An Integrative Model for Understanding Obsessive-Compulsive Disorder: Merging Cognitive Behavioral Theory with Insights from Clinical Neuroscience

Neurocognitive performance in obsessive-compulsive disorder before and after treatment with cognitive behavioral therapy

BACKGROUND

Cross-sectional studies have reported neurocognitive performance deficits in obsessive-compulsive disorder (OCD), particularly on tasks assessing response inhibition and proactive control over stimulus-driven behaviors (task control). However, it is not clear whether these deficits represent trait-like markers of OCD or are state-dependent.

METHODS

This study examined performance on two neurocognitive tasks in OCD patients (N = 26) before and after cognitive behavioral therapy (CBT) and matched healthy controls (HCs, N = 19). Tasks included the stop-signal task (assessing response inhibition) and the Object Interference (OI) task (assessing a specific form of task control). OCD patients completed these tasks and clinical ratings before and after 17 sessions of CBT delivered by expert therapists over two months. HCs completed tasks before and after 2-months. This design used CBT as a tool to reduce OCD symptoms to determine whether neurocognitive performance similarly improves.

RESULTS

Results showed that OCD patients and HCs did not significantly differ in their stop-signal performance at either time point. In contrast, OCD patients exhibited impaired performance on the OI task at baseline and their OI performance improved after treatment, resolving the deficit relative to HC.

LIMITATIONS

The sample size was small, particularly for the healthy control group. We also tested only two neurocognitive tasks. Future study with larger sample sizes and more tasks is warranted.

CONCLUSIONS

These results suggest that task control deficits in OCD may be sensitive to symptom state. The possibility that improving task control represents a neurocognitive mechanism of successful CBT represents an important direction for future research.

Pediatric early-onset neuropsychiatric obsessive compulsive disorders

At the time of this writing, most pediatricians or child psychiatrists will probably have treated a child with early acute-onset obsessive compulsive disorder (OCD) behaviors due to the pediatric autoimmune neuropsychiatric disorder associated with Group A beta-hemolytic streptococcus, abbreviated PANDAS, described more than two decades ago; or Tourette syndrome, incorporating motor and vocal tics, described more than a century ago. One typically self-limited post-infectious OCD resulting from exposure to other putative microbial disease triggers defines PANS, abbreviating pediatric autoimmune neuropsychiatric syndrome. Tourette syndrome, PANDAS and PANS share overlapping neuroimaging features of hypometabolism of the medial temporal lobe and hippocampus on brain 18Fluorodeoxyglucose positron emission tomography fused to magnetic resonance imaging (PET/MRI) consistent with involvement of common central nervous system (CNS) pathways for the shared clinical expression of OCD. The field of pediatric neuropsychiatric disorders manifesting OCD behaviors is at a crossroads commensurate with recent advances in the neurobiology of the medial temporal area, with its wide-ranging connectivity and cortical cross-talk, and CNS immune responsiveness through resident microglia. This review advances the field of pediatric neuropsychiatric disorders and in particular PANS, by providing insights through clinical vignettes and descriptive clinical and neuroimaging correlations from the author's file. Neuroscience collaborations with child psychiatry and infectious disease practitioners are needed to design clinical trials with the necessary rigor to provide meaningful insights into the rational clinical management of PANS with the aim of developing evidence-based guidelines for the clinical management of early, abrupt-onset childhood OCD to avert potentially life-long neuropsychological struggles.

Cognitive disengagement syndrome symptoms in obsessive-compulsive disorder with and without attention deficit hyperactivity disorder

OBJECTIVE

Comorbidity between Obsessive-Compulsive Disorder (OCD) and Attention Deficit/Hyperactivity Disorder (ADHD) appears complex in terms of etiology, phenomenology, and treatment. There is a need to identify possible factors which are related to the co-occurrence of OCD and ADHD in adults. Cognitive Disengagement Syndrome (CDS) may contribute to this comorbidity through its associations with ADHD, emotional dysregulation, cognitive processes, and neuropsychological deficits.

METHODS

In this study, we compared CDS and various sociodemographic and clinical characteristics in OCD patients with (n = 44) and without ADHD (n = 72), and healthy controls (n = 43), using the Yale Brown Obsessive-Compulsive Scale, Wender Utah Rating Scale, Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale, Barkley's Adult Sluggish Cognitive Tempo Rating Scale, Beck Depression Inventory, and Beck Anxiety Inventory.

