Mental Contamination in Obsessive-Compulsive Disorder: Associations With Contamination Symptoms and Treatment Response.

The most common symptom of obsessive-compulsive disorder (OCD) is contamination fear. Feelings of contamination can be provoked through contact with a physical contaminant, referred to as contact contamination (CC), as well as in the absence of one, referred to as mental contamination (MC). Prior research indicates that CC and MC are distinct, and MC may interfere with treatment for CC. However, no study to date has examined how MC may be associated with responses to physical contaminants and treatment response for CC. This study examined the relationships between CC and MC in a sample of individuals with elevated contamination symptoms (N = 88), half of whom met diagnostic criteria for OCD. Participants engaged in three sessions of exposure and response prevention (ERP) for CC and completed self-report measures and behavioral tasks assessing CC and MC at pretreatment, posttreatment, and follow-up. As hypothesized, at pretreatment, MC was positively associated with reactivity to physical contaminants, even after participants washed their hands. ERP for CC was associated with unique changes in CC and MC across self-report and behavioral measures, and greater pretreatment MC predicted greater posttreatment CC, though this effect was evident in only one of two CC measures. Additionally, specificity analyses indicated changes in MC were independent of changes in disgust propensity, a related construct. Pretreatment disgust propensity also predicted treatment outcome, though the addition of pretreatment disgust propensity as a covariate reduced the relationship between pretreatment MC and posttreatment CC to nonsignificance. Results suggest MC plays an important role in the manifestation and treatment of CC symptoms and may represent a manifestation of disgust proneness. Theoretical and clinical implications are discussed.

Impulse control disorders in Parkinson's disease: Review of pathophysiology, epidemiology, clinical features, management, and future challenges.

Impulsive-compulsive behavior (ICB) in Parkinson's disease (PD) suggests a combination of impulse control disorders (ICDs), such as pathological gambling, hypersexuality, compulsive eating, excessive buying, and compulsive behaviors, such as punding, dopamine dysregulation syndrome (DDS), hoarding, and hobbyism. Hypersexuality and gambling are common in male patients while compulsive buying is common in women patients. Recent studies reveal the prevalence of ICB to be more than 25% among the PD patients. The nigrostriatal, mesocortical, and mesolimbic dopaminergic pathways play a crucial role in the pathogenesis of ICDs in PD patients. The greater tonic release of dopamine creates a state of relative dopamine deficit and reduced reward sensation and impulsive behaviors. The major risk factors for ICB are the use of dopamine agonist (DA), male gender, young patient, depression, smoking, drug abuse, Parkin mutation, and family history of ICDs. Single nucleotide polymorphism in dopamine receptors D1, D2, and D3 also acts as a major risk factor. Questionnaire for impulsive-compulsive disorders in PD is the most widely adopted screening tool for the detection of ICB in PD. The major treatment for PD is to discontinue DAs and use prolonged release formulation of the DAs. The role of deep brain stimulation (DBS) and apomorphine in the treatment of ICB is still uncertain. Though DBS can reduce the risk of DDS, it can precipitate new ICBs such as hypersexuality.

Greater mindful eating practice is associated with better reversal learning.

Mindfulness-based interventions are thought to reduce compulsive behavior such as overeating by promoting behavioral flexibility. Here the main aim was to provide support for mindfulness-mediated improvements in reversal learning, a direct measure of behavioral flexibility. We investigated whether an 8-week mindful eating intervention improved outcome-based reversal learning relative to an educational cooking (i.e., active control) intervention in a non-clinical population. Sixty-five healthy participants with a wide BMI range (19-35 kg/m2), who were motivated to change their eating habits, performed a deterministic reversal learning task that enabled the investigation of reward- and punishment-based reversal learning at baseline and following the intervention. No group differences in reversal learning were observed. However, time invested in the mindful eating, but not the educational cooking intervention correlated positively with changes in reversal learning, in a manner independent of outcome valence. These findings suggest that greater amount of mindfulness practice can lead to increased behavioral flexibility, which, in turn, might help overcome compulsive eating in clinical populations.

High-Frequency Stimulation of the Subthalamic Nucleus Blocks Compulsive-Like Re-Escalation of Heroin Taking in Rats.

