify whether this shift might be more likely a cause or a consequence of the disorder.

Anxiety during the long-term course of obsessive-compulsive disorder

OBJECTIVE

The study aimed to investigate anxiety and its relation with obsessive-compulsive symptoms during the long-term course of obsessive-compulsive disorder (OCD).

METHODS

We used data from the Netherlands OCD Association (NOCDA) study, which included 419 participants with OCD (aged 18-79 years). Severity of obsessive-compulsive symptoms and anxiety at baseline and after two, four, and six years were entered into three models, which were analyzed using structural equation modeling: 1) the cross-lagged model, which assumes that anxiety and obsessive-compulsive symptoms are two distinct groups of symptoms interacting directly on the long-term; 2) the stable traits model, which assumes that anxiety and obsessive-compulsive symptoms result from two distinct latent factors, which are stable over the time and interact with each other; and 3) the common factor model, which assumes that anxiety and obsessive-compulsive symptoms are presentations of the same latent factor.

RESULTS

The cross-lagged model and the stable traits model both were valid models with a good model fit. The common factor model had a poor model fit and was rejected.

LIMITATIONS

The duration of OCD varied widely between the participants (0-64 years). The majority experienced obsessive-compulsive symptoms since several years, which may have affected results on the course of anxiety and the interaction between anxiety and obsessive-compulsive symptoms.

CONCLUSIONS

Anxiety and obsessive-compulsive symptoms in OCD patients do not result from a shared underlying factor but are distinct, interacting symptom groups, probably interacting by distinct latent factors.

A closer look to neural pathways and psychopharmacology of obsessive compulsive disorder

The intricate neural pathways involved in obsessive-compulsive disorder (OCD) affect areas of our brain that control executive functioning, organization, and planning. OCD is a chronic condition that can be debilitating, afflicting millions of people worldwide. The lifetime prevalence of OCD in the US is 2.3%. OCD is predominantly characterized by obsessions consisting of intrusive and unwanted thoughts, often with impulses that are strongly associated with anxiety. Compulsions with OCD encompass repetitive behaviors or mental acts to satisfy their afflicted obsessions or impulses. While these factors can be unique to each individual, it has been widely established that the etiology of OCD is complex as it relates to neuronal pathways, psychopharmacology, and brain chemistry involved and warrants further exploration.

Understanding the prevalence and manifestation of anxiety and other socio-emotional and behavioural difficulties in children with Developmental Language Disorder

BACKGROUND

It is well-documented that children with Developmental Language Disorder (DLD) have a higher likelihood of experiencing anxiety, as well as other socio-emotional and behavioural (SEB) difficulties. Despite this, there is little consensus as to how these difficulties manifest. This study aims to understand the prevalence of broader SEB difficulties and anxiety, informing intervention development by understanding the relationships between them.

METHODS

A mixed-methods, case-control study was conducted. First, an online survey was completed by 107 parents of either children with DLD ("DLD sample"; n = 57) or typically developing children ("typical sample"; n = 50), aged 6-12 years old. Binary SEB statements informed by previous qualitative work (e.g. "my child requires routine/sameness"; "my child has frequent tantrums") provided an insight into the prevalence of SEB difficulties in both DLD and typical samples. Validated measures of anxiety, emotion regulation, intolerance of uncertainty, insistence on sameness, family stress and coping mechanisms were also collected. Correlation and mediation analyses were run using these validated measures to understand the manifestation of anxiety in children with DLD in more detail. Qualitative interviews were then carried out with a select panel of survey respondents (n = 4).

RESULTS

The DLD sample scored significantly higher on all binary SEB statements than the typical sample: experiencing anxiety (80.7%, p < .05), requiring routine and sameness (75.4%, p < .001) and emotional dysregulation (75.4%; p < .001) were the most common difficulties reported for children with DLD. Using the validated scales, family stress and coping mechanisms were found to only correlate with the manifestation of anxiety in the typical group, not the DLD group. "Intolerance of uncertainty" and "insistence on sameness" were found to fully mediate the relationship between DLD diagnosis and symptoms of anxiety. Parent's interviews provided contextual support for the analysis, as well as highlighting sensory sensitivities as a focus for future research.

