Brain and Behavior Based Strategies in the Treatment of OCD

The webinar is introduced by Dr. Jeff Borenstein, President and CEO of the Brain & Behavioral Research Foundation, which funds innovative neuroscience and psychiatry research. The focus is on understanding and treating brain and behavior disorders, including OCD. Dr. Borenstein highlights the foundation's significant financial support for scientific grants globally. He introduces Dr. Christopher Pittenger, an associate professor at Yale University School of Medicine, who will present on brain and behavior-based strategies for treating OCD. Dr. Pittenger outlines the webinar, which includes a description of OCD, its prevalence, biological and psychological aspects, and some novel research findings.

Dr. Pittenger provides a comprehensive overview of Obsessive-Compulsive Disorder (OCD), explaining the persistent and unwanted thoughts, images, or urges known as obsessions, and the repetitive behaviors or mental acts, compulsions, performed in response. He discusses the disorder's prevalence, affecting approximately one in 40 individuals globally, and emphasizes the importance of recognizing and treating OCD due to its significant impact on quality of life. The presentation also covers the evolution of OCD's definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the common categories of obsessions and compulsions.

The discussion shifts to the neurobiology of OCD, with Dr. Pittenger explaining the neural circuitry abnormalities associated with the disorder. He references early positron emission tomography (PET) studies that identified hyperactive regions in the brains of individuals with OCD, particularly the orbitofrontal cortex, basal ganglia, and thalamus. These regions form a circuit that is implicated in the symptoms of OCD. The presentation also reviews how this circuit is affected when symptoms are induced and how it responds to treatment.

Dr. Pittenger delves into the conceptualization of OCD, describing a cycle that begins with intrusive cognitions and leads to maladaptive interpretations, anxiety, compulsions, and relief. This cycle is self-reinforcing and can become stuck, contributing to the persistence of OCD symptoms. He updates the traditional understanding of the OCD cycle, emphasizing the role of maladaptive interpretations and the various factors that can exacerbate or trigger the cycle, such as thought control attempts, environmental triggers, and avoidance behaviors.

The presentation explores the complexities of OCD, including the development of habits and compulsions that can become automatic and the influence of characterological predispositions that may lead to maladaptive interpretations. Dr. Pittenger discusses how different emotions, such as anxiety, disgust, or a sense of incompleteness, can drive the cycle and how these emotions can be misinterpreted as signs of the importance of intrusive thoughts. The complexities are illustrated through various components that can interact and contribute to the OCD cycle.

Dr. Pittenger outlines the standard treatments for OCD, emphasizing cognitive behavioral therapy (CBT) with exposure and response prevention as a first-line treatment. He explains how CBT aims to interrupt the OCD cycle by triggering the negative thoughts and anxiety without engaging in compulsions, leading to a reduction in symptoms over time. Additionally, he discusses the use of selective serotonin reuptake inhibitors (SSRIs) as a class of antidepressants that have been proven effective in treating OCD, highlighting their benefits and the importance of using higher doses for better responses.

The presentation moves on to new directions in pharmacological treatment for OCD, particularly when SSRIs are not effective. Dr. Pittenger mentions the use of glutamate modulators, which are drugs that affect the glutamate projections in the brain, as a potential treatment. He discusses the early studies and trials of different glutamate modulators, including Riluzole and Memantine, and their potential benefits for OCD patients. The talk also touches on the need for more research and larger trials to confirm the effectiveness of these new treatment options.

Dr. Pittenger discusses the potential of ketamine, an antidepressant known for its rapid effects, in treating OCD. He presents findings from studies where ketamine was administered to individuals with OCD, showing some improvement in symptoms. However, the results are not conclusive, and more research is needed. The presentation also briefly touches on other experimental treatments, such as psychedelic drugs like psilocybin and other serotonin modulators, which have shown some promise but require further investigation.

The final part of the presentation introduces neurofeedback as a non-pharmacological approach informed by brain biology. Dr. Pittenger explains that neurofeedback involves learning to control brain activity, specifically the hyperactivity observed in the orbitofrontal cortex of individuals with OCD. Early pilot studies suggest that neurofeedback can lead to improvements in anxiety and brain connectivity. While this approach is not yet a proven treatment, it represents an exciting frontier in OCD research.

The presentation concludes with a review of the key points discussed during the webinar, including the overview of OCD, the brain imaging studies, the cognitive processes involved in OCD, standard treatments, and new directions in research. Dr. Pittenger expresses gratitude to the foundation, colleagues, staff, and funders for their support in OCD research. The session ends with a Q&A, addressing questions about the potential of transcranial magnetic stimulation (TMS) and deep TMS for OCD, as well as inquiries about the age of onset and differences between early and late onset OCD.