OCD Rossouw1

7/28/2019 OCD Rossouw1

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By

Dr Pieter Rossouw (MClin Psych., Ph.D., MAPS, MCClin)

TheNeurobiological Roots of

Obsessive-Compulsive

Disorder

the implications

for treatment


2/9The Neuropsychotherapist.com

Obsessive-Compulsive DisorderBy Dr Pieter Rossouw

The compulsive hand washing of Lady Macbeth inShakespeares Macbeth, is often referred to as anexample of OCD.

Thou wouldst be great,/Art not without ambition,but without/The illness should attend it . If at thisstage she needs to use a ritual of hand washing to easeher anxiety, she hides it, though her gentlewoman tellsher doctor later when he witnesses the lady sleepwalk-ing, It is an accustomd action with her, to seem thuswashing her hands. I have known her continue in this a

quarter of an hour.

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Dr Pieter Rossouw

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dsm iv-trThe Diagnostic and Statistical Manual of Mental

Disorders (DSM IV- TR) describes the diagnosticcriteria of OCD as:

Either obsessions or compulsions:

Obsessions as dened by (1), (2), (3), and (4):

1. recurrent and persistent thoughts, impuls-es, or images that are experienced at sometime during the disturbance, as intrusive andinappropriate and that cause marked anxietyor distress

2. the thoughts, impulses, or images are not sim-ply excessive worries about real-life problems

3. the person attempts to ignore or suppress suchthoughts, impulses, or images, or to neutralizethem with some other thought or action

4. the person recognizes that the obsessionalthoughts, impulses, or images are a product ofhis or her own mind (not imposed from withoutas in thought insertion)

Clients often report thatthey feel driven to per-

form ritualistic behav-iours in an attempt tomitigate anxiety pro-

duced by unsettling obsessivethoughts. Are there any neuralcorrelates linked with OCD? Arethey linked to genetics, neuralstructures or neurochemicals?What role does nurture (early lifeexperiences) play in the patho-

genesis of OCD? In this brief over-view we address some of thesequestions and explore the im-plications for therapeutic inter-ventions. Obsessive-compulsivedisorder (OCD) is a conditioncharacterized by obsessions (re-curring uncomfortable thoughts)and compulsions (ritualistic acts).

If another Axis I disorder is

present, the content of the ob-sessions or compulsions is not re-

stricted to it (e.g., preoccupationwith food in the presence of anEating Disorder; hair pulling in thepresence of Trichotillomania; con-cern with appearance in the pres-ence of Body Dysmorphic Disor-der; preoccupation with drugs inthe presence of a Substance UseDisorder; preoccupation with hav-ing a serious illness in the presence

of Hypochondriasis; preoccupa-tion with sexual urges or fantasiesin the presence of a Paraphilia; or

guilty ruminations in the presenceof Major Depressive Disorder).

The disturbance is not due tothe direct physiological eects ofa substance (e.g., a drug of abuse,a medication) or a general medi-cal condition. (APA 2000).

PrevalenceOCD aects about 2-3% of

the general population and is thefourth most common disorder

after phobias, substance abuseand major depression (Bear et. al2010). The typical age of onset islate adolescence with equal gen-der distribution.

Genetic basisThere is evidence of a genetic

basis for OCD. Concordance ratesfor monozygotic twins range

from 53% to 87% and dizygotictwins from 22% to 47%. (Miguel

et.al. 1997). As the concordance

rate is less than 100% it meansthat, although the genetic ex-pression plays a major role in thedevelopment of OCD. The envi-

ronmental factors are vital to thedevelopment of the disorder. This

does not rule out the genetic andneurobiological pathogenesis ofthe disorder but neuroscientistsrealise more and more that un-derstanding disorders involvesunderstanding a complex interac-tion of nature and nurture.

Nature vs NurtureHowever complex, it is this

same interaction that providesa window for treatment from anenvironmental perspective. Theenvironmental perspective hasdemonstrated itself as probablythe most powerful intervention

to treat mental disorders. It sim-ply means that enriched envi-ronments (like talking therapies,physical safety, nutrition, exer-

cise, quality sleep) play a vital rolein establishing new (more eec-

tive) synaptic connections andthus changing the neural path-ways and memory systems thatmaintain pathological behaviours.