CONCLUSIONS

Parents of children with DLD appear to cope well with their children's complex SEB needs. Intervention focussing on intolerance of uncertainty may help the management of difficulties with anxiety. Behaviours such as insistence on sameness should be investigated further, as potential indicators for anxiety amongst children with DLD.

Deep brain stimulation for extreme behaviors associated with autism spectrum disorder converges on a common pathway: a systematic review and connectomic analysis

OBJECTIVE

Individuals with autism spectrum disorder (ASD) may display extreme behaviors such as self-injury or aggression that often become refractory to psychopharmacology or behavioral intervention. Deep brain stimulation (DBS) is a surgical alternative that modulates brain circuits that have yet to be clearly elucidated. In the current study the authors performed a connectomic analysis to identify brain circuitry engaged by DBS for extreme behaviors associated with ASD.

METHODS

A systematic review was performed to identify prior reports of DBS as a treatment for extreme behaviors in patients with ASD. Individual patients' perioperative imaging was collected from corresponding authors. DBS electrode localization and volume of tissue activated modeling were performed. Volumes of tissue activated were used as seed points in high-resolution normative functional and structural imaging templates. The resulting individual functional and structural connectivity maps were pooled to identify networks and pathways that are commonly engaged by all targets.

RESULTS

Nine patients with ASD who were receiving DBS for symptoms of aggression or self-injurious behavior were identified. All patients had some clinical improvement with DBS. Connectomic analysis of 8 patients (from the systematic review and unpublished clinical data) demonstrated a common anatomical area of shared circuitry within the anterior limb of the internal capsule. Functional analysis of 4 patients identified a common network of distant brain areas including the amygdala, insula, and anterior cingulate engaged by DBS.

CONCLUSIONS

This study presents a comprehensive synopsis of the evidence for DBS in the treatment of extreme behaviors associated with ASD. Using network mapping, the authors identified key circuitry common to DBS targets.

Understanding why people with OCD do what they do, and why other people get involved: supporting people with OCD and loved ones to move from safety-seeking behaviours to approach-supporting behaviours

The distress inherent in obsessive compulsive disorder (OCD) can often lead to partners, family members and friends becoming entangled with the OCD in terms of being drawn into performing certain behaviours to try and reduce the distress of their loved one. In the past this has often been referred to somewhat pejoratively as collusion, or more neutrally as accommodation. In this paper we emphasise that this is usually a natural human response to seeing a loved one in distress and wanting to help. This paper provides detailed clinical guidance on how to understand this involvement and how to include others in the treatment of OCD along with practical tips and hints around potential blocks that may require troubleshooting. It also details the relatively recently introduced concept of approach-supporting behaviours, and provides guidance on how to distinguish these from safety-seeking behaviours. The ‘special case’ of reassurance seeking is also discussed.

Key learning aims

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Maladaptive Daydreaming and Obsessive-Compulsive Symptoms: A confirmatory and exploratory investigation of shared mechanisms

Maladaptive Daydreaming (MD) is a newly proposed mental disorder characterized by excessive, vivid fantasy activity impairing functioning. There is a high comorbidity of MD with Obsessive-Compulsive Spectrum Symptoms (OCSS), yet the mechanisms responsible for this relationship are still unclear. The present study set out to explore the relationship between MD and OCSS by: (1) examining dissociation, trauma, sense of control, and mind-wandering as potential mediators; (2) exploring whether MD is more strongly related to obsessions or compulsions; and (3) identifying patterns of specific obsessions and/or compulsions common in an MD sample. A group of 510 participants with self-identified MD completed a battery of online questionnaires. Dissociation and sense of control significantly mediated the MD-OCSS association. MD was moderately related to both obsessions and compulsions but was significantly more strongly related to the former. Frequently endorsed obsessions and compulsions among MD participants included checking and repetition compulsions, intrusive obsessions, and body-related obsessions and compulsions. We conclude that dissociative mechanisms, including dissociative absorption, play a major role in the relationship between MD and OCSS and may lead to consequent checking when transitioning back to reality, altered embodiment, intrusive images, and thoughts, and an impaired sense of mental control. Clinicians working with OCSS should be aware of the possible role of MD in the development or maintenance of symptoms. Future work should develop useful interventions for this type of shared psychopathology.

