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Posts Tagged ‘OCD

Rapid Effects Of Intensive Therapy Seen Patients With Obsessive-compulsive disorder (OCD)

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In a study that may significantly advance the understanding of how cognitive-behavioral therapy affects the brain, researchers have shown that significant changes in activity in certain regions of the brain can be produced with as little as four weeks of daily therapy in patients with obsessive-compulsive disorder (OCD). The discovery could have important clinical implications, according to principal investigator Sanjaya Saxena, M.D., Director of the Obsessive-Compulsive Disorders Program at the University of California, San Diego (UCSD) School of Medicine, whose findings are published on line this week in the journal Molecular Psychiatry.
“The study is exciting because it tells us more about how cognitive-behavioral therapy works for OCD and shows that both robust clinical improvements and changes in brain activity occur after only four weeks of intensive treatment,” said Saxena.OCD is an anxiety disorder in which individuals have unreasonable fears or worries that they try to manage through ritualized compulsive behaviors to reduce the anxiety. For example, a patient may experience the urgent need to engage in certain rituals, such as hand washing or repeatedly checking that the oven is off or the front door is locked.

Past studies using functional brain imaging studies of patients with OCD have demonstrated that elevated activity along the frontal-subcortical circuits of the brain decreases in response to treatment with serotonin reuptake inhibitor (SRI) medications or cognitive-behavioral therapy. However, clinical improvement of OCD symptoms was expected to require up to 12 weeks of behavioral therapy or medication treatment, the standard treatments for OCD. Only a handful of studies have looked at how therapy affects brain function, and all previous studies had examined changes over several months of treatment.

Saxena and colleagues at the David Geffen School of Medicine at UCLA made two novel discoveries in their study of 10 OCD patients and 12 control subjects.

“First of all, we discovered significant changes in brain activity solely as the result of four weeks of intensive cognitive-behavioral therapy,” said Saxena. “Secondly, these changes were different than those seen in past studies after a standard 12-week therapeutic approach using SRI medications or weekly behavioral therapy.”

The researchers obtained positron emission tomography (PET) scans of the ten OCD patients both before and after they received four weeks of a therapy known as “exposure and response prevention,” which gradually desensitizes patients to things that provoke obsessional fears or worries.

“This is the primary kind of therapy used for OCD. It teaches patients to pay attention to their internal experiences and tolerate scary thoughts without having to act on them,” said Saxena. “They learn that nothing terrible happens if they refrain from their usual compulsive behaviors.”

The normal control subjects received no treatment and were scanned twice, several weeks apart, and metabolic changes in the brain were compared between the two groups. After four weeks of therapy and without any changes in medication, the OCD patients showed significant improvements in OCD symptoms, depression, anxiety and overall functioning.

The PET scans of OCD patients demonstrated significant decreases in glucose metabolism — a measure of brain cell activity — in the right and left thalamus after treatment. These are areas of the brain involved in OCD and where changes have been seen in numerous past studies after longer-term treatment.

However, the PET scans in this study also showed a significant increase in activity in an area of the brain called the right dorsal anterior cingulate cortex, a region involved in reappraisal and suppression of negative emotions. Increasing activity in this region corresponded to the OCD patients’ improvement in clinical symptoms after the four-week course of intensive therapy. Activity in this area had previously been found to increase after cognitive-behavioral therapy for major depression. Therefore, the researchers theorize that response to cognitive-behavioral therapy across a variety of disorders may require activation of the dorsal anterior cingulate cortex, according to Saxena.

PET scan showing improvement

PET scans of OCD patients show the same reductions in brain caudate nucleus activity (center of brain) that occur following successful drug treatment are also produced by successful behavior therapy

Mol Psychiatry. 2008 Jan 8 [Epub ahead of print]
Rapid effects of brief intensive cognitive-behavioral therapy on brain glucose metabolism in obsessive-compulsive disorder.

1Department of Psychiatry, School of Medicine, University of California, San Diego, La Jolla, CA, USA.