RESULTS

In addition to contamination obsessions (OR = 7.733, p = 0.002), male gender (OR = 3.732, p = 0.031), high anxiety (OR = 1.053, p = 0.02), and high CDS symptoms (OR = 1.145, p = 0.037) were associated with comorbidity between OCD and ADHD.

CONCLUSION

We suggest that CDS may serve as a valuable construct for understanding the nature of comorbidity between OCD and ADHD.

No Impaired Inhibition of Stimulus-Driven Behavior in Pediatric Obsessive-Compulsive Disorder: a Partial Test of the Habit Formation Model

The mechanisms that underlie obsessive-compulsive disorder (OCD) are elusive. The habit formation model of OCD postulates that compulsions arise from an imbalance between goal-directed and habit formation systems, stemming from impaired inhibition of stimulus-driven actions. Few studies have examined the core tenets of the habit formation model in pediatric OCD. We administered the object-interference task, which assesses the ability to inhibit stimulus-driven behavior, to 67 youths with OCD, 43 youths with an anxiety disorder (and no OCD), and 48 youths without any mental disorder. Impaired inhibition of stimulus-driven behavior was calculated by comparing response times to neutral non-nameable objects, neutral nameable objects, distress-eliciting objects, and incompleteness-eliciting objects. Youths with OCD did not differ significantly from youths with anxiety disorders and the non-clinical group on any response cost measure. All groups showed small response costs in relation to all three categories of non-neutral objects, with the clearest cost emerging in relation to distress-eliciting objects. Individual differences in response cost were not significantly correlated with any interview- or self-rated measure of OCD severity. Using the object-interference task, no evidence was found for impaired inhibition of stimulus-driven behavior in youths with OCD. We explore several possible interpretations of this result, including limitations of the task itself, the broader constraints of experimental methods in detecting such mechanisms, and the possibility that an imbalance between goal-directed and habit systems may not be a fundamental feature of pediatric OCD.

Neurobiological Mechanisms Underlying Psychological Dysfunction After Brain Injuries

Despite the presentation of similar psychological symptoms, psychological dysfunction secondary to brain injury exhibits markedly lower treatment efficacy compared to injury-independent psychological dysfunction. This gap remains evident, despite extensive research efforts. This review integrates clinical and preclinical evidence to provide a comprehensive overview of the neurobiological mechanisms underlying neuropsychological disorders, focusing on the role of key brain regions in emotional regulation across various forms of brain injuries. It examines therapeutic interventions and mechanistic targets, with the primary goal of identifying pathways for targeted treatments. The review highlights promising therapeutic avenues for addressing injury-associated psychological dysfunction, emphasizing Nrf2, neuropeptides, and nonpharmacological therapies as multi-mechanistic interventions capable of modulating upstream mediators to address the complex interplay of factors underlying psychological dysfunction in brain injury. Additionally, it identifies sexually dimorphic factors as potential areas for further exploration and advocates for detailed investigations into sex-specific patterns to uncover additional contributors to these disorders. Furthermore, it underscores significant gaps, particularly the inadequate consideration of interactions among causal factors, environmental influences, and individual susceptibilities. By addressing these gaps, this review provides new insights and calls for a paradigm shift toward a more context-specific and integrative approach to developing targeted therapies for psychological dysfunction following brain injuries.

The deer mouse (Peromyscus maniculatus bairdii) as a model organism to explore the naturalistic psychobiological mechanisms contributing to compulsive-like rigidity: A narrative overview of advances and opportunities

Deer mice (Peromyscus maniculatus bairdii), a wildtype species native to North America, have been investigated for their spontaneous compulsive-like behaviour. The repetitive and persistence nature of three unique compulsive-like phenotypes in deer mice, i.e., high stereotypy (HS), large nesting behaviour (LNB) and high marble burying (HMB), are characterized by behavioural and cognitive rigidity. In this narrative review, we summarize key advances in the model's application to study obsessive-compulsive disorder (OCD), emphasizing how it may be used to investigate neurobiological and neurocognitive aspects of rigidity. Indeed, deer mice provide the field with a unique naturalistic and spontaneous model system of behavioural and cognitive rigidity that is useful for investigating the psychobiological mechanisms that underpin a range of compulsive-like phenotypes. Throughout the review, we highlight new opportunities for future research.

Are the Symptom Dimensions in Obsessive Compulsive Disorder Related to Thought-Action Fusion, Magical Thinking, and Schizotypal Personality Traits?

Introduction

This study aimed to investigate the relationship between symptom dimensions within obsessive-compulsive disorder and thought-action fusion, magical thinking, and schizotypal personality traits.