It's a matter of (executive) load: Separation as a load-dependent resetting procedure

Lee and Schwarz made considerable theoretical advances in the psychology of cleansing by proposing that cleaning actions might serve as separation procedures between two psychological entities. Here, we propose that the effectiveness of the separation process may be modulated by the available amount of executive resources, and that separation may operate as a load-dependent resetting procedure.

Diagnostic Correlates of Nonsuicidal Self-Injury Disorder among Veterans with Psychiatric Disorders

With its recent inclusion in the Diagnostic and Statistical Manual, nonsuicidal self-injury disorder (NSSID) has received limited research attention, especially in samples of military veterans. The present study sought to identify diagnostic predictors of NSSID within a veteran sample. Study participants included 124 veterans with at least one psychiatric diagnosis. Chi-square tests and t-tests evaluated bivariate associations between NSSID and twenty diagnostic correlates. Logistic regression models identified psychiatric disorders that were unique correlates of NSSID among veterans. Veterans with lifetime NSSID (n = 59) met criteria for a greater number of lifetime disorders than veterans with other psychiatric disorders. Bivariate associations were noted between NSSID and borderline personality disorder, depression, obsessive-compulsive disorder, generalized anxiety disorder, and cannabis use disorder. In the logistic regression model, only borderline personality disorder (AOR = 7.67) and obsessive-compulsive disorder (AOR = 3.23) continued to be associated with NSSID. The present study represents the first examination of the association between NSSID and psychiatric disorders among veterans. The findings shed light on psychiatric disorders associated with lifetime NSSID in veterans, with special consideration toward obsessive-compulsive disorder as a risk factor for NSSID.

Co-occurrence, Assessment and Treatment of Obsessive Compulsive Disorder in Children and Adults With Autism Spectrum Disorder

PURPOSE OF REVIEW

This review aims to give an update on research in the past 5 years regarding the co-occurrence, assessment and treatment of obsessive compulsive disorder (OCD) in individuals with autism spectrum disorder (ASD).

RECENT FINDINGS

Recent findings affirm not only a high prevalence of OCD amongst individuals with ASD (and vice versa) but also notable variability in assessment methods and results. There remain limited validated measures with which to assess OCD in those with ASD, which are often difficult to differentiate. Adapted and function-based CBT programs specifically designed for ASD demonstrate promising results, but additional randomised controlled trials are needed. Though some exciting progress has been made in the area of treatment of OCD in ASD, progress remains hampered by inconsistent measurement of OCD in ASD. Future priorities include development of brief, valid assessment tools and determining the efficacy and effectiveness of newly developed and adapted treatment programs.

A study of the Repeated Actions Diary in patients suffering from obsessive compulsive disorder

The structured Repeated Action Diary (RAD) collects in vivo data on compulsions and their various characteristics. Certain compulsions (i.e., those ending because the patient feels certain that it is safe to stop) are then compared with uncertain compulsions. The compulsion profile in patients with obsessive compulsive disorder (OCD) was assessed by using the RAD. Thirty-two patients from two sources participated in the study. Before pooling the two subgroups, we checked that they did not differ significantly with regard to demographic and clinical variables. Patients reported several categories of compulsion. The most frequently reported compulsions were washing and checking. In a given person, checking compulsions (in contrast to washing compulsions) were often produced by several different obsessions. Almost all the patients reported repeating the compulsions because of a need to feel sure. There were far more "certain" compulsions than "uncertain" compulsions. The number of repetitions was significantly lower for certain compulsions than for uncertain compulsions. The person felt greater relief from guilt and responsibility and a greater decrease in discomfort at the end of a compulsive episode for certain compulsions than for uncertain compulsions. In conclusion, the need to ritualize (prompted by uncertainty, i.e., potential danger) might explain the maintenance (or posttreatment recurrence) of OCD in many patients. The need for certainty in the completion of a compulsion may be worth considering as a therapeutic tool. The development of an approach based on the need for certainty might help to improve treatment outcomes.

Association Splitting for Obsessive-Compulsive Disorder: A Systematic Review

Background:

Association splitting is a cognitive technique that targets obsessions in obsessive-compulsive disorder (OCD) by weakening biased semantic associations among OCDrelevant concepts.

Objective:

In this systematic review, we examine studies on the efficacy of association splitting for reducing OCD symptoms.

Methods:

Following PRISMA guidelines, six studies were included, with diversity in sample characteristics, mode of administration (i.e., self-help vs therapist-assisted), language of administration, comparator groups, etc.

