Is the brain capable of guiding treatment for OCD?

A study conducted by Columbia University holds promise for helping people find effective therapies.

In many cases, cognitive-behavioral therapy with exposure and response prevention (ERP) is an effective method for obsessive compulsive disorder (OCD). 

What is OCD?

An individual with OCD often experiences distressing repetitive thoughts and behaviors throughout their lifetime. “Treating OCD at younger ages can prevent a lifetime of distress, but better and more targeted treatments needed,” according to Kate Fitzgerald, MD [1].

It is currently impossible to predict who will benefit from ERP, per the Ruane Professor of Child and Adolescent Psychiatry at Columbia University and the New York State Psychiatric Institute. Fitzgerald adds that Nearly 50 percent of people with OCD continue to have clinically significant symptoms after receiving ERP.

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Can OCD be classified as an anxiety disorder?

OCD was historically classified as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). According to the DSM-IV, it is no longer classified under the “Anxiety Disorders” section but under “Obsessive-Compulsive and Related Conditions.” [2]

Researchers noted a number of differences between OCD and anxiety disorders that led to the change. In OCD, repetitive, unhelpful rituals are used to deal with unwanted thoughts. Perhaps you are unaware that your thoughts and compulsions, like excessive hand washing, are irrational. 

When you are anxious, you are likely to dwell on real-world concerns, such as the fear of being mocked or judged. The source of your fear may be avoided, but strange rituals won’t be performed to soothe your distress.

Interventions for OCD and anxiety disorders can also vary. If you are dealing with an anxiety disorder, you may need to gradually face your fears, whereas, if you are dealing with OCD, it is also crucial to address the compulsive behaviors.  

Recent human study on OCD

Fitzgerald led a study published in the American Journal of Psychiatry that used neuroimaging to determine whether the brain can predict ERP response in teens and adults [3].

Here, a resting-state fMRI study is conducted when participants are awake but not focused on anything. In 116 participants (composed of 54 adolescents and 62 adults), brain connectivity patterns were measured after 12 weeks of ERP or a control therapy involving stress reduction and problem-solving (stress management therapy or SMT). Through randomisation, the team was able to isolate the effects of ERP from the non-specific outcomes of seeing a therapist every week.

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It was found that exposure therapy reduced OCD symptoms the most pronouncedly and clinically significant way across all age groups. Researchers noticed some striking differences between participants’ brain scans before and after treatment, however.  

Adults and adolescents who responded most effectively to exposure-based therapy had the most active cortical-subcortical connections before treatment. Conversely, those with lower connectivity in these circuits responded more positively to SMT. In addition, adolescents have weaker connectivity between parts of the prefrontal cortex associated with fear conditioning and anxiety symptoms than adults. 

Plans and looking forward

Fitzgerald, a child psychiatrist, said that identifying neural differences might guide treatment development for OCD. Although ERP is effective, as many as 50 precent of those treated fail to respond fully. 

As part of her lab’s next steps, she is developing new treatments for children with OCD and improving existing treatments.

As a first step, cognitive training will be used to alter the balance of connectivity in brain circuits for cognitive control in youth with OCD. It is possible that boosting function in cognitive control circuits could help children with OCD respond to ERP during childhood and adolescence because the brain is still developing. 

Dr. Fitzgerald’s team is already testing a play-based cognitive training camp to help preschoolers with a wide range of anxiety symptoms, including obsessions and compulsions. With other faculty at Columbia, including Dr. Rachel Marsh, director of MRI Research and New York State Psychiatric Institute, Dr. Fitzgerald will soon begin testing video game-based cognitive training that aims to “prime” brain connectivity to help OCD-affected children benefit from ERP [4]. 

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[1] https://www.columbiapsychiatry.org/news/can-brain-guide-treatment-ocd
[2] https://www.helpguide.org/articles/anxiety/obssessive-compulsive-disorder-ocd.htm
[3] https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.21111173
[4] https://www.columbiapsychiatry.org/research/research-areas/child-and-adolescent-psychiatry/fitzgerald-lab/current-studies

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