OCD aects about 2-3% of the general

population and is the fourth most common

disorder after phobias, substance abuse and

major depression



Obsessive-Compulsive Disorder

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OCDis not only linked to neural

activation patterns in theOFC-striatum-amygdala-

thalamus loop.There is also evidence of

neurochemical indicators.

The neuroanatomical circuitlinked to OCDWhilst doing research on neural circuits

of epileptic patients in Paris, Jean Talairach

stimulated the cingulum (part of the cingu-late gyrus the belt that spans over the cor-pus callossum) and found that when this areais stimulated patients could not suppressthe urge to engage in repetitive behaviours.This area is very close to key limbic struc-tures especially the amygdala (Talairach1973). More elaborate studies followed. In1989 Jack Modell and colleagues identiedthe link with the orbitofrontal cortex (OFC)

(Modell et. al. 1989). The OFC is known for

its key role in advanced cognitions and asso-ciations and more recently linked to the de-velopment and maintenance of personality.Research suggests that the frontal lobes andcingulate cortex project neural messages tothe striatum (the input centre of the basal

ganglia) andthen projecti n h i b i t o r y

impulses to

the thala-mus (the in-put centreof externalstimuli).

Effectivefunctioningof this neu-roanatomi-

cal circuitdepends on

the appropriate information being transmit-ted from the thalamus to the frontal cortex.Neural circuits that are overactive and notresponding to feedback from the thalamus

tend to engage excessively in particularpatterns. These patterns can demonstrate

themselves in neural circuits linked with ob-sessions (thoughts/ images) or compulsions(behaviours) or both.

The OCD loopThe role of the striatum has been men-

tioned in this loop. The function of thestriatum is known to be its involvement inmovement it enables us to carry out basicautomatic behaviours (like grooming) with-out having to focus on the activity. Even-tually this enables us to carry out multipletasks while focussing on higher cognitive or

complex activities (driving a car, listeningto the radio, changing gears and talking to

the passenger).OCD is considered to be the result of a

neural pattern that is not eectively regulat-ed resulting in ongoing activation of the OFCand striatum (like the sensor of the smokealarm that sets o too easily). The role ofthe striatum is considered to be so vital inunderstanding OCD that some researchers

suggested that it should not be classied asan anxiety disorder but a movement disor-

der however the link with the amygdala andfear response still validates the classica-tion under the anxiety disorders (Lambert &Kinsley 2011; LeDoux 2003).

When the OCD loop is established theactivation can happen at either end itcan initiate from a sensory input an actualevent activated through the thalamus (Ineed to lock the car; I need to make sureit is locked and lock it again and again) or a

thought/image (did I lock the car?; I needto go back and check).

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Dr Pieter Rossouw

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The neurochemistry of OCDOCD is not only linked to neural activa-

tion patterns in the OFC-striatum-amygda-la-thalamus loop. There is also evidence ofneurochemical indicators. A number of neu-rotransmitters and neuromodulators havebeen investigated in relation to OCD. On

some levels, OCD can be viewed as a be-havioural addiction. Rats with increasedcellular activity in the nucleus accumbensdemonstrate increased Dopaminergic ac-tivity (linked with pleasure reward but alsowith addiction) and decreased GABA activ-ity (linked with relaxation and toning downof Dopaminergic action).

Assisting the brain to experience in-creased GABA activity linked with reward(Dopamine release) is one of the vital goals

in addressing OCD. Enhancing Dopaminerelease through high performance activities(eg. Exercise), increase the adrenalin endor-phin levels and does not contribute to downregulate neural activity linked to OCD. Thisdoes not mean physical exercise is not ben-ecial however it seems exercise should notbe the therapeutic focus to manage OCD.

Oxytocin is a neuropeptide that is re-leased by the posterior

pituitary and is releasedwith breast-feeding andsocial bonding. This pep-tide plays a vital role in at-tachment and safety andforms a vital component inneural development es-pecially during the rst 10months after birth. Oxy-tocin seems to enhance

the expression of groom-ing, reproductive and af-liative behaviours.

Oxytocin is also linked with emotionaland physical safety. The absence of thesefactors lead to decrease of Oxytocin produc-tion, up regulation of the amygdala activity,increased thalamus scanning of the environ-ment for cues of threat and enhancement ofthe activation of the OCD loop.

Treatment for OCDPsychopharmacological treatment was,

for many years, the treatment of choice. SS-RIs (selective serotonin reuptake inhibitors)

were used with mixed success. Most studies

indicate that SSRIs may have an indirect ef-fect on OCD (Dolberg et. al. 1996; Eineberg& Gale 2005) however long term neuralchanges have not been demonstrated.