Results:

Results indicated that association splitting, as a self-help intervention, was efficacious in reducing overall OCD symptom severity, specific OCD symptoms (i.e., sexual obsessions), subclinical unwanted intrusions, and thought suppression, with small-to-large effect sizes (e.g., across relevant studies, ds = .28-1.07). Findings were less clear when association splitting was administered on a therapist-assisted basis as an add-on to standard cognitive-behavior therapy (CBT). Nonetheless, across studies, the majority of participants reported high acceptability, ease of comprehension, and adherence to daily association splitting practice.

Conclusion:

Although association splitting is an efficacious and acceptable self-help intervention for OCD symptoms, future studies should include appropriate comparison groups, conduct longitudinal assessments, examine efficacy for different symptom dimensions, and assess changes in semantic networks as proof of mechanistic change. There should also be greater representation of marginalized groups in future studies to assess association splitting’s utility in circumventing barriers to face-to-face CBT. Ethical considerations are also discussed.

Pedophilia-Themed Obsessive-Compulsive Disorder: Assessment, Differential Diagnosis, and Treatment with Exposure and Response Prevention

Fears of sexually harming children are fairly common among clients suffering from obsessive-compulsive disorder (OCD), yet these symptoms are largely unrecognized and frequently misdiagnosed by mental health professionals. Specifically, clients with pedophilia-themed OCD (P-OCD) experience excessive worries and distressing intrusive thoughts about being sexually attracted to, and sexually violating, children. Expressing these concerns may provoke misjudgments from uninformed mental health professionals that a client is presenting instead with pedophilic disorder. This misdiagnosis and subsequent improper interventions can then contribute to increased fear, anxiety, and in many cases, depression, in affected clients. Therefore, it is imperative that mental health professionals first possess a good understanding of this common manifestation of OCD. As such, in this article, we described obsessions and compulsions typical of P-OCD, in order to inform the reader of the distinctive differences between P-OCD and pedophilic disorder. Information about how to assess for P-OCD symptoms is then provided, followed by suggestions on how to tailor aspects of exposure and response prevention to treat this specific form of OCD.

Trapped in a Daydream: Daily Elevations in Maladaptive Daydreaming Are Associated With Daily Psychopathological Symptoms

Background: Maladaptive Daydreaming (MD) characterizes individuals who engage in vivid, fanciful daydreaming for hours on end, neglecting real-life relationships and responsibilities, resulting in clinical distress and functional impairment. Sufferers have embraced the term MD in cyber-communities devoted to this problem because it seemed to uniquely fit their experience and since existing diagnostic labels and their therapies seemed inadequate. However, scientific research in the field has been scarce, relying on cross-sectional or case study designs. Existing knowledge on MD suggests the involvement of dissociative and obsessive-compulsive symptoms, as well as positive reinforcement comparable to processes in addiction disorders. The present study aimed to rigorously explore factors that accompany MD employing a longitudinal daily-diary design, hypothesizing that temporal increases in MD will associate concurrently with, and will temporally precede, other symptoms and emotional changes. In addition, we aimed to explore which symptoms may act as precursors to increases in MD, in order to identify possible mechanisms bringing about daydreaming in these individuals. Methods: In a sample of 77 self-diagnosed individuals with MD we assessed relevant daily symptoms for 14 days, including MD, depression, general anxiety, social anxiety, obsessive-compulsive symptoms, and dissociation, as well as positive and negative emotion. Results: Increases in MD were strongly related to concurrent increases in all other symptoms and negative emotion, and to decreased positive emotion. Obsessive-compulsive symptoms, dissociation, and negative emotion also temporally followed MD. Obsessive-compulsive symptoms were the only consistent temporal antecedent of MD. Conclusions: MD and obsessive-compulsive symptoms coincided in what seems to be a vicious cycle; understanding possible shared mechanisms between these symptoms may inform our understanding of the etiology of MD. For example, Serotonin levels may possibly be involved in the development or maintenance of this condition. The findings may also provide clues as to potentially beneficial interventions for treating MD. For example, perhaps utilizing response prevention techniques may be useful for curbing or intercepting unwanted daydreaming. Future studies on MD should address its compulsory nature.

