Neuropsychological Research in Obsessive-Compulsive Disorder: Current Status and Future Directions

Externally orienting cues improve cognitive control in OCD

BACKGROUND AND OBJECTIVES

An executive overload model of obsessive-compulsive disorder (OCD) posits that broad difficulties with executive functioning in OCD result from an overload on the executive system by obsessive thoughts. It implies that, if individuals with OCD "snap out" of their obsessive thoughts, their performance on neurocognitive tasks will improve.

METHODS

We test this prediction using the revised Attention Network Test, ANT-R, and distinct subsamples of data from unmedicated OCD and healthy controls (HC). ANT-R includes Simon and Flanker tasks; in both, incongruent trials take longer to resolve ('conflict costs'). On some trials, a warning cue helps participants to respond faster ('alerting benefits'). In OCD (N = 34) and HC (N = 46), matched on age, IQ, and sex, we tested (1) the effect of OCD on alerting benefits, and (2) the effect of OCD on warning cue related reductions in conflict costs. In a distinct subsample of OCD (N = 32) and HC (N = 51), we assessed whether alerting benefits and cue-related reductions in conflict costs are associated differently with different OCD symptoms.

RESULTS

A warning cue can help individuals with OCD more than HC to improve performance on Simon and Flanker tasks. This effect is positively associated with severity of contamination symptoms.

LIMITATIONS

This study did not directly assess how distracted participants are by obsessive thoughts. It relied on the ANT-R subtraction measures. Symptom severity was assessed using self-report measures.

CONCLUSIONS

Difficulties in resolving conflict during decision-making in OCD can be modulated by a warning cue presented immediately before an attentional task.

Guilt and Shame in Patients with Obsessive-Compulsive Disorders

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a tremendous psychiatric illness with a variety of severe symptoms. Feelings of shame and guilt are universal social emotions that fundamentally shape the way people interact with each other. Mental illness is therefore often related to pronounced feelings of shame and guilt in a maladaptive form.

METHODS

A total of 62 participants (38 women and 24 men) were clinically and psychometrically investigated.

RESULTS

The OCD patients (n = 31) showed a maladaptive guilt and shame profile, characterized by increased interpersonal feelings of guilt accompanied by a stronger tendency to self-criticism and increased punitive sense of guilt with a simultaneous prevailing tendency to perfectionism, as well as an increased concern for the suffering of others. The proneness to profuse shame in OCD patients seems to be in the context of the violation of inner values and a negative self-image with persistent self-criticism.

CONCLUSION

Although there are limitations with a small sample size in this monocentric approach, our study underlines the importance of an individual consideration of the leading obsessive-compulsive symptomatology, especially in the context of very personal feelings of guilt and shame. Further multidimensional studies on guilt and shame could contribute to their implementation more strongly in individualized psychotherapy.

Cognitive Training in Obsessive-Compulsive Disorder: A Systematic Review

Background

Cognitive training (CT) for illness-linked neuropsychological deficits has been attempted in psychiatric disorders and, more recently, in obsessive-compulsive disorder (OCD). However, studies are few and far between, with a limited understanding of factors contributing to efficacy. This article aims to provide a comprehensive critical review of studies employing CT in OCD.

Methods

This systematic review follows the Preferred Reporting of Items for Systematic Review and Meta-Analyses Protocols. Empirical studies that used any form of CT/remediation in individuals with OCD were included.

Results

Eight articles met the criteria for inclusion, of which five were randomized controlled trials, two were case series, and one was an open-label trial. The studies have predominantly demonstrated improved trained cognitive functions, with only two showing generalization to untrained domains like clinical symptoms and socio-occupational functioning.

Conclusion

There are few controlled trials of CT in OCD, which limits conclusions of efficacy. Given the sparse research in the area, the review summarizes the current status of research and examines important methodological considerations that may inform future studies.