In more extreme cases, neurosurgery hasbeen introduced.

Anterior cingulotomy was originallyper- formed in 1952. In this procedurethe anterior portion of the cyngulategyrus is excised. The success rate wasaround 50% with long term eect of30% (Jenike et.al 1996).

Subcaudate tractotomy is a proce-dure in which lesions are made inthe orbito frontal cortex. Clinical im-provement was seen in around 50%

of patients (Goktepe, Young & Bridg-es 1975).

Limbic leucotomy is a procedure ofbilateral lesions introduced to thelower medial portion of the orbito-frontal areas and bilateral lesions ofthe anterior cingulate area. Successrates are as high as 84% with no longterm side eects (Perse 1988).

Deep brain stimulation. This proce-

dure, especially used in treatmentof Parkinsons disease consists of a

battery operated neurostimulatorthat is implanted in the subclaviculararea allowing for continual stimula-tion of the brain. Limited informationis available regarding the ecacy ofthis intervention (Denys & Mantione

2009).

PsychotherapyA variety of psychotherapeutic interven-

tions were used over the course of the last

When the OCD loopis established theactivation canhappen at either end it can initiate froma sensory input anactual event acti-vated through thethalamus (I needto lock the car; Ineed to make sureit is locked and lockit again and again)

or a thought/image(did I lock the car?;I need to go backand check).

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Obsessive-Compulsive Disorder

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A neuropsychotherapeutic approach takes intoconsideration the fact that the OCD loop iswell established...

100 years. While the psychoanalytical ap-proach focussed on the meaning of the ob-sessions and compulsions the behaviouralapproaches were more directly focused ontreating the actions. The Exposure and Re-sponse Prevention (ERP) proved to be therst empirically validated successful treat-

ment (Kobak et.al 1998). Patients were in-structed to expose themselves to fearedstimuli and encouraged to stay in contactwith the stimuli and not to avoid the stimuli.

Due to this approach (facing the fear headon) a signicant number of clients tend todrop out during the program (Marks 1997).

Cognitive therapy focuses on the cogni-tive aspect rather the behavioural aspect ofthe OCD loop. The key is on developing an

anxiety prole and facing the fear (Clark& Beck 2012) and assisting the client to es-tablish a sense of cognitive control.

NeuropsychotherapyThe challenge with managing OCD is theprevalence of the OCD loop in terms of neu-ral activity and the neuromodulators (thekey role players being Oxytocin, Serotonin,GABA and Dopamine). Both these systemsplay a vital role in maintaining a level of con-gruence and control (albeit dysfunctional).As the OCD loop links closely with primitivesystems in the brain evolution, cognitive in-terventions may not be that successful un-

less these systems are taken into account.This means that concepts like facing the

fear may have a counter productive resultwhen the client is not provided with a warmsafe and secure environment. Well estab-lished therapeutic rapport and empatheticunderstanding is vital for down regulationof limbic activity, ensuring a decrease ofstress hormones that excite the OCD loop.

A safe, trusting relationship also encour-

ages oxytocin and GABA reactions resultingin more eective cortical blood ow to thefrontal cortical regions and up regulatingeective cognitive patterns (an importantreason why cognitive therapy is at least pre-ferred to behavioural therapy).

A neuropsychotherapeutic approach

takes into consideration the fact that theOCD loop is well established and neuro-modulators and stress hormones feed theOCD pattern. As a result the therapeutic alli-

ance need to be established and new neuralconnections introduced.

This means learning to relax (feelinggood - GABA linked with Dopamine) needsto be introduced to the neural pathways andthen a hierarchy of control (slow exposure

to the OCD loop) developed whilst keepingthe stress response down regulated. This isa balance of neural excitability (changingsynaptic connections towards new neu-

ral pathways) and synaptic inhibition (lessactivation of default unhelpful patterns)

A safe, trusting relationship also encourages oxytocin andGABA reactions resulting in more eective cortical blood ow

to the frontal cortical regions and up regulatingeective cognitive patterns

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Dr Pieter Rossouw

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(Grawe 2007).

This process is en-hanced with cogni-tive activities such aschallenging unhelp-ful thoughts and im-ages. The clinicianneeds to be mindfulof demonstrations ofdistress and assist theclient to identify this

as: my OCD loop iskicking in what do Ineed to do to shift the neurons in my brainto activate the new pattern rather than theold pattern.