Restricted, Repetitive Behaviors in Autism Spectrum Disorder and Obsessive-Compulsive Disorder: A Comparative Review

This review paper critically examines literature regarding restricted and repetitive behaviors (RRBs) in Autism Spectrum Disorder (ASD) and Obsessive-Compulsive Disorder (OCD). The similar behavioral profiles of these disorders presents the potential for confusion regarding diagnoses and intervention efforts. As such, this review highlights the similarities and differences between RRBs in ASD and OCD. The developmental trajectories of RRBs are presented, followed by an exploration of three constructs implicated in RRB manifestation: anxiety, executive functioning, and sensory phenomena. While RRBs tend to develop with some similarity in both disorders, the differing role of anxiety highlights important distinctions between ASD and OCD. We urge researchers and clinicians to think critically about the dimensions that affect RRB presentation. Future research should use this review as a starting point to further elucidate the differences between RRBs in these two populations.

Induced not just right and incompleteness experiences in OCD patients and non-clinical individuals: An in vivo study

BACKGROUND AND OBJECTIVES

Research on incompleteness and not-just right experiences, (INC/NJREs) indicate that some OCD symptom dimensions are motivated by these experiences rather than by anxiety. Most published data are correlational, using non-clinical individuals. This study sought to examine INC/NJREs in vivo in non-clinical and OCD individuals.

METHODS

Study 1: Ninety-three undergraduates were randomly assigned to a INC/NJREs induction (n=44) or non-induction task (n=47). Scores on self-reports assessing INC, NJREs, OCD, Anxiety, and Depression were also recorded. Study 2: Twenty adults with OCD performed the induction task and completed the same questionnaire-packet as the non-clinical participants.

RESULTS

Study 1: The induction-group scored higher on several DVs of the experimental task, as INC/NJREs and uncomfortable physical sensations predicted impulses/urges to do something. All the DVs correlated with INC, NJREs, and OCD symptoms. Anxiety was only related to suppressing difficulties of the most intense sensation. Study 2: Results were comparable to those found in non-clinical people. Induced INC/NJREs correlated with compulsions severity and were associated with ordering, washing, and hoarding symptoms. OCDs did not differ from non-clinical subjects in the number of induced INC/NJREs, but they were more disturbing, difficult to suppress, and instigated more urges to do in OCDs.

LIMITATIONS

The small group of OCDs and the lack of a non-OCD clinical group kept us from drawing conclusions about the specificity of INC/NJREs to some OCD symptoms.

CONCLUSIONS

Findings support the role of INC/NJREs as stimuli triggering urges and/impulses to do and their impact on OCD severity.

If it is absurd, then why do you do it? The richer the obsessional experience, the more compelling the compulsion

Mounting evidence suggests that obsessive intrusions are often accompanied and amplified by perceptual experiences of different modalities (e.g., feeling dirt on one's skin while experiencing intrusive thoughts about contamination). Pilot studies conducted online with individuals endorsing mild obsessive-compulsive symptoms have linked the co-occurrence of perceptual experiences and obsessions to the severity of subsequent compulsive behaviour as well as low insight. However, it is presently unclear whether sensory experiences accompany all types of obsessional thoughts or are restricted to certain preoccupations (e.g., contamination and aggression). The present study examined a clinical inpatient and outpatient sample with a formally diagnosed obsessive-compulsive disorder (N = 34). Perceptual properties of intrusive thoughts were assessed with the Sensory Properties of Obsessions Questionnaire. The prevalence of perception-laden obsessive thoughts was comparable with prior studies (73.5%), but the intensity was significantly greater. No association was observed between perceptual experiences and expert-rated insight. However, the severity of perception-laden obsessions predicted the frequency of and impairment associated with compulsive behaviour. This was particularly strong for obsessions about contamination. The present study confirms the high prevalence and clinical relevance of perceptual experiences that accompany obsessions and further challenges the traditional trichotomy splitting mental phenomena into thoughts, intrusions, and hallucinations.

The inner world of overactive monitoring: neural markers of interoception in obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) patients typically overmonitor their own behavior, as shown by symptoms of excessive doubt and checking. Although this is well established for the patients' relationship with external stimuli in the environment, no study has explored their monitoring of internal body signals, a process known to be affected in anxiety-related syndromes. Here, we explored this issue through a cardiac interoception task that measures sensing of heartbeats. Our aim was to explore key behavioral and electrophysiological aspects of internal-cue monitoring in OCD, while examining their potential distinctiveness in this condition.