Opioid addiction, including addiction to heroin, has markedly increased in the past decade. The cost and pervasiveness of heroin addiction, including resistance to recovery from addiction, provide a compelling basis for developing novel therapeutic strategies. Deep brain stimulation may represent a viable alternative strategy for the treatment of intractable heroin addiction, particularly in individuals who are resistant to traditional therapies. Here we provide preclinical evidence of the therapeutic potential of high-frequency stimulation of the subthalamic nucleus (STN HFS) for heroin addiction. STN HFS prevented the re-escalation of heroin intake after abstinence in rats with extended access to heroin, an animal model of compulsive heroin taking. STN HFS inhibited key brain regions, including the substantia nigra, entopeduncular nucleus, and nucleus accumbens shell measured using brain mapping analyses of immediate-early gene expression and produced a robust silencing of STN neurons as measured using whole-cell recording ex vivo. These results warrant further investigation to examine the therapeutic effects that STN HFS may have on relapse in humans with heroin addiction.

Development of Brazilian prototypes for short-term psychotherapies / Desenvolvimento de protótipos brasileiros para psicoterapias de curta duração

Abstract Introduction: The Psychotherapy Process Q-Set (PQS) prototype method is used to measure the extent to which ideal processes of different psychotherapies are present in real cases, allowing researchers to examine how adherence to these models relates to or predicts change. Results from studies of short-term psychotherapies suggest that the original psychodynamic prototype is more suitable for studying psychoanalysis and long-term psychodynamic psychotherapy than its time-limited counterparts. Furthermore, culture probably influences how therapies are typically conducted in a given country. Therefore, it seems appropriate to develop Brazilian prototypes on which to base studies of short-term psychodynamic and cognitive-behavioral processes in this country. Objective: To develop prototypes for studying processes of short-term psychotherapies and to examine the degree of adherence of two real psychotherapy cases to these models. Methods: Expert clinicians used the PQS to rate a hypothetical ideal session of either short-term psychodynamic psychotherapy (STPP) or cognitive-behavioral therapy (CBT). Ratings were submitted to Q-type factor analysis to confirm the two groups. Regressive factor scores were rank ordered to describe the prototypes. These ideal models were correlated with ratings of actual therapy processes in two complete psychotherapy cases, one STPP and the other CBT. Results: Agreement levels between expert ratings were high and the two ideal models were confirmed. As expected, the PQS ratings for actual STPP and CBT cases had significant correlations with their respective ideal models, but the STPP case also adhered to the CBT prototype. Conclusion: Overall, the findings reveal the adequacy of the prototypes for time-limited therapies, providing initial support of their validity.

Resumo Introdução: O método dos protótipos derivados do Psychotherapy Process Q-Set (PQS) mensura em que medida processos de diferentes psicoterapias estão presentes em casos reais, permitindo pesquisadores examinarem como a adesão a esses modelos se relaciona com ou prediz a mudança. Resultados de estudos com psicoterapias breves sugerem que o protótipo psicodinâmico original é mais adequado para estudar psicanálise e psicoterapia psicodinâmica de longo prazo do que suas variantes de tempo limitado. Além disso, a cultura provavelmente influencia o modo como as psicoterapias são tipicamente conduzidas em determinado país. Portanto, parece apropriado o desenvolvimento de protótipos brasileiros para subsidiar estudos de processos psicodinâmicos e cognitivo-comportamentais de curto prazo neste país. Objetivo: Desenvolver protótipos para o estudo dos processos de psicoterapias de curta duração e examinar o grau de adesão de dois casos reais de psicoterapia a esses modelos. Métodos: Especialistas brasileiros usaram o PQS para avaliar uma sessão hipotética ideal de psicoterapia psicodinâmica breve (PPB) ou de terapia cognitivo-comportamental (TCC). A análise fatorial do tipo Q foi realizada para confirmar os dois fatores. Os escores fatoriais regressivos foram ordenados para descrever os protótipos. Os protótipos foram correlacionados com as avaliações de processos reais de terapia em dois casos completos, um de PPB e outro de TCC. Resultados: Houve alta concordância entre especialistas, e os dois modelos ideais foram confirmados. Como esperado, os escores do PQS para os casos reais de PPB e TCC apresentaram correção significativa com seus respectivos modelos ideais, mas o caso de PPB aderiu também ao protótipo TCC. Conclusões: No geral, os resultados revelam a adequação dos protótipos para terapias com tempo limitado, fornecendo suporte inicial de sua validade.

[Aripiprazole, gambling disorder and compulsive sexuality]. / Aripiprazole, jeu pathologique et sexualité compulsive.

