Understanding Treatment Response and Resistance in Obsessive Compulsive Disorder in the Context of Cognitive Neuropsyhological Model

Abstract

ÖZETBilişsel davranışçı terapiler (BDT), antidepresanlar ve nöro-düzenleme teknikleri obsesif kompulsif bozukluğun (OKB) tedavisinde çeşitli aşa-malarda kullanılan güncel tedavi seçenekleridir. Bir psikiyatrik bozuklukta psikolojik yaklaşımlardan cerrahi tekniklere kadar bambaşka yaklaşımları tedavi etkisinde ortak kılan unsurlar ilgili literatürde yeterince tanımlanmamıştır. Bilişsel Nöropsikolojik Model güncel bir yaklaşım olarak farklı psikopatolojiler için psikolojik ve nörobiyolojik modellerin duygusal işlemleme süreçlerinin bozulması aracılığıyla bağdaştığı ortak bir çatı önermektedir. Bu yazıda OKB'de farklı tedavi seçeneklerinin etkinliğini anlamak için yukarıdan-aşağı ve aşağıdan-yukarı bozulmuş duygusal işlemleme süreçlerini bütünleştiren bir yaklaşım tanımlanmış-tır. Bu modele göre bilişsel terapi bilgi işleme yanlılıklarını doğrudan etkilemek yerine, yukarıdan-aşağı duygusal işlemleme süreçleri üzerin-deki etkileri aracılığıyla şemalar üzerinde aşamalı bir kırılma yaratır. Antidepresanlar ve davranışçı terapinin ise beynin duygusal işlemlemesini aşağıdan-yukarı süreçler yoluyla değiştirdiği öne sürülür. OKB'si olan hastalarda BDT ve ilaç tedavisine direnç sık karşılaşılan bir durumdur ve bu tedavi seçeneklerine olumsuz yanıtı yordayan birçok etmen tanımlanmıştır. Belirti şiddeti, bazı özel belirtilerin varlığı, zayıf içgörü, dissosiyasyon eğilimi ve ailesel katılım hem BDT hem ilaç tedavisine direnç ile ilişkili bulunmuş etmenlerdir. Bu farklı etmenlerin varlığını tedavi direnci ile ilişkili kılan altta yatan nedenler Bilişsel Nöropsikolo-jik Model bağlamında tartışılmıştır. In this paper, an integrated approach of disrupted top-down and bottom-up emotional processing has been described to understand the efficacy of the different treatment modalities for OCD. In this model, the cognitive therapy is proposed to contribute to the gradual breakdown of schemata through the effect on top-down emotional processing instead of acting on information processing biases directly. Antidepressant drugs and behavioral therapy are proposed to alter the brain's emotion processing in a bottom-up process. Resistance to pharmacotherapy and CBT is a common problem in the patients with OCD, and a lot of factors have been described as negative predictors of these treatment options. The severity of symptoms, presence of specific symptoms, poorer insight, high level of dissociation and family accommodation are the factors associated with resistance to both pharmacotherapy and CBT. The underlying reasons establishing an association between the presence of these diverse factors and treatment resistance were discussed in the context of CNM.

Executive functions and insight in OCD: a comparative study

“…Obsessive-compulsive disorder (OCD) affects 2% of adults worldwide and 10% of the adult clinical population [1]. Cognitive-behavioural psychotherapy is ineffective in 20% of cases and selective serotonin reuptake inhibitors (SSRIs) in 40% [2], although other studies suggest higher percentages for both treatments, around 40-60% [3]. Three factors can account for these low success rates: comorbidity, intensity of the symptoms and insight [4], with a prevalence of the latter [5][6][7][8][9][10].…”

“…Three factors can account for these low success rates: comorbidity, intensity of the symptoms and insight [4], with a prevalence of the latter [5][6][7][8][9][10]. Around 15-36% of OCD patients have poor insight [5,[11][12][13][14][15][16], which makes insight one of the most promising topics for future research in OCD [3,17,18].…”

Traumatic Experiences and Obsessive-Compulsive Symptoms

“…This model especially held with emotional abuse and emotional neglect as specific predictors of dissociation and OCSs. Given the negative impact of dissociative symptoms on the course and outcome of OCD (Besiroglu, 2016; Rufer et al, 2006; Semiz et al, 2014), it is important that traumatic experiences (especially those concerning relational experiences of neglect, rejection, and psychological abuse) and dissociation are carefully evaluated in patients suffering from OCSs (Liotti and Costantini, 2011). For some emotionally traumatized individuals with OCSs, clinical interventions aimed to improve mentalizing and metacognitive capacities, self-regulation skills, and meaning reconstruction (Bateman and Fonagy, 2013; Bluett et al, 2014; Peeters et al, 2021) might minimize the activation of dissociative processes and foster integration of mental states related to traumatic experiences, helping these people to heal from their posttraumatic vulnerabilities.…”

Is mirtazapine augmentation effective for patients with obsessive-compulsive disorder who failed to respond to sertraline monotherapy? A placebo-controlled, double-blind, clinical trial

“…OCD is a severe mental disorder that causes intense distress to the patients and their families. It would also lead to severe disability and functional decline (Beşiroğlu, 2016). As such, looking for new medications that may alleviate the pain of these patients is always a medical priority.…”