Eventually the goal of Neuropsychother-apy for OCD is to shift the synaptic strength

of the OCD loop toward a new, well estab-lished neural pathway that links more eec-tively with the left prefrontal cortical region

to problem solve more eectively and inte-grate high levels of controllable congruencein all situations.

References:

American Psychiatric Association, 2000.Diagnostic and statistical manual of

mental disorders (4th ed TR). Washing-ton, APA.

Bear, M.F. et.al. 2010. Neurosurgery for ob-sessive -compulsive disorder: Contem-porary approaches. Journal of ClinicalNeuroscience. 17: 1-5.

Clark, D.A. & Beck, A. T. 2012. The AnxietyWorkbook. The Cognitive BehavioralSolution. New York, The Guilford Press.

Denys, D. & Mantione, M. 2009. Deep brainstimulation in obsessive-compulsivedisorder.

Progress in Brain Research. 175, 419-427.Dolberg, O.T. et.al. 1996. The pathogen-

esis and

treatment of obsessive-compulsive disor-der. Clinical Neuropharmachology. 19(20), 129- 147.

Eineberg, N.A. & Gale, T.M. 2005. Evidence-

based pharmacotherapy of obsessive-compulsive disorder. InternationalJournal of Neuropsychopharmacology.8, 107-129.

Goktepe, E.O. 1975. A further review of

the results of stereotactic subcaudatetractotomy. British Journal of Psychiatry.126, 270-280.

Grawe, K. 2007. Neuropsychotherapy. HowNeurosciences inform Eective Psycho-

therapy. New York, Taylor & Francis.Jenike, M.A. et.al. 1996. Cerebral structural

abnormalities in obsessive-compulsivedisorder. Archives of General Psychiatry.53, 625-632.

Kobak, K.A. et.al. 1998. Behavioural versus

pharmacological treatments of obses-sive- compulsive disorder: A meta-analy-sis. Psychopharmacology. 136, 205-216.

Lambert, K.G. & Kinsley, C.H. 2011. Clini-

cal Neuroscience. Psychopathology andthe Brain. New York, Oxford UniversityPress.

LeDoux, J. 2003. Synaptic Self. How ourbrains become who we are. New York,Penguin Group.

Miguel, E.C. et.al. 1997. Obsessive-com-pulsive disorder. Neuropsychiatry of theBasal Ganglia. 20 (4), 863-883.

Marks, I. 1997. Behaviour therapy forobsessive-compulsive disorder: a decadeof progress. Canadian Journal of Psy-chiatry. 42, 1021- 1027.

Perse, T. 1988. Obsessive-compulsivedisorder: A treatment review. Journal ofClinical Psychiatry. 49,48.

learning to relaxneeds to be intro-duced to the neuralpathways and then ahierarchy of controldeveloped whilstkeeping the stressresponse downregulated.

Dr Pieter Rossouwspecialises in Neuropsychotherapy in Australia and is an expert

in anxiety and mood disorders. He has published ve scientic

books and over twenty scientic articles. He has been involvedin research in extensive clinical trials and presented research

papers at thirty international conferences worldwide. He is on

the Advisory Board of The Neuropsychotherapist.

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Pieter J. RossouwMClin Psych; PhD; MAPS; CCLIN.

Pieter is the Director of the Master of Counselling Program at the School of Psychology and the School of So-cial Work and Human Services at The University of Queensland, Australia. His research and teaching focuses on

Neuropsychotherapy. Pieter is also the Director of Mediros a company that provides training in Neurobiologyand Neuropsychotherapy.

Pieter has established a distinguished career as Clinical Psychologist, Lecturer, Clinical Consultant and Super-visor. He has been in Private Practice for the past 25 years. Pieter holds Honours Degrees in Philosophy and Psy-chology, a Master Degree in Clinical Psychology and a PhD. Pieter is a member of the Australian Psychological So-ciety and the APS College of Clinical Psychologists. He provides Mental Health training for GPs and is accreditedat the Royal Australian College of General Practitioners. In this role he developed and facilitated a Clinical Auditfor General Practitioners (30 PD point activity) with over 600 GP's Nationwide involved in the training.