INTRODUCTION: Aripiprazole, an atypical or second-generation antipsychotic, is usually well tolerated. It is an approved treatment for schizophrenia and mania in bipolar disorder type 1. Unlike the other antipsychotics, it has high affinity agonist properties for dopamine D2 and D3 receptors. It has also 5-HT1A partial agonist and 5-HT2A antagonist properties. Aripiprazole is a first or second line treatment frequently used because it has reduced side effects such as weight gain, sleepiness, dyslipidemia, insulin resistance, hyperprolactinemia and extrapyramidal symptoms. CASE-REPORT: We report the case of a 28-year-old male patient diagnosed with schizoid personality disorder. He was a moderate smoker with occasional social gambling habits. After several psychotic episodes, he was first treated with risperidone, but he experienced excessive sedation, decreased libido, erectile dysfunction and was switched to 15 mg aripiprazole. He developed an addiction habit for gambling at casino slot machines. Due to large gambling debts, he requested placement on a voluntary self-exclusion list. Thereafter, he turned his attention towards scratch card gambling. The patient described his experience of gambling as a "hypnotic state". He got several personal loans to obtain money to continue gambling. He was then referred to an addiction unit. Before being treated with aripiprazole, he was an exclusive heterosexual with a poor sexual activity. Under treatment, he switched to a homosexual behavior with hypersexuality, unprotected sex and sadomasochistic practices. The craving for gambling and compulsive sexual behavior ceased two weeks after aripiprazole was discontinued and he was switched to amisulpride. Thereafter, he reported a return to a heterosexual orientation. DISCUSSION: Compulsive behaviors such as gambling, hypersexuality and new sexual orientation are common in patients with Parkinson's disease treated with dopaminergic agonists. These behaviors involve the reward system, with an enhanced dopaminergic activity in the mesolimbic pathways and occur more frequently in young subjects, males with previous gambling habits and tobacco use. A few cases of aripiprazole-induced pathological gambling as well as aripiprazole-induced hypersexuality have been reported. To our knowledge, we are the first to report a case of gambling disorder associated with hypersexuality and change of sexuality orientation. Aripiprazole is the only antipsychotic with agonist properties for the D2 dopamine receptor. It may also act as an enhancer in the mesolimbic dopaminergic pathways. Aripiprazole also has 5-HT1A partial agonist and 5-HT2A antagonist properties that may promote sexual activity. CONCLUSION: Aripiprazole is an antipsychotic associated with reduced side effects compared to other antipsychotics. We report the case of a patient who experienced gambling disorder, hypersexuality and a new sexual orientation under treatment. These side effects are little known. They are usually difficult for patients to mention due to feelings of guilt. The consequences on social life, family and health may be serious. Clinicians and patients should be aware about the possible issue of these behavior disorders with aripiprazole.

A Substance Called Food: Long-Term Psychodynamic Group Treatment for Compulsive Overeating.

Obesity has proven difficult to treat. Many approaches neglect to address the deep-rooted underlying psychological issues. This paper describes a psychodynamically oriented approach to treating compulsive overeating as an addiction. Common to all addictions is a compulsion to consume a substance or engage in a behavior, a preoccupation with using behavior and rituals, and a lifestyle marked by an inability to manage the behavior and its harmful consequences. The approach represents a shift away from primarily medical models of intervention to integrated models focusing on the psychological underpinnings of obesity. Long-term psychodynamic group psychotherapy is recommended as a primary treatment.

Repetitive transcranial magnetic stimulation to treat substance use disorders and compulsive behavior.

Compulsions, like pathological gambling, binge-eating disorder, alcohol, tobacco or cocaine abuse and compulsive shopping have similar neurophysiological processing. This study aimed to examine the efficacy of repetitive transcranial magnetic stimulation (rTMS) in improving patient control over compulsive behavior. The rTMS modulatory role in cortical mesolimbic pathways possibly implies improvement of the inhibitory control system and compulsive consumption drive. Thus, craving reduction would be a component for control achievement. Within this context, 17 studies were found. Most studies applied rTMS over the left dorsolateral prefrontal cortex. Craving reduction was observed in 10 studies and was associated with improved control of compulsion in two of them. In one study reduction in consumption was found without reduction in craving. In addition, improvement in decision making was found in one study.

Impulsive and compulsive behaviors in Parkinson Study Group (PSG) centers performing deep brain stimulation surgery.