METHOD

We administered a heartbeat detection (HBD) task (with related interoceptive confidence and awareness measures) to three matched groups (OCD patients, panic disorder patients, healthy controls) and recorded ongoing modulations of two task-relevant electrophysiological markers: the heart evoked potential (HEP) and the motor potential (MP).

RESULTS

Behaviorally, OCD patients outperformed controls and panic patients in the HBD task. Moreover, they exhibited greater amplitude modulation of both the HEP and the MP during cardiac interoception. However, they evinced poorer confidence and awareness of their interoceptive skills.

CONCLUSIONS

Convergent behavioral and electrophysiological data showed that overactive monitoring in OCD extends to the sensing of internal bodily signals. Moreover, this pattern discriminated OCD from panic patients, suggesting a condition-distinctive alteration. Our results highlight the potential of exploring interoceptive processes in the OCD spectrum to better characterize the population's cognitive profile. Finally, these findings may lay new bridges between somatic theories of emotion and cognitive models of OCD.

Is "not just right experience" (NJRE) in obsessive-compulsive disorder part of an autistic phenotype?

OBJECTIVE

Harm avoidance (HA) and "not just right experience" (NJRE) have been proposed to be 2 core motivational processes underlying obsessive-compulsive disorder (OCD). The objective of this study was to explore whether NJRE demarcates a neurodevelopmental OCD subgroup distinct from HA related to autistic traits and/or to a broader phenotype of cognitive rigidity and sensory processing difficulties associated with an earlier age of OCD onset.

METHODS

A correlational design investigated whether NJRE and HA are distinct entities in OCD and explored their relationship to autism spectrum disorder (ASD) traits measured by the Autism Quotient (AQ), sensory processing, set-shifting, and age of OCD onset in an OCD sample (N=25).

RESULTS

NJRE was only moderately (r=.34) correlated to HA and not significant in this study. Consistent with predictions, NJRE was associated with sensory processing difficulties and an earlier age of OCD onset. No significant relationships were found between NJRE and ASD traits as measured by the AQ or set-shifting difficulties.

CONCLUSIONS

These preliminary findings suggest a lack of evidence demonstrating NJRE as a manifestation of core autistic traits as measured by the AQ. However, NJRE was associated with sensory abnormalities and an earlier age of OCD onset. The role of NJRE as a developmental, and possibly neurodevelopmental, risk factor for OCD possibly warrants further investigation.

Toward Understanding the Heterogeneity in OCD: Evidence from narratives in adult patients

BACKGROUND

Current attempts at understanding the heterogeneity in obsessive-compulsive disorder have relied on quantitative methods. The results of such work point toward a dimensional structure for obsessive-compulsive disorder. Existing qualitative work in obsessive-compulsive disorder has focused on understanding specific aspects of the obsessive-compulsive disorder experience in greater depth. However, qualitative methods are also of potential value in furthering our understanding of obsessive-compulsive disorder heterogeneity by allowing for open-ended exploration of the obsessive-compulsive disorder experience and correlating identified subtypes with patient narratives.

OBJECTIVE

We explored variations in patients' experience prior to, during and immediately after performing their compulsions.

METHOD

Semi-structured interviews were conducted with 20 adults with obsessive-compulsive disorder, followed by inductive thematic analysis. Participant responses were not analyzed within the context of an existing theoretical framework, and themes were labeled descriptively.

RESULTS

The previous dichotomy of 'anxiety' vs 'incompleteness' emerged organically during narrative analysis. In addition, we found that some individuals with obsessive-compulsive disorder utilized their behaviors as a way to cope with stress and anxiety more generally. Other participants did not share this experience and denied finding any comfort in their obsessive-compulsive behaviors. The consequences of attentional difficulties were highlighted, with some participants describing how difficulty focusing on a task could influence the need for it to be repeated multiple times.

CONCLUSIONS

The extent to which patients use obsessive-compulsive disorder as a coping mechanism is a relevant distinction with potential implications for treatment engagement. Patients may experience ambivalence about suppressing behaviors that they have come to rely upon for management of stress and anxiety, even if these behaviors represent symptoms of a psychiatric illness.