Before relocating to Australia, Pieter was a Professor in Clinical Psychology for 11 years. He was a guest lec-turer at Universities in Canada, Holland and South Africa where he also spearheaded a Psycho-Therapeutic Assis-tance Program to support people being exposed to trauma. In Sydney he worked as Senior Clinical Psychologist

at the Northern Beaches Adolescent Service Department of Health, he was the Clinical Director of the St John ofGod Psychiatric Hospitals both Richmond and Burwood Hospitals as well as worked in Private Practice. He pro-vided clinical supervision to many Masters and PhD students as Clinical Associate of the Universities of Sydney,New South Wales, Western Sydney, Macquarie, Wollongong and Newcastle. Currently he is involved in full timeresearch in the elds of neurobiology and neuropsychotherapy as well as clinical training for clinicians, psycholo-gists and general practitioners.

Pieter specialises in neuropsychotherapy and is an expert in anxiety and mood disorders. He has published5 Scientic Books and 20 scientic articles. He has been involved in research in extensive clinical trials and pre -sented research papers at 30 International Conferences worldwide.

He is a member of the Global Association for Interpersonal Neurobiology Studies, the International Societyfor Traumatic Stress Studies, the International Association for Family Therapy and the Professional Associationfor Drug and Alcohol Workers. He also facilitates a Global Neuropsychotherapeutic Interest Group through itse-Journal (Neuropsychotherapy in Australia) and local specialist research and discussion groups. Currently it has

over 2500 active members comprising of clinicians and academics in the eld ofneuroscience.

Pieter developed three 2-day APS, specialist endorsed workshops The Brainand Anxiety: Utilizing Neurobiological Information as Psychotherapeutic Tool; TheNeuroscience of Depression: New Opportunities for Eective Treatment; and TheDeveloping Brain and the Neuroscience of Memory and Trauma. He also runs neu-

ropsychotherapy applied skills classes.

Contact Pieter: [email protected]@mediros.com.au

Go to www.mediros.com.aufor information onAustralian Neuropsychotherapy Workshops
mailto:p.rossouw%40uq.edu.aumailto:pieter%40mediros.com.auhttp://www.mediros.com.au/http://www.mediros.com.au/http://www.mediros.com.au/mailto:pieter%40mediros.com.aumailto:p.rossouw%40uq.edu.au


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The Developing Brain and the Neuroscienceof Memory & Trauma

Implications for eective skills based interventions

The psychological and neurobiological eects of trauma have signi-cant implications for well being. Theoretical and treatment modalitiesfor trauma have been the focus of study for many researchers. Recent

discoveries in neurobiology have changed the landscape of theory andtreatment of Psychological Trauma. These discoveries assisted with ourunderstanding of neural processes, memory and neural communication.Clarity about these concepts assists clinicians towards more eectiveinterventions with clients suering from the aftermath of trauma.

The Brain and AnxietyUtilizing neurobiological information as a psychotherapeautic tool

Anxiety is a prevalent problem among Australians. Over one quarterof adults suer from anxiety in any given year. The last decade of brainresearch made possible by fascinating advances in brain imaging andneurobiological data has moved the understanding of anxiety disordersinto a new dimension. Although we can successfully treat clients withoutknowing the full implication of research, we can be more eective withmore people in less time if we have a grasp of the neurobiology and whyand how our treatment methods change brain function

The Neuroscience of DepressionNew opportunities for eective treatment

Depression is a common disorder without geographic, educational,socioeconomic, or racial boundaries. Recent advances in neuroscienceprovided new dimensions to the understanding and treatment of de-pression. Discoveries in the association of depression with neural plastic-ity and neurogenesis as well as insight in the role of talking therapies tochange neural functioning as well as neural structure opened fascinating

new perspectives and treatment options.

Neuropsychotherapy for AnxietyNeuropsychotherapy for Depression

Applied strategies for treatment

These workshops look at recent advances and research into anxietyand depression and the implications for therapeutic interventions.
http://www.mediros.com.au/workshops/anxskills%23summaryhttp://www.mediros.com.au/workshops/depskills%23summaryhttp://www.mediros.com.au/workshopshttp://www.mediros.com.au/workshops/depression%23summaryhttp://www.mediros.com.au/workshops/anxiety%23summaryhttp://www.mediros.com.au/workshops/memory#summaryhttp://www.mediros.com.au/workshops/depskills%23summaryhttp://www.mediros.com.au/workshops/anxskills%23summary

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