BACKGROUND: Impulse control disorders (ICDs), dopamine dysregulation syndrome (DDS), and dopamine agonist withdrawal syndrome (DAWS) have been reported commonly in Parkinson's disease (PD) populations. The treatment approaches may be widely variable and there is not much information on these syndromes in the setting of deep brain stimulation (DBS). OBJECTIVE: To evaluate (1) ICDs, DAWS and DDS pre- and post DBS in PD and (2) to investigate pre-DBS treatment strategies regarding these behaviors among Parkinson Study Group (PSG) centers. METHODS: Forty-eight PSG centers were surveyed on ICDs, DAWS and DDS, as well as on potential relationships to DBS and treatment approaches. RESULTS: Sixty-seven percent of PSG centers reported that they served a population of over 500 PD patients per year, and 94% of centers performed DBS surgery. Most centers (92%) reported screening for ICDs, DAWS and DDS. Of the centers screening for these symptoms, 13% reported always employing a formal battery of pre-operative tests, 46% of sites inconsistently used a formal battery, while 23% of sites reported never using a formal battery to screen for these symptoms. The estimated numbers of centers observing ICDs, DAWS and DDS pre-operatively in individuals with PD were 71%, 69%, and 69%, respectively. PSG DBS centers observing at least one case of a new de novo occurrence of an ICD, DAWS or DDS after DBS surgery were 67%, 65% and 65%, respectively. CONCLUSIONS: The results suggest that addiction-like syndromes and withdrawal syndromes are prevalent in expert PSG centers performing DBS. Most centers reported screening for these issues without the use of a formal battery, and there were a large number of centers reporting ICDs, DAWS and DDS post-DBS. A single treatment strategy did not emerge.

Neurosurgical targets for compulsivity: what can we learn from acquired brain lesions?

Treatment efficacy of deep brain stimulation (DBS) and other neurosurgical techniques in refractory obsessive-compulsive disorder (OCD) is greatly dependent on the targeting of relevant brain regions. Over the years, several case reports have been published on either the emergence or resolution of obsessive-compulsive symptoms due to neurological lesions. These reports can potentially serve as an important source of insight into the neuroanatomy of compulsivity and have implications for targets of DBS. For this purpose, we have reviewed all published case reports of patients with acquired or resolved obsessive-compulsive symptoms after brain lesions. We found a total of 37 case reports describing 71 patients with acquired and 6 with resolved obsessive-compulsive symptoms as a result of hemorrhaging, infarctions or removal of tumors. Behavioral symptoms following brain lesions consisted of typical obsessive-compulsive symptoms, but also symptoms within the compulsivity spectrum. These data suggests that lesions in the cortico-striato-thalamic circuit, parietal and temporal cortex, cerebellum and brainstem may induce compulsivity. Moreover, the resolution of obsessive-compulsive symptoms has been reported following lesions in the putamen, internal capsule and fronto-parietal lobe. These case reports provide strong evidence supporting the rationale for DBS in the ventral striatum and internal capsule for treatment of compulsivity and reveal the putamen and fronto-parietal cortex as promising new targets.

Indirect basal ganglia pathway mediation of repetitive behavior: attenuation by adenosine receptor agonists.

Repetitive behaviors are diagnostic for autism and common in related neurodevelopmental disorders. Despite their clinical importance, underlying mechanisms associated with the expression of these behaviors remain poorly understood. Our lab has previously shown that the rates of spontaneous stereotypy in deer mice (Peromyscus maniculatus) were negatively correlated with enkephalin content, a marker of striatopallidal but not striatonigral neurons. To investigate further the role of the indirect basal ganglia pathway, we examined neuronal activation of the subthalamic nucleus (STN) using cytochrome oxidase (CO) histochemistry in high- and low-stereotypy mice. CO activity in STN was significantly lower in high-stereotypy mice and negatively correlated with the frequency of stereotypy. In addition, exposure to environmental enrichment, which attenuated stereotypy, normalized the activity of STN. Co-administration of the adenosine A(2A) receptor agonist CGS21680 and the A(1) receptor agonist CPA attenuated stereotypy dose-dependently. The significant reduction associated with the lowest dose of the drug combination tested was due to its effects on mice with lower baseline levels of stereotypy. Higher doses of the drug combination were required to show robust behavioral effects, and presumably requisite activation of the indirect pathway, in high-stereotypy mice. These findings support that decreased indirect pathway activity is linked to the expression of high levels of stereotypy in deer mice and that striatal A(1) and A(2A) receptors may provide promising therapeutic targets for the treatment of repetitive behaviors in neurodevelopmental disorders.