Self-Regulation of Anterior Insula with Real-Time fMRI and Its Behavioral Effects in Obsessive-Compulsive Disorder: A Feasibility Study

Introduction

Obsessive-compulsive disorder (OCD) is a common and chronic condition that can have disabling effects throughout the patient's lifespan. Frequent symptoms among OCD patients include fear of contamination and washing compulsions. Several studies have shown a link between contamination fears, disgust over-reactivity, and insula activation in OCD. In concordance with the role of insula in disgust processing, new neural models based on neuroimaging studies suggest that abnormally high activations of insula could be implicated in OCD psychopathology, at least in the subgroup of patients with contamination fears and washing compulsions.

Methods

In the current study, we used a Brain Computer Interface (BCI) based on real-time functional magnetic resonance imaging (rtfMRI) to aid OCD patients to achieve down-regulation of the Blood Oxygenation Level Dependent (BOLD) signal in anterior insula. Our first aim was to investigate whether patients with contamination obsessions and washing compulsions can learn to volitionally decrease (down-regulate) activity in the insula in the presence of disgust/anxiety provoking stimuli. Our second aim was to evaluate the effect of down-regulation on clinical, behavioural and physiological changes pertaining to OCD symptoms. Hence, several pre- and post-training measures were performed, i.e., confronting the patient with a disgust/anxiety inducing real-world object (Ecological Disgust Test), and subjective rating and physiological responses (heart rate, skin conductance level) of disgust towards provoking pictures.

Results

Results of this pilot study, performed in 3 patients (2 females), show that OCD patients can gain self-control of the BOLD activity of insula, albeit to different degrees. In two patients positive changes in behaviour in the EDT were observed following the rtfMRI trainings. Behavioural changes were also confirmed by reductions in the negative valence and in the subjective perception of disgust towards symptom provoking images.

Conclusion

Although preliminary, results of this study confirmed that insula down-regulation is possible in patients suffering from OCD, and that volitional decreases of insula activation could be used for symptom alleviation in this disorder.

Neural Circuitry of Interoception: New Insights into Anxiety and Obsessive-Compulsive Disorders

Over the past century, much research has investigated how the brain processes signals from the body (interoception) and how this processing may be disturbed in patients with psychiatric disorders. In this paper, I discuss the literature examining the relationship between interoceptive awareness and emotional and cognitive processes, and review the evidence suggesting that anxiety and obsessive-compulsive disorder (OCD) are characterized by abnormal interoception. A network of cortical and subcortical brain regions centered on the insula has repeatedly been implicated in interoception and is abnormal in anxiety and OCD. The investigation of interoception provides a framework for understanding behavioral and neural mechanisms of anxiety and OCD, although additional research is needed to directly link insula functioning to aberrant interoception in these disorders. Future work targeting interoception may be useful for the development of novel treatments.

The relationships between obsessive-compulsive symptom dimensions and cognitions in obsessive-compulsive disorder

Several studies have linked obsessive-compulsive symptoms to specific obsessive-compulsive cognitions, however methodologies have varied, and no study has determined obsessive-compulsive symptoms using the most widely used clinician rating scale, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Considering that almost all studies that used factor analysis to ascertain OCD symptom dimensions were based on the Y-BOCS and that self-report instruments assessing obsessive-compulsive symptoms correlate poorly with the Y-BOCS, there is a need to use the Y-BOCS to examine the relationship between obsessive-compulsive cognitions and obsessive-compulsive symptom dimensions. This study examined the relationship between five Y-BOCS-derived obsessive-compulsive symptom dimensions and the three obsessive-compulsive cognitive domains identified by the obsessive-beliefs questionnaire (OBQ). The symmetry/ordering symptom dimension was associated with increased perfectionism/intolerance of uncertainty, the unacceptable/taboo thoughts symptom dimension was associated with increased importance/control of thoughts and the doubt/checking symptom dimension was associated with increased responsibility/threat estimation. There was no statistical evidence of an association between any OBQ belief sub-scale and the hoarding symptom dimension nor the contamination/cleaning symptom dimension. The findings encourage symptom-based approaches to cognitive-behavioural therapy for some OCD symptoms and call for further research on cognitions associated with contamination/cleaning symptoms and hoarding.

