The Science & Treatment of Obsessive Compulsive Disorder (OCD)

Obsessive Compulsive Disorder (OCD) and Obsessive Compulsive Personality Disorder (OCPD)

• OCD includes thoughts (obsessions) and actions (compulsions)
  • Obsessions are intrusive and recurrent
  • Compulsions provide brief relief but often reinforce obsessions
• OCPD is distinct from OCD 
  • People with OCPD may be “obsessive” but do not have the same intrusive, recurrent obsessions as those with OCD

Treatments for OCD

• Range from behavioral therapies to drug therapies and brain stimulation
• Some holistic or natural therapies may also be effective
• The sequence of applying these therapies is important for successful outcomes

Understanding the Brain and Nervous System in OCD

• Provides insight into how thought is translated into action
• Offers a greater understanding of goal-​​directed behavior
• Helps differentiate between OCD and OCPD

Therapy Options for OCD

• By understanding the disease state, individuals can better direct treatments for themselves or others

• Information covered in the podcast can also provide insight into general human functioning and behavior
  Obsessive-​​Compulsive Disorder (OCD)

• OCD is different from obsessive-​​compulsive personality disorder 
  • OCD: intrusive and recurrent obsessions
  • Obsessive-​​compulsive personality disorder: patterns of thought that people invite or like
• OCD is extremely common 
  • Estimates: 2.5% to 4% of people suffer from OCD
  • Many cases go unnoticed or unreported due to shame or hiding
• Debilitating effects of OCD 
  • Ranked 7^th in most debilitating illnesses
  • Takes time away from other aspects of life
  • Focus on obsessions and compulsions prevents focus on other tasks
  • Often related to taboo topics
• Three general categories of OCD 
  • Checking obsessions and compulsions 
    • Example: checking locks or stoves multiple times
  • Repetition obsessions and compulsions 
    • Example: counting numbers or performing actions repeatedly
  • Order obsessions and compulsions 
    • Example: cleanliness, symmetry, or incompleteness
    • Can also involve disgust or contamination concerns
• OCD can affect multiple domains of life 
  • Thought patterns and behaviors take over the environment
  • Can impact work, school, relationships, and daily activities
    Obsessions, Compulsions, and Anxiety
• Obsessions and compulsions are bound by anxiety 
  • Anxiety: heightened state of autonomic arousal without a clear and present danger
• Example: fear of turning left on a street 
  • Obsession: belief that turning left will lead to something bad happening
  • Compulsion: always turning right to avoid the perceived danger
  • Anxiety reinforces the obsession and compulsion

Genetic Component of OCD

• 40–50% of OCD cases have some genetic component 
  • Based on twin studies
  • Not always directly inherited from a parent
• Genetic component not always useful for treatment, as genes cannot be controlled

Neural Mechanisms of OCD

• Understanding the biological mechanisms can help shed light on why particular treatments work or don’t work
• Brain’s main functions: 
  • Housekeeping: digestion, heart rate, breathing, sensory functions
  • Prediction: anticipating what will happen next based on past experiences and memory systems
• Neural circuitry in OCD not fully understood, but involves the interaction between housekeeping functions and prediction systems
  Obsessive Compulsive Disorder (OCD) and the Brain
• OCD involves neural circuits in the brain 
• Nervous system connects brain and body, affecting reactions to thoughts and experiences
• Neural circuits involved in OCD include:
• Cortex: involved in perception and understanding
• Striatum: involved in action selection and holding back action (go and no-​​go behaviors)
• Thalamus: relays sensory information to the cortex, allowing certain experiences to pass through to conscious awareness
• Thalamic Reticular Nucleus: serves as a gate, regulating which information is allowed to pass through to conscious awareness and which is not
• Dysfunction in these circuits is thought to underlie OCD