Abnormalities of Hippocampal Subfield and Amygdalar Nuclei Volumes and Clinical Correlates in Behavioral Variant Frontotemporal Dementia with Obsessive-Compulsive Behavior-A Pilot Study

(1) Background: The hippocampus (HP) and amygdala are essential structures in obsessive-compulsive behavior (OCB); however, the specific role of the HP in patients with behavioral variant frontotemporal dementia (bvFTD) and OCB remains unclear. (2) Objective: We investigated the alterations of hippocampal and amygdalar volumes in patients with bvFTD and OCB and assessed the correlations of clinical severity with hippocampal subfield and amygdalar nuclei volumes in bvFTD patients with OCB. (3) Materials and methods: Eight bvFTD patients with OCB were recruited and compared with eight age- and sex-matched healthy controls (HCs). Hippocampal subfield and amygdalar nuclei volumes were analyzed automatically using a 3T magnetic resonance image and FreeSurfer v7.1.1. All participants completed the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Neuropsychiatric Inventory (NPI), and Frontal Behavioral Inventory (FBI). (4) Results: We observed remarkable reductions in bilateral total hippocampal volumes. Compared with the HCs, reductions in the left hippocampal subfield volume over the cornu ammonis (CA)1 body, CA2/3 body, CA4 body, granule cell layer, and molecular layer of the dentate gyrus (GC-ML-DG) body, molecular layer of the HP body, and hippocampal tail were more obvious in patients with bvFTD and OCB. Right subfield volumes over the CA1 body and molecular layer of the HP body were more significantly reduced in bvFTD patients with OCB than in those in HCs. We observed no significant difference in amygdalar nuclei volume between the groups. Among patients with bvFTD and OCB, Y-BOCS score was negatively correlated with left CA2/3 body volume (τb = -0.729, p < 0.001); total NPI score was negatively correlated with left GC-ML-DG body (τb = -0.648, p = 0.001) and total bilateral hippocampal volumes (left, τb = -0.629, p = 0.002; right, τb = -0.455, p = 0.023); and FBI score was negatively correlated with the left molecular layer of the HP body (τb = -0.668, p = 0.001), CA4 body (τb = -0.610, p = 0.002), and hippocampal tail volumes (τb = -0.552, p < 0.006). Mediation analysis confirmed these subfield volumes as direct biomarkers for clinical severity, independent of medial and lateral orbitofrontal volumes. (5) Conclusions: Alterations in hippocampal subfield volumes appear to be crucial in the pathophysiology of OCB development in patients with bvFTD.

Atypical neurocognitive functioning in children and adolescents with obsessive-compulsive disorder (OCD)

Atypical neurocognitive functioning has been found in adult patients with obsessive-compulsive disorder (OCD). However, little work has been done in children and adolescents with OCD. In this study, we investigated neurocognitive functioning in a large and representative sample of newly diagnosed children and adolescents with OCD compared to non-psychiatric controls. Children and adolescents with OCD (n = 119) and non-psychiatric controls (n = 90) underwent psychopathological assessment, intelligence testing, and a neurocognitive test battery spanning cognitive flexibility, planning and decision-making, working memory, fluency, and processing speed. The MANOVA main effect revealed that children and adolescents with OCD performed significantly worse than the control group (p < .001, [Formula: see text] = 0.256). Atypical patient performance was particularly found for indices of cognitive flexibility, decision-making, working memory, and processing speed. We found no evidence of differences in planning or fluency. Moreover, we found no significant associations between neurocognitive performance and OCD symptom severity or comorbidity status. Our results indicate that children and adolescents with OCD show selective atypical neurocognitive functioning. These difficulties do not appear to drive their OCD symptoms. However, they may contribute to lifespan difficulties and interfere with treatment efficacy, an objective of our research currently.

Role of Cognitive Control in Psychotherapy: An Integrated Review

Background

Cognitive control (CC), including shifting, updating, and inhibiting functions, may play an integral role in various aspects of psychotherapy; however, research on this is limited. This review aims to link the disparate lines of evidence on CC as they relate to psychotherapy processes, techniques, and outcomes.