Interpersonal reassurance seeking in obsessive-compulsive disorder and its relationship with checking compulsions

This study aimed to examine interpersonal reassurance seeking (IRS) in obsessive-compulsive disorder (OCD) and the relationship between IRS and checking compulsions. One hundred and forty adults with OCD underwent a comprehensive assessment, which included obtaining information on seeking reassurance from others because of their obsessions. Sixty-seven (47.9%) participants reported IRS. They exhibited more psychopathology than participants without IRS, tended to have a greater overall severity of OCD and were far more likely to have checking compulsions. Participants with IRS also had more severe obsessions, suggesting that IRS plays a role as an additional coping strategy when obsessions are more prominent. The severity of obsessions and the absence of obsessions about a need to collect and keep objects were independent predictors of IRS, whereas the presence of obsessions about unintentional harm and not being married or in a de facto relationship independently predicted checking compulsions. Although a close relationship exists between IRS and checking compulsions, these results suggest important differences, with implications for understanding the factors that contribute to IRS and checking compulsions.

'Impulsive compulsivity' in obsessive-compulsive disorder: a phenotypic marker of patients with poor clinical outcome

Although traditionally obsessive-compulsive disorder (OCD) and impulse control disorders (ICD) have represented opposing ends of a continuum, recent research has demonstrated a frequent co-occurrence of impulsive and compulsive behaviours, which may contribute to a worse clinical picture of some psychiatric disorders. We hypothesize that individuals with 'impulsive' OCD as characterized by poor insight, low resistance, and reduced control towards their compulsions will have a deteriorative course, greater severity of hoarding and/or symmetry/ordering symptoms, and comorbid ICD and/or substance use disorders (SUD). The sample consisted of 869 individuals with a minimum score of 16 on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Of these, 65 had poor insight, low resistance, and reduced control towards compulsions ('poor IRC') and 444 had preserved insight, greater resistance and better control over compulsions ('good IRC'). These two groups were compared on a number of clinical and demographic variables. Individuals with poor IRC were significantly more likely to have a deteriorative course (p < 0.001), longer duration of obsessions (p = 0.017), greater severity of symmetry/ordering (p < 0.001), contamination/cleaning (p < 0.001) and hoarding (p = 0.002) symptoms, and comorbid intermittent explosive disorder (p = 0.026), trichotillomania (p = 0.014) and compulsive buying (p = 0.040). Regression analysis revealed that duration of obsessions (p = 0.037) and hoarding severity (p = 0.005) were significant predictors of poor IRC. In the absence of specific measures for impulsivity in OCD, the study highlights the utility of simple measures such as insight, resistance and control over compulsions as a phenotypic marker of a subgroup of OCD with impulsive features demonstrating poor clinical outcome.

The nature and correlates of avoidance in obsessive-compulsive disorder

OBJECTIVES

Avoidance in obsessive-compulsive disorder (OCD) has been neglected by research. This study aimed (i) to collect information on the nature and frequency of avoidance in people with OCD and ascertain the types of obsessions related to avoidance; (ii) compare OCD individuals with and without avoidance, and (iii) determine predictors of avoidance in people with OCD.

METHOD

A total of 124 OCD adults underwent a comprehensive assessment. Participants were asked whether they engaged in any avoidance behaviour because of their OCD, and the nature and number of instances of such avoidance were recorded. The instances of avoidance were grouped according to the type of obsession and compulsion that they were related to.

RESULTS

A total of 74 (59.7%) participants reported OCD-related avoidance. Avoidance was most commonly related to contamination obsessions. Almost 80% of all contamination obsessions and more than 50% of all aggressive obsessions were associated with avoidance, and contamination obsessions were significantly more common among the participants with avoidance. In contrast, very few obsessions about a need to collect and keep objects and obsessions about a need for ordering, arranging and doing things right or in an exact way were associated with avoidance; these types of obsessions were also significantly more common among the participants without avoidance. The strongest predictor of avoidance was the presence of contamination obsessions. Participants with avoidance had a significantly more severe OCD than those without avoidance.

CONCLUSIONS

Avoidance is common in OCD, and it is particularly frequently associated with contamination obsessions. There is a weak link between avoidance and hoarding and between avoidance and ordering/arranging/symmetry obsessions and compulsions. These results, along with the finding that OCD with avoidance is a more severe illness, have implications for the future diagnostic criteria, description, subtyping and treatment of OCD and for its relationship with other anxiety disorders.