Methods

This research was designed as a cross-sectional case-control study. The study population involved patients with obsessive-compulsive disorder, and healthy controls who did not exhibit any psychiatric disorders following the Structured Clinical Interview for DSM-IV (SCID-I). Thought-Action Fusion Scale (TAFS), Magical Ideation Scale (MIS), Vancouver Obsessional-Compulsive Inventory (VOCI), Schizotypal Personality Questionnaire (SPQ), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI) were administered to all participants. The two groups were compared in terms of sociodemographic variables and scale scores, Spearman's correlation analysis was performed to examine the relationship between TAFS total and all subscale scores, magical thinking, schizotypal personality traits and OCD symptom dimensions scores.

Results

The study comprised 37 patients with OCD and 36 healthy controls. The patient group exhibited significantly higher scores in TAF total and all subscales, MIS, SCQ, BDI, and BAI, compared to the healthy control group. Positive correlations between magical ideation scores and VOCI-obsessions and VOCI-hoarding subscale scores and between schizotypal personality scores and VOCI-obsessions, VOCI-hoarding, VOCI-just right, VOCI indecisiveness scores was found.

Conclusions

The relationship between symptom dimensions in obsessive-compulsive disorder such as sexual, religious, aggression, hoarding, symmetry/ordering and magical thinking and schizotypal personality traits shows that these variables are among the determining factors for OCD symptoms. .

From Cognitive Function to Treatment Efficacy in Obsessive-Compulsive Disorder: Insights from a Multidimensional Meta-Analytic Approach

Meta-analysis is a statistical tool used to combine and synthesise the results of multiple independent studies on a particular topic. To this end, researchers isolate important moderators and mediators to investigate their influence on outcomes. This paper introduces a novel approach to meta-analysis, known as multidimensional meta-analysis (mi-MA), to study memory performance in those with obsessive-compulsive disorder (OCD). Unlike traditional meta-analyses, mi-MA allows researchers to extract multiple data points (e.g., using different measures) from single studies and groups of participants, facilitating the exploration of relationships between various moderators while avoiding multicollinearity issues. Therefore, in the first instance, we outline the use of the mi-MA approach to quantify the impact of complex models of memory performance in individuals with OCD. This approach provides novel insights into the complex relationship between various factors affecting memory in people with OCD. By showcasing the effectiveness of mi-MA in analysing intricate data and modelling complex phenomena, the paper establishes it as a valuable tool for researchers exploring multifaceted phenomena, both within OCD research and beyond.

Neuronal correlates of intensification and acceptance of symptoms during exposure therapy in patients with obsessive-compulsive disorder

Introduction

Cognitive behaviour therapy with exposure and response prevention is efficient in treating patients with obsessive-compulsive disorder (OCD). Nevertheless, it would be helpful for many patients to complement the therapeutic treatment with acceptance strategies to further increase the therapeutic benefit. The aim of the present study was to examine neurobiological responses to acceptance and intensification strategies during symptom provocation alongside the psychotherapeutic process.

Method

A total of 23 patients diagnosed with OCD (subtype: washing/contamination fear) was instructed to utilise either an acceptance strategy (ACS) or an intensification strategy (INS) to cope with their emotional and cognitive reactions to personalised symptom-triggering and neutral pictures. Fourteen patients participated twice: at the beginning [T1] and at the end [T2] of an inpatient multimodal treatment including cognitive behaviour therapy with response prevention to assess functional variations.

Results

For the contrast of T1 and T2, ACS showed increased brain activity in the left inferior frontal gyrus (IFG), left caudate body, and posterior cingulate gyrus (PCC). They also showed decreased activity in the left anterior insula. INS showed decreased activation in right lingual gyrus and right caudate body. At T2, ACS showed increased activation compared to INS in the left cerebrum: IFG, caudate nucleus, middle and superior temporal gyrus, and PCC/cuneus. For the comparison of T1 and T2, the ACS revealed increased brain activity in the left IFG, left caudate body, and right inferior parietal lobe. It showed decreased activity in the left anterior insula. The INS revealed decreased activity in right lingual gyrus and right caudate body.The psychometric questionnaires suggested that patients were able to reduce obsession, compulsion, and depression symptoms. Furthermore, patients rated the ACS as more useful for themselves compared with the INS.

Conclusion

The increased left IFG activity using ACS (T1 vs. T2) could be interpreted as a better inhibitory top-down process, while the increased PCC response might be due to a better reappraisal strategy after therapy. ACS seems to mobilise neuronal activations under therapy, especially in the left hemisphere. Both strategies showed reductions in emotional networks as a neuronal correlate of therapy success. Overall, ACS may be more efficient than INS, as rated by the patients and as in accordance with neurobiological findings.

