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Psychotherapy for Treatment-Resistant Obsessive-Compulsive Disorder

Nisha Giridharan
x
Nisha Giridharan
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Affiliations

  • Department of Neurosurgery, Baylor College of Medicine, 1 Baylor Plaza, Suite S100, Houston, TX, USA
, MDa
,
Orri Smárason
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Orri Smárason
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Affiliations

  • Faculty of Psychology, University of Iceland, Nýi Garður Sæmundargata 12, Reykjavík 102, Iceland
, MAb
,
Nicole R. Provenza
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Nicole R. Provenza
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Affiliations

  • Department of Neurosurgery, Baylor College of Medicine, 1 Baylor Plaza, Suite S100, Houston, TX, USA
, PhDa
,
Garrett P. Banks
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Garrett P. Banks
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Affiliations

  • Department of Neurosurgery, Baylor College of Medicine, 1 Baylor Plaza, Suite S100, Houston, TX, USA
, MDa
,
Ben Shofty
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Ben Shofty
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Affiliations

  • Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, UT, USA
, MD, PhDc
,
Wayne K. Goodman
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Wayne K. Goodman
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Affiliations

  • Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA
, MDd
,
Sameer A. Sheth
x
Sameer A. Sheth
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Affiliations

  • Department of Neurosurgery, Baylor College of Medicine, 1 Baylor Plaza, Suite S100, Houston, TX, USA
, MD, PhDa
,
Eric A. Storch
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Eric A. Storch
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Affiliations

  • Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA

Correspondence

  • Corresponding author. Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Suite 4-400, Houston, TX 77030, USA.
, PhDd,∗,'Correspondence information about the author PhD Eric A. Storch
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Eric A. Storch
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Affiliations

  • Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA

Correspondence

  • Corresponding author. Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Suite 4-400, Houston, TX 77030, USA.
Psychotherapy for Treatment-Resistant Obsessive-Compulsive Disorder
DOI: https://doi.org/10.1016/j.ypsc.2023.03.010

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Figures

Fig. 1

Cortico-striato-thalamo-cortical (CSTC) circuit dysfunction in OCD. (A) OCD is associated with dysfunction in multiple CSTC loops, spanning both cortical and subcortical regions including the orbitofrontal cortex (OFC), dorsolateral prefrontal cortex (dlPFC), dorsal anterior cingulate cortex (dACC), ventromedial prefrontal cortex (vmPFC), striatum, globus pallidus internus (GPi), globus pallidus externus (GPe), substantia nigra pars reticulata (SNr), and thalamus. (B) Coordinated activity from these structures provides feedback to the thalamus both directly and indirectly. During normal functioning, the direct and indirect pathways provide excitatory and inhibitory cortical feedback in a balanced manner. In OCD, the direct pathway is overactivated relative to the indirect pathway, leading to pathological excitation of cortex.

Obsessive-compulsive disorder is a neuropsychiatric illness associated with significant disability. The neurobiology of the disease is thought to be related to dysregulation of cortico-striato-thalamo-cortical loops that leads to overexcitation of the orbitofrontal cortex. Standard evidence-based therapies include exposure and response prevention and serotonin reuptake inhibitors, but 10% to 15% of patients fail to achieve response to these treatments. Treatment resistance has been defined by a lack of meaningful improvement in time spent on obsessions and compulsions and the distress associated with them. This article discusses intensive cognitive-behavioral therapy, alternative psychotherapy programs, and neurosurgery as therapeutic options for refractory cases.

Keywords:

Cognitive-behavioral therapy, Exposure and response prevention, Neurosurgery, Obsessive-compulsive disorder, Psychotherapy, Treatment-resistance

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