Methods

A systematic search of the literature on neuropsychological domains relating to psychotherapy in adults with anxiety/depression yielded 18 eligible studies. The review also uses a narrative format to explore other potential links between CC and psychotherapy that are underinvestigated, and highlights the need for research and application to evidence-based practice of psychotherapy.

Results and conclusions

Findings suggest that CC may predict psychotherapy outcomes and also improve as a function of psychotherapy. Analog sample studies suggest a possible link between CC and techniques for regulation of cognition and emotion, such as reappraisal, mindfulness, and cognitive restructuring. CC may also play an integral role in the regulation of behavior. Study of CC in the context of psychotherapy may potentially explain individual differences in psychotherapy outcomes and mechanisms of action of various psychotherapy techniques and processes. Such an understanding may have possible implications for "best fit" matching clients to therapies and modifying psychological interventions to account for poorer CC abilities. CC may be enhanced through training and further research is warranted on the impact of such training in facilitating better long-term psychotherapy outcomes.

High treatment resistance is associated with lower performance in the Stroop test in patients with obsessive-compulsive disorder

Around 50% of the patients with obsessive-compulsive disorder (OCD) are resistant to treatment, and patients with OCD show alterations in a broad range of cognitive abilities. The present study investigated the links between treatment-resistance, executive and working memory abilities, and the severity of OCD symptoms among 66 patients with OCD. The patients performed seven tests gauging their executive functions and working memory and filled in questionnaires for OCD severity and insight into their pathology. In addition, the executive and working memory abilities of a subset of these patients were compared with those of individually matched control participants. In contrast with previous studies, patients' treatment resistance was evaluated by considering the clinical outcomes of all the treatments that they received during the course of their disease. Higher treatment resistance was associated with lower performance in one particular executive test, the Stroop test, which assessed patients' ability to inhibit prepotent/automatic responses. Older age and more severe OCD symptoms were also associated with higher treatment resistance. Regardless of OCD severity, the patients displayed small to moderate deficits across most components of executive functions compared to control participants. Interestingly, patients with OCD took more time than control participants to perform speeded neuropsychological tests but never made more errors. Altogether, this study shows that the treatment-resistance of patients with OCD may be reliably quantified over the course of years and treatments using Pallanti and Quercioli's (2006) treatment resistance-related scales. The data suggest that the Stroop test could be used clinically to anticipate treatment outcomes in to-be-treated patients.

An fMRI study of cognitive planning before and after symptom provocation in pediatric obsessive-compulsive disorder

BACKGROUND

Pediatric obsessive-compulsive disorder (OCD) has been associated with poorer planning in laboratory, school and home settings. It is unclear whether this impairment is a standalone cognitive issue or the result of OCD symptoms. No study has examined the influence of provoked distress on planning performance and neural correlates in pediatric OCD.

METHODS

Before and after a symptom provocation task, youth with OCD (n = 23; 9 boys; mean age ± standard deviation 15.1 ± 2.6 years) and matched healthy controls (n = 23) completed the Tower of London task during functional MRI scanning.

RESULTS

During planning, participants with OCD recruited the left superior frontal gyrus to a greater extent than healthy controls after symptom provocation (group × time point interaction; t ₄₄ = 5.22, p < 0.001). In a seeded, region of interest-constrained, functional connectivity analysis, we identified greater connectivity between the left superior frontal gyrus and the right middle frontal gyrus, left precuneus and left inferior parietal lobule in participants with OCD than healthy controls. We also identified greater connectivity between the right amygdala and right medial frontal gyrus in patients with OCD than healthy controls, but only before symptom provocation.

LIMITATIONS

The fixed-order design of the study and the number of participants taking medication (n = 20) should be noted.

CONCLUSION

Participants with OCD demonstrated greater amygdalar-cortical connectivity before symptom provocation, while sustaining greater recruitment and connectivity of task-related planning areas throughout the task. These results suggest that brain activity and connectivity is altered after symptom provocation, in the absence of impaired planning performance.