Novel five-phase model for understanding the nature of misophonia, a conditioned aversive reflex disorder

Background: Misophonia is a recently identified condition in which a person perceives a subtle stimulus (e.g., eating sounds, hair twirling) and has an intense, negative emotional response. Misophonia cannot be classified with established nosological systems. Methods: We present a novel five-phase model of misophonia from a cognitive-behavioral framework. This model identifies a learned reflex of the autonomic nervous system as the primary etiology and maintenance of misophonia. Phase one is anticipatory anxiety and avoidance. Phase two is a conditioned physical reflex (for example, the tensing of calf muscles) that develops through stimulus-response Pavlovian conditioning. Phase three includes intense negative emotional responses and accompanying physiological distress, thoughts, urges, and emotion-driven behavior. Phase four is the individual's coping responses to emotional distress, and phase five is the environmental response and resulting internal and external consequences of the coping behaviors. Each phase helps explain the maintenance of the response and the individual's impairment. Results: Anticipatory anxiety and avoidance of phase one contributes to an increased arousal and awareness of triggers, resulting in increased severity of the trigger experience. Both the Pavlovian-conditioned physical reflex of phase two and the emotion-driven behavior caused by the conditioned emotional response of phase three increase with in vivo exposure to triggers. Phase four includes internal and external coping behaviors to the intense emotions and distress, and phase five includes the consequences of those behaviors. Internal consequences include beliefs fiveand new emotions based on environmental responses to anger and panic. For example, the development of emotions such as shame and guilt, and beliefs regarding how 'intolerable' the trigger is. Conclusions: We assert misophonia is a multi-sensory condition and includes anticipatory anxiety, conditioned physical reflexes, intense emotional and physical distress, subsequent internal and external responses, and environmental consequences.

The Effect of Symptom-Provocation on Inhibitory Control in Obsessive-Compulsive Disorder Patients Is Contingent upon Chronotype and Time of Day

Studies have shown that alertness can affect inhibitory control, the mechanism responsible for stopping behaviors, thoughts, or emotions. Inhibitory control is particularly important for helping individuals with Obsessive-Compulsive Disorder (OCD) resisting their symptoms. Chronotype is the mechanism governing an individual's fluctuation of alertness throughout the day. Previous studies have shown that individuals with a 'morning' chronotype have worse OCD symptoms in the evening and vice versa. We administered a novel 'symptom-provocation stop signal task' (SP-SST), in which individually tailored OCD triggers were presented and inhibitory control was measured. Twenty-five treatment-seeking OCD patients completed the SP-SST three times per day for seven consecutive days. Stop signal reaction time (SSRT), which measures inhibitory control, was calculated separately for symptom-provocation trials and for neutral trials. Results yielded that: (a) stopping was significantly harder in the symptom-provocation compared to neutral trials, and (b) the chronotype by time-of-day interaction predicts inhibition for both symptom-provocation and neutral trials, indicating better inhibition in the optimal time of day. Furthermore, we concluded that individually tailored OCD triggers have a detrimental effect on inhibitory control. Most importantly, higher alertness levels, which can be predicted by the interaction of chronotype and time of day, affect inhibitory control, both in general and for OCD triggers specifically.

Pediatric neuropsychiatric disorders with motor and nonmotor phenomena

The concept of pediatric autoimmune neuropsychiatric disorders associated with group A beta-hemolytic streptococcus (PANDAS) has become seminal since first introduced more than two decades ago. At the time of this writing, most neurologists, pediatricians, psychiatrists, and general pediatricians will probably have heard of this association or treated an affected child with PANDAS. The concept of an acute-onset, and typically self-limited, postinfectious autoimmune neuropsychiatric disorder resembling PANDAS manifesting vocal and motor tics and obsessive-compulsive disorder has broadened to other putative microbes and related endogenous and exogenous disease triggers. These disorders with common features of hypometabolism in the medial temporal lobe and hippocampus in brain 18fluorodeoxyglucose positron emission tomography fused to magnetic resonance imaging (FDG PET-MRI), form a spectrum: with the neuropsychiatric disorder Tourette syndrome and PANDAS with its well-defined etiopathogenesis at one end, and pediatric abrupt-onset neuropsychiatric syndrome (PANS), alone or associated with specific bacterial and viral pathogens, at the other end. The designation of PANS in the absence of a specific trigger, as an exclusionary diagnosis, reflects the current problem in nosology.