How does overeaters anonymous help its members? A qualitative analysis.

Overeaters Anonymous (OA) is a 12-step, self-help group for individuals who perceive themselves to have problems with compulsive overeating. Despite the popularity of OA and the frequent use of addictions-based treatments for eating disorders, little is known about how OA is helpful. The purpose of this qualitative study was to explore members' experiences with and perceptions of OA. We conducted three focus groups with self-selected members of OA (N = 20). We present three primary themes that emerged from the analysis of the focus groups' discussions, which emphasize why individuals entered OA, OA's 'tools', and how individuals perceived OA to 'work'. Overall, although participants agreed OA was helpful to them, there was no consensus regarding how OA 'works'.

High frequency stimulation and temporary inactivation of the subthalamic nucleus reduce quinpirole-induced compulsive checking behavior in rats.

Obsessive-compulsive disorder (OCD) represents a highly prevalent and impairing psychiatric disorder. Functional and structural imaging studies implicate the involvement of basal ganglia-thalamo-cortical circuits in the pathophysiology of this disorder. In patients remaining resistant to pharmaco- and behavioral therapy, modulation of these circuits may consequently reverse clinical symptoms. High frequency stimulation (HFS) of the subthalamic nucleus (STN), an important station of the basal ganglia-thalamo-cortical circuits, has been reported to reduce obsessive-compulsive symptoms in a few Parkinson's disease patients with comorbid OCD. The present study tested the effects of bilateral HFS of the STN and of bilateral pharmacological inactivation of the STN (via intracranial administration of the GABA agonist muscimol) on checking behavior in the quinpirole rat model of OCD. We demonstrate that both HFS and pharmacological inactivation of the STN reduce quinpirole-induced compulsive checking behavior. We conclude that functional inhibition of the STN can alleviate compulsive checking, and suggest the STN as a potential target structure for HFS in the treatment of OCD.

Post-surgery group therapy for gastric bypass patients.

BACKGROUND: The prevalence of both compulsive eating patterns (bingeing and "grazing") and psychosocial distress and/or psychiatric co-morbidity in patients seeking bariatric surgery has been documented. While surgery is often seen as the solution, research has shown that these problems can persist postoperatively and may adversely affect outcome. This paper will describe a postoperative psychotherapy group process designed specifically for gastric bypass patients. METHODS: A semi-structured cognitive-behavioral group therapy program adapted from a treatment program for compulsive eaters was designed for patients who had been identified (by questionnaire and clinical interview) as having compulsive eating problems before surgery. Therapy addresses eating patterns as well as the emotional adjustments following surgery. RESULTS: 16 12-week therapy groups have been conducted to date. The groups are small and designed to help patients understand the stages of postoperative adjustment and the tasks, both eating-related and psychological, associated with each stage. Feedback from participants has been very positive with patients reporting the need for a therapy group in addition to the traditional support group. CONCLUSION: Since both disturbed eating patterns and psychological difficulties are seen following surgery, it is imperative that treatment programs be developed to address these issues. The group process is a highly effective intervention but must be designed for the special needs of these patients. Measures of success need to take psycho-social factors into account as well as eating behaviors and weight loss. Outcome studies are needed to compare those receiving treatment vs those who do not.

Catastrophic medical complication in psychogenic excoriation.

Compulsive skin picking generally has limited potential health consequences. We describe a case with severe neurologic sequelae and review the literature to assess factors that likely contributed to the failure to prevent this severe outcome. Despite efforts to integrate treatment, our patient had severe medical complications, an epidural abscess and subsequent paralysis, as a result of compulsive skin picking. Psychogenic excoriation should not be underestimated as a cause of medical complications or as a treatment challenge, particularly in light of the numerous complicating factors often present in such cases.

Behavioural psychotherapy of uncommon referrals.

In a behavioural clinic, over a period of nine years, trainee nurse-therapists treated 65 unusual referrals (8 per cent) out of a total of 800 patients. The remainder had phobic, obsessive-compulsive, sexual and social disorders, which responded encouragingly to behavioural treatment. Of the unusual referrals, useful results were obtained by behavioural treatment for stuttering, hairpulling, tics, and writer's cramp; bulimia is worth further study. Unresponsive conditions included compulsive gambling and obesity.