Obsessive-compulsive disorder (OCD) is not a disorder of over-cleanliness but one of disordered brain processing of certainty. OCD which is characterized by repeated behaviours such as cleaning and checking despite clear objective evidence of cleanliness, orderliness, and correctness is often regarded as a disorder of ‘fussiness’. However, the disorder stems from the difficulty in processing uncertainty in the brain, the foundation of which is still unknown. This particular research uses brain imaging to get a closer look at the foundation of uncertainty processing in OCD.
What is obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder (OCD) features a pattern of unwanted thoughts and fears (obsessions) that leads one to do repetitive behaviours (compulsions). These obsessions and compulsions interfere with daily activities and cause significant distress.
A person may try to ignore or stop these obsessions, but that only increases an individual’s distress and anxiety. Ultimately, one feels driven to perform compulsive acts to try to ease stress. Despite efforts to ignore or get rid of, bothersome thoughts or urges, they keep coming back. This leads to more ritualistic behaviour — the vicious cycle of OCD.
This study published in Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, by Elsevier, uses brain imaging to get a closer look at the underpinnings of uncertainty processing in OCD.
Focus on brain areas implicated in decision-making
The researchers, led by Valerie Voon, PhD, of the University of Cambridge, examined a group of OCD sufferers, another group of people with severe OCD who had undergone a surgical procedure called a capsulotomy for treatment purposes and healthy individuals. The researchers wanted to look at processing in OCD, but they also wanted to look at how capsulotomy affected processing.
Dr. Voon explained, “We used a simple card gambling task like that commonly used in drinking games. Participants faced with an open card simply bet whether they thought the next card would be higher or lower than the open card. At the extremes, with high or low open cards, certainty is high, but uncertainty was much higher with cards near the middle of the deck.”
The dorsal anterior cingulate cortex (dACC) and anterior insula (AI), two brain regions associated with decision-making, were the main focus of the functional magnetic resonance imaging (fMRI) tests. When determining certainty, OCD participants showed abnormal activity in this circuitry compared to unaffected controls.
The cognitive mechanism is a core feature underlying why OCD develops
Dr. Voon said, “Critically, patients with OCD showed slower decision-making, but only when the outcomes were more certain. Because these impairments appeared in both the OCD patients and those who had improved after capsulotomy surgery, that suggests this cognitive mechanism might be a core feature underlying why OCD develops, irrespective of how severe the symptoms might be.”
Dr. Voon added, “The imaging data may provide a representation of how OCD patients might struggle with their symptoms. Whereas healthy individuals might be able to say, ‘This is clean’ and stop cleaning, people with OCD might struggle with that sense of certainty, and perhaps spend more time wondering ‘Is this still a bit dirty, or is this clean enough,’ and clean further.”
The findings make clear that OCD is not a disorder of over-cleanliness but one of disordered brain processing of certainty.
Cameron Carter, MD, Editor of Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, said of the work, “This very interesting study provides an important new perspective on the mechanism underlying the disabling symptoms of OCD and suggests that developing new therapies targeting uncertainty processing in the disorder, as well as the neural systems underlying these processes, such as the dACC and AI, may offer new hope to those suffering from this difficult to treat and disabling disorder.”
Materials provided by Elsevier. Note: Content