Which Kind of OCD Treatment Works Best?

 By Jim Windell

           Some research suggests that nearly a third of all people receiving treatment for OCD get the wrong treatment. But new research indicates that therapists may – at least at some point in the future – be able to select the most effective treatment for those with OCD.

          A new study, conducted at the University of Michigan and recently published in the American Journal of Psychiatry, suggests that therapists could be capable of predicting which type of therapy will help teens and adults with OCD. The two types of therapies used in this research were either a treatment that exposes clients to the specific subject of their obsessive thoughts and compulsive behaviors or one that focuses on general stress reduction and a problem-solving approach.

          The new study examined advanced brain scans of 87 teens and adults with moderate to severe OCD who were randomly assigned to 12 weeks of one of the two types of therapy. The researchers found that in general, both types of therapy reduced OCD symptoms, however, the approach known as “exposure therapy,” a form of cognitive behavioral therapy (CBT), was more effective and reduced symptoms more as time went on, compared with stress-management therapy (SMT).

          But when the researchers looked back at the brain scans taken before the patients began therapy, and linked them to individual treatment response, they found striking patterns. Those participants who started out with more activation in brain circuits for processing cognitive demands and reward during the tests were more likely to respond to CBT, but those who started out with less activation in those same areas during the same tests were more likely to respond well to SMT.

          "We found that the more OCD-specific form of therapy, the one based on exposure to the focus of obsession and compulsion, was better for relieving symptoms, which in itself is a valuable finding from this head-to-head randomized comparison of two treatment options," says Stephan Taylor, M.D.. Taylor is the study's senior author and a professor of psychiatry at Michigan Medicine, U-M's academic medical center. Taylor went on to say: "But when we looked at the brain to see what was behind that response, we found that the more strength patients had in certain brain areas were linked to a greater chance of responding to exposure-based CBT."

          The brain regions and circuits that had the strongest links to treatment have already been identified as important to OCD. Stronger activity in the circuit called the cinguloopercular network during the cognitive task and stronger activity in the orbitostriato-thalamic network when a reward was at stake, was associated with better response to exposure-based CBT. But lower activity in both regions was associated with better response to the stress-reduction SMT.

          While the researchers caution that it's too early for their work to be used by patients and mental health therapists, they are planning and conducting further studies that will test the framework and see if it also applies to children with OCD or obsessive tendencies.

          Kate Fitzgerald, M.D., a pediatric OCD specialist at Michigan Medicine and co-senior author of the paper, explains that easily administered behavioral tests could be developed to help therapists recommend CBT to those who have the most cognitive control and reward responsiveness, and SMT to those who would benefit most from being taught to relax and use problem-solving techniques to improve their response to stressors.

          "Our research shows that different brains respond to different treatments, and if we can build on this knowledge we could move toward a more precision-medicine approach for OCD," Fitzgerald says.

          Published article:            Norman, L.J., Mannella, K.A., Yang, H., Angstadt, M., Abelson, J.L., Himle, J.A.,  Fitzgerald, K.D., & Taylor, S.F. (2020). Treatment-Specific Associations Between Brain Activation and Symptom Reduction in OCD Following CBT: A Randomized fMRI Trial. American Journal of Psychiatry, 2020; appi.ajp.2020.1 DOI: 10.1176/appi.ajp.2020.19080886

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