Brief intensive cognitive-behavioral therapy (CBT) using exposure and response prevention significantly improves obsessive-compulsive disorder (OCD) symptoms in as little as 4 weeks. However, it has been thought that much longer treatment was needed to produce the changes in brain function seen in neuroimaging studies of OCD. We sought to elucidate the brain mediation of response to brief intensive CBT for OCD and determine whether this treatment could induce functional brain changes previously seen after longer trials of pharmacotherapy or standard CBT. [(18)F]-fluorodeoxyglucose positron emission tomography brain scans were obtained on 10 OCD patients before and after 4 weeks of intensive individual CBT. Twelve normal controls were scanned twice, several weeks apart, without treatment. Regional glucose metabolic changes were compared between groups. OCD symptoms, depression, anxiety and overall functioning improved robustly with treatment. Significant changes in normalized regional glucose metabolism were seen after brief intensive CBT (P=0.04). Compared to controls, OCD patients showed significant bilateral decreases in normalized thalamic metabolism with intensive CBT but had a significant increase in right dorsal anterior cingulate cortex activity that correlated strongly with the degree of improvement in OCD symptoms (P=0.02). The rapid response of OCD to intensive CBT is mediated by a distinct pattern of changes in regional brain function. Reduction of thalamic activity may be a final common pathway for improvement in OCD, but response to intensive CBT may require activation of dorsal anterior cingulate cortex, a region involved in reappraisal and suppression of negative emotions.Molecular Psychiatry advance online publication, 8 January 2008; doi:10.1038/sj.mp.4002134.

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What Treatment Will Make Patients Give Up Their Compulsions?

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Written by huehueteotl

January 22, 2008 at 4:24 pm

What Treatment Will Make Patients Give Up Their Compulsions?

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Behavior therapy [exposure and response prevention (ERP)] and cognitive therapy (CT) have proven effective in the treatment of obsessive-compulsive disorder. Direct comparisons between these treatment modalities have exposed no differences in efficacy.

However, very little research has been conducted into the differences between the change processes in ERP and CT. This investigation is a first attempt to study change by measuring scores on a weekly basis rather than at specific stages in the treatment and follow-up.

The Authors used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at weekly intervals to rate and compare the severity of the obsessions and compulsions of 61 completers of either CT or ERP. The aim was to ascertain whether the process of change in CT is different from the process of change in ERP. The Authors expected that ERP would primarily affect behavior, thus reducing compulsions first, while CT would primarily affect thought, thus reducing obsessions first.

At the end of the study, no differences were found between ERP and CT with respect to the change process for obsessions and compulsions. Secondly, it emerged that changes in compulsions predicted all treatment effects better than changes in obsessions. The authors concluded that their results suggest that reduction of compulsions is the process through which both ERP and CT affect change.

Psychother Psychosom. 2008;77(1):38-42. Epub 2007 Dec 14.
Cognitive versus behavior therapy: processes of change in the treatment of obsessive-compulsive disorder.

Department of Psychiatry and Institute for Research in Extramural Medicine, VU University Medical Center and GGZ Buitenamstel, Amsterdam, The Netherlands.

BACKGROUND: Behavior therapy [exposure and response prevention (ERP)] and cognitive therapy (CT) have proven effective in the treatment of obsessive-compulsive disorder. Direct comparisons between these treatment modalities have exposed no differences in efficacy. However, very little research has been conducted into the differences between the change processes in ERP and CT. This investigation is a first attempt to study change by measuring scores on a weekly basis rather than at specific stages in the treatment and follow-up. METHODS: We used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at weekly intervals to rate and compare the severity of the obsessions and compulsions of 61 completers of either CT or ERP. The aim was to ascertain whether the process of change in CT is different from the process of change in ERP. We expected that ERP would primarily affect behavior, thus reducing compulsions first, while CT would primarily affect thought, thus reducing obsessions first. RESULTS: Firstly, no differences were found between ERP and CT with respect to the change process for obsessions and compulsions. Secondly, it emerged that changes in compulsions predicted all treatment effects better than changes in obsessions. CONCLUSIONS: These results suggest that reduction of compulsions is the process through which both ERP and CT affect change.

Written by huehueteotl

January 21, 2008 at 4:59 pm

Brain Pattern Associated With Genetic Risk Of Obsessive Compulsive Disorder

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Cambridge researchers have discovered that individuals with obsessive compulsive disorder (OCD) and their close family members have distinctive patterns in their brain structure. This is the first time that scientists have associated an anatomical trait with familial risk for the disorder.

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Obsessive compulsive disorder, positive correlation. Positive correlation with obsessive compulsive disorder symptom intensities while contaminants placed in folded hands. WOEXP: 323.

Philip K. McGuire; C. J. Bench; C. D. Frith; I. M. Marks; Richard S. J. Frackowiak; R. J. Dolan. Functional anatomy of obsessive-compulsive phenomena. British Journal of Psychiatry 164(4):459-468, 1994. PMID: 8038933. WOBIB: 104. These new findings could help predict whether individuals are at risk of developing OCD and lead to more accurate diagnosis of the disorder.