Studying OCD in the Lab

• Researchers use neuroimaging techniques (MRI, PET) to study brain activity in people with OCD
• Experiments involve evoking obsessions and compulsions in subjects with OCD
• Example: presenting a contaminated towel to someone with a germ obsession and compulsion to hand wash
• Brain regions that are more active during obsessions and compulsions are part of the corticostriatal thalamic loop
• Drug treatments (e.g., SSRIs) can suppress obsessions and compulsions, as well as the activity in these neural circuits
  Obsessive-​​Compulsive Disorder (OCD) Diagnosis and Treatments
• Yale Brown Obsessive Compulsive Scale (Y‑BOCS) is a common diagnostic tool 
  • Defines obsessions and compulsions
  • Categories include aggressive obsessions, contamination obsessions, sexual obsessions, saving obsessions, moral obsessions, and need for symmetry and exactness
  • Identifies target symptoms and the fears driving the obsessions
• Cognitive Behavioral Therapy (CBT) and Exposure Therapy 
  • Powerful treatment for many people with OCD
  • Addresses the underlying neural circuitry that generates OCD and interrupts it
  • Different from CBT and exposure therapies for other mental challenges and disorders

Cognitive Behavioral Therapy (CBT) and Exposure Therapy for OCD

• Exposure-​​based CBT 
  • Encourages or forces patients to define their biggest, most catastrophic fear
  • Helps disrupt the corticostriatal thalamic loop and provide relief from symptoms
  • Identifies the fear driving the obsession and compulsion
  • Different from CBT and exposure therapies for other mental challenges and disorders
    Cognitive Behavioral Therapy (CBT) for OCD
• CBT focuses on identifying the utmost fear in OCD patients 
  • OCD patients often not consciously aware of their fears
  • Clinicians probe patients to reveal the underlying obsession
• Goal of CBT for OCD: increase anxiety, not decrease it 
  • Interrupt the neural circuit of anxiety relief brought on by compulsions
  • Teach patients to tolerate anxiety without engaging in compulsions
• CBT for OCD is distinct from other anxiety-​​related disorders 
  • Involves bringing patients close to their fears and interrupting the circuit
• Staircasing: gradual and progressive increase in anxiety 
  • Done in a clinical setting with a trained and licensed clinician
• Homework: vital component of CBT for OCD 
  • Patients practice tolerating anxiety and interrupting compulsions outside of the clinical setting
  • Helps patients deal with familiar environments that may trigger obsessions and compulsions
• Condition place preference/​​avoidance: feeling something repeatedly in a given environment 
  • Can influence how patients feel when returning to familiar environments
  • Important to address in CBT for OCD to ensure long-​​term success of treatment
    Daytime and Nighttime Break-ins
• Common in the Bay Area, leading to stolen items 
• Reminder to not leave anything in cars

Cognitive Behavioral Therapy (CBT) for OCD

• Homework assignments given by clinicians
• Home visits by therapists to observe patients’ behaviors in their environment
• Exposure therapy: gradually increasing anxiety levels and preventing compulsions
• Goals: disconfirm fears, challenge beliefs, intervene in thoughts and behaviors, break habit of ritualizing and avoiding

CBT and Exposure Therapy Protocol

• Two planning sessions with the patient
• 15 exposure sessions done twice a week or more
• Can take 10–12 weeks for treatment

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Drugs that prevent the reuptake of serotonin at the synapse
• Used in the treatment of OCD
• Can also take 10–12 weeks or longer for treatment

Dr. Helen Blair Simpson

• MD, PhD, and expert in OCD research and treatment
• Conducts research on OCD mechanisms and treatments
• Treats OCD patients in her own clinic
• Explores the best treatments for OCD patients by comparing CBT, placebo, and SSRIs
  SSRIs and Cognitive Behavioral Therapy for OCD
• SSRIs (selective serotonin reuptake inhibitors) increase serotonin availability in the brain 
• Study compared cognitive behavioral therapy (CBT), SSRIs, placebo, and CBT + SSRIs for OCD treatment 
  • Placebo had no significant effect on OCD symptoms
  • CBT had a dramatic effect in reducing OCD symptoms
  • SSRIs had a significant effect in reducing OCD symptoms, but not as much as CBT
  • Combining CBT and SSRIs from the outset did not lead to further decrease in OCD symptoms
• Adding CBT to someone already taking SSRIs further improves their symptoms 
  • Ideal scenario: combine drug treatment with CBT or use CBT alone (with physician’s advice)
• Common SSRIs: Fluoxetine (Prozac), Fluvoxamine (Fluvox), Paroxetine, Sertraline, Citalopram, etc. 
  • Side effects vary: appetite changes, libido changes, transient effects
  • Important to work closely with a psychiatrist for proper dosage and monitoring
• Little evidence that serotonin system is disrupted in OCD, despite SSRIs being effective in reducing symptoms
  Pharmacotherapeutic Strategies and New Targets in OCD
• Review by Christopher Pittenger from Yale University School of Medicine 
• Serotonin system not directly disrupted in OCD, but SSRIs can be effective
• Serotonin 2A and 1A receptors are potential targets for drug development 
  • Psilocybin, a psychedelic, is being studied for its potential in treating OCD 
    • Clinical trials at Johns Hopkins School of Medicine show effectiveness in treating depression
    • Results for OCD treatment are inconclusive so far

Serotonin and Cognitive Flexibility

• Serotonin implicated in cognitive flexibility and inflexibility, which are themes in OCD
• Low levels of serotonin can lead to cognitive inflexibility and challenges in task switching
• Serotonergic drugs are most effective in treating OCD, despite no direct evidence of serotonin system disruption

Combination Treatments for OCD

• Some patients do not respond to CBT or SSRIs, leading to exploration of other drug treatments 
  • Combination of SSRIs and neuroleptics (drugs that tap into dopamine or glutamate systems)
• Neuromodulators like dopamine and serotonin change the overall activity patterns in the brain 
  • Affect different circuits, making certain circuits more or less likely to be active

Alternative Drug Treatments for OCD

• Psilocybin and cannabis have been explored for OCD treatment 
  • Cannabis can reduce anxiety, but its effectiveness in treating OCD is still under investigation 
    • Study by Dr. Blair Simpson: Acute Effects of Cannabinoids on Symptoms of Obsessive Compulsive Disorder 
      • 14 adults with OCD, randomized, placebo-controlled
      • Participants smoked cannabis with varying levels of THC and CBD
      • Results inconclusive, further research needed
        CBD and OCD
• Study in 2020: first placebo-​​controlled investigation of cannabis in adults with OCD 
• Explored different percentages of THC and CBD in cannabis cigarettes
• Results: smoked cannabis (with THC or CBD) had little acute impact on OCD symptoms
• Smaller reductions in anxiety compared to placebo
• No clear evidence that cannabis or CBD can alleviate OCD symptoms

Ketamine and OCD

• Ketamine acts on the glutamate system, disrupting the relationship between glutamate and the NMDA receptor
• Used extensively for the treatment of trauma and depression
• Early studies on ketamine therapy for OCD show some relief for some patients, but not overwhelmingly effective
• More extensive clinical trials needed

Transcranial Magnetic Stimulation (TMS) and OCD

• Non-​​invasive treatment using a magnetic coil to suppress or activate particular brain regions
• Can interrupt motor behaviors (compulsions) associated with OCD
• Some effectiveness in reducing OCD symptoms, but not a magic bullet
• Best used in combination with drug treatments or cognitive behavioral therapy (CBT)

Cannabis and OCD

• Cannabis increases focus, which may not be beneficial for OCD symptoms
• Study did not show improvement in OCD symptoms with cannabis or CBD
• Thoughts are not as bad as actions: important for OCD sufferers to understand

Hormones and OCD

• Research on the roles of hormones in OCD is ongoing
• Understanding the relationship between hormones and OCD may lead to new treatment options
  OCD and Intrusive Thoughts
• People with OCD have intrusive and disturbing thoughts 
• Treatment for OCD involves supporting the patient and helping them realize thoughts are just thoughts
• Thoughts are not actions; actions can harm us, thoughts can be troubling but are not as bad as actions

