Can the Brain Guide Treatment for OCD?

Cognitive-behavioral therapy with exposure and response prevention (ERP), a first-line treatment for obsessive compulsive disorder (OCD), has been shown to be effective for many individuals, but not all. Characterized by distressing repetitive thoughts and behaviors, OCD often begins in childhood and continues throughout one’s life.

“Treating OCD at younger ages can prevent a lifetime of distress, but better and more targeted treatments needed,” says Kate Fitzgerald, MD, the Ruane Professor of Child and Adolescent Psychiatry at Columbia University and New York State Psychiatric Institute, adding that, “Nearly 50% of people with OCD continue with clinically significant illness after receiving ERP, and it’s currently impossible to predict who will benefit.”

In a study led by Dr. Fitzgerald and published Dec. 7 in the American Journal of Psychiatry, researchers used neuroimaging to determine whether the brain can predict response to ERP in teens and adults with OCD. 

Using resting-state fMRI—in which study participants are awake but not focused on a particular task—the researchers measured brain connectivity patterns in 116 participants (54 adolescents and 62 adults) randomly assigned to 12 weeks of either ERP or a control therapy involving stress reduction and problem-solving (such as stress management therapy, or SMT). Randomization allowed the team to isolate the effects of ERP from non-specific effects of seeing a therapist on a weekly basis. 

The study showed that across all age groups, both therapies reduced OCD symptoms, although exposure therapy proved to have more pronounced and clinically significant effects. However, when the research team examined the brain scans taken before participants began treatment, they noticed some striking differences.  

Adolescents and adults who had the greatest response to exposure-based therapy had the most active pre-treatment connections in cortical-subcortical circuits involved in cognitive control, while those who had lower connectivity in these circuits responded more positively to SMT.  

Additionally, weak connectivity between striatal region of the brain with areas of the prefrontal cortex linked to fear conditioning and anxiety symptoms, uniquely characterized treatment response in adolescents compared with adults. 

Next steps for OCD treatment Dr. Fitzgerald, a child psychiatrist, said that understanding neural differences could help  guide the development of novel treatments. This is important because, even though ERP is effective, as many as 50% of those treated fail to fully respond.  

Her lab is now working on next steps to both develop new treatments for children with OCD and make existing therapies more effective.

“One direction that we will take is to use cognitive training to shift the balance of connectivity in brain circuits for cognitive control in OCD- affected youth. The brain is still developing through childhood and adolescence, and it is possible that boosting function in circuits for cognitive control could help children with OCD respond to ERP,” Dr. Fitzgerald said.  

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.     

Contributors to the paper include Stefanie Russman Block (first author), Ph.D., Luke J. Norman, Ph.D., Xiaoxi Zhang, M.D., Kristin A. Mannella, B.A., Huan Yang, M.D., Ph.D., Mike Angstadt, M.S., James L. Abelson, M.D., Ph.D., Joseph A. Himle, Ph.D., Stephan F. Taylor, M.D., Kate D. Fitzgerald, M.D. (lead author).