Obsessive compulsive disorder is a prevalent illness that affects 2–3 % of the population. OCD patients suffer from obsessions (unwanted, recurrent thoughts, concerns with themes of contamination and ‘germs’, the need to check household items in case of fire or burglary, the symmetrical order of objects or fears of harming oneself or others) as well as compulsions (repetitive behaviours related to the obsessions such as washing and carrying out household safety checks). These symptoms can consume the patient’s life, causing severe distress, alienation and anxiety.

OCD is known to run in families. However, the complex set of genes underlying this heritability and exactly how genes contribute to the illness are unknown. Such genes may pose a risk for OCD by influencing brain structure (e.g. the amount and location of grey matter in the brain) which in turn may impact upon an individual’s ability to perform mental tasks.

In order to explore this idea, the researchers used cognitive and brain measures to determine whether there are biological markers of genetic risk for developing OCD. Using magnetic resonance imaging (MRI), the Cambridge researchers captured pictures of OCD patients’ brains, as well as those of healthy close relatives (a sibling, parent or child) and a group of unrelated healthy people.

Participants also completed a computerised test that involved pressing a left or right button as quickly as possible when arrows appeared. When a beep noise sounded, volunteers had to attempt to stop their responses. This task objectively measured the ability to stop repetitive behaviours.

Both OCD patients and their close relatives fared worse on the computer task than the control group. This was associated with decreases of grey matter in brain regions important in suppressing responses and habits.

Lara Menzies, in the Brain Mapping Unit at the University of Cambridge, explains, “Impaired brain function in the areas of the brain associated with stopping motor responses may contribute to the compulsive and repetitive behaviours that are characteristic of OCD. These brain changes appear to run in families and may represent a genetic risk factor for developing the condition. The current diagnosis of OCD available to psychiatrists is subjective and therefore knowledge of the underlying causes may lead to better diagnosis and ultimately improved clinical treatments.

“However, we have a long way to go to identify the genes contributing to the distinctive brain structure found in OCD patients and their relatives. We also need to identify other contributing factors for OCD, to understand why close relatives that share similar brain structures don’t always develop the disorder.”

Brain. 2007 Sep 13; [Epub ahead of print]

Neurocognitive endophenotypes of obsessive-compulsive disorder.

Menzies L, Achard S, Chamberlain SR, Fineberg N, Chen CH, Del Campo N, Sahakian BJ, Robbins TW, Bullmore E.

Brain Mapping Unit, University of Cambridge, Department of Psychiatry, Queen Elizabeth II Hospital, Welwyn Garden City, Department of Experimental Psychology, Behavioural and Clinical Neurosciences Institute, University of Cambridge, Cambridge, CB2 3EB, Department of Psychiatry, Addenbrooke’s Hospital, Cambridge, CB2 2QQ and Clinical Unit Cambridge, Addenbrooke’s Centre for Clinical Investigations, Clinical Pharmacology & Discovery Medicine, GlaxoSmithKline, Cambridge CB2 2QQ, UK.

Endophenotypes (intermediate phenotypes) are objective, heritable, quantitative traits hypothesized to represent genetic risk for polygenic disorders at more biologically tractable levels than distal behavioural and clinical phenotypes. It is theorized that endophenotype models of disease will help to clarify both diagnostic classification and aetiological understanding of complex brain disorders such as obsessive-compulsive disorder (OCD). To investigate endophenotypes in OCD, we measured brain structure using magnetic resonance imaging (MRI), and behavioural performance on a response inhibition task (Stop-Signal) in 31 OCD patients, 31 of their unaffected first-degree relatives, and 31 unrelated matched controls. Both patients and relatives had delayed response inhibition on the Stop-Signal task compared with healthy controls. We used a multivoxel analysis method (partial least squares) to identify large-scale brain systems in which anatomical variation was associated with variation in performance on the response inhibition task. Behavioural impairment on the Stop-Signal task, occurring predominantly in patients and relatives, was significantly associated with reduced grey matter in orbitofrontal and right inferior frontal regions and increased grey matter in cingulate, parietal and striatal regions. A novel permutation test indicated significant familial effects on variation of the MRI markers of inhibitory processing, supporting the candidacy of these brain structural systems as endophenotypes of OCD. In summary, structural variation in large-scale brain systems related to motor inhibitory control may mediate genetic risk for OCD, representing the first evidence for a neurocognitive endophenotype of OCD