Hormones in OCD

• Study: “Neurosteroid levels in Patients with Obsessive Compulsive Disorder”
• Explored serum neurosteroid levels in people with OCD
• Compared serum levels of progesterone, pregnenolone, DHEA, cortisol, and testosterone in 30 patients with OCD and 30 healthy controls
• Findings:
  • Females with OCD: significantly elevated cortisol and DHEA
  • Males with OCD: increased cortisol and significant reductions in testosterone
• Relationship between hormones and GABA: 
  • DHEA is a potent antagonist of the GABA system
  • Testosterone also affects the GABA system
  • Hormone patterns in OCD patients result in overall reduction in GABA, leading to increased excitation in certain brain networks

Potential Treatments

• Manipulations of hormone systems might prove useful in adjusting the symptoms of OCD
• Many treatments for reducing DHEA, increasing testosterone, or reducing cortisol are FDA-​​approved and available in generic form
• Hormones impact neurotransmitters and neuromodulators, which impact the circuits involved in OCD
• Testosterone therapy has been effective in treating anxiety-​​related disorders, but not specifically studied in OCD
  Nontraditional Treatments for OCD
• Mindfulness meditation
  • Increases ability to focus
  • Can be useful in OCD treatment by impacting focus on cognitive behavioral therapies
  • Indirectly improves OCD symptoms
• Nutraceuticals (over-​​the-​​counter supplements) 
  • Large number of compounds and supplements explored for OCD treatment
  • Some examples:
    • 5‑HTP and tryptophan (serotonin pathway) 
      • Can improve/​​reduce OCD symptoms similarly to SSRIs
    • Inositol (900mg)
      • Can improve sleep, reduce anxiety, and enhance focus/​​alertness
      • High dosages (10–12 grams) can cause gastric discomfort
  • Future exploration of nutraceuticals in combination with behavioral therapies and brain-​​machine interfaces

Obsessive Compulsive Personality Disorder (OCPD)

• Distinct from OCD 
  • Does not have intrusive thoughts or overwhelming obsessions
  • Obsessions can sometimes serve or be welcomed by the individual
• Important to be careful with language and not confuse OCPD with OCD
  Obsessive Compulsive Disorder (OCD) vs. Obsessive Compulsive Personality Disorder (OCPD)
• OCD and OCPD are different disorders with different effects on a person’s life 
• Both can cause impairments in psychosocial functioning and quality of life
• Key differences between the two: 
  • OCD is characterized by intrusive thoughts and obsessions that disrupt normal functioning
  • OCPD can be both adaptive and maladaptive, depending on the context and degree of expression

OCD

• Intrusive thoughts and obsessions
• Interrupts normal functioning in life
• Impairing in mild, moderate, or severe forms

OCPD

• Can be productive and enhance functioning in certain domains of life (e.g., work, home organization)
• Can synergize well with activities and professions that require precision and delayed gratification (e.g., architecture, science, mathematics, engineering)
• Range of expressions, some adaptive and some maladaptive, depending on context

Superstitions and Motor Sequences

• Research by Bensolevsky at Harvard on motor sequences and learning
• As animals and humans learn a particular motor sequence, they often introduce irrelevant motor patterns that persist
• Example: pitchers in baseball performing the same sequence of irrelevant motor patterns before each pitch
  Superstitions and OCD
• Superstitions: beliefs linked to the probability of an outcome with no rational relationship 
• Can become compulsions and obsessions when repeated often enough
• People with OCD tend to have more superstitions
• People with more superstitions tend to have a tendency towards OCD
• Obsessive Compulsive Personality Disorder (OCPD) represents the next level along the continuum

Treatments for OCD

• Cognitive Behavioral Therapy (CBT)
• Drug treatments like SSRIs
• Drug treatments that tap into the glutamate system and dopamine system (neuroleptics)
• Exploration of substances like Ketamine, psilocybin, and cannabis 
  • Initial studies don’t show much promise for cannabis and CBD in treating OCD
• Brain machine interface, like transcranial magnetic stimulation
• Combinations of behavioral and drug treatments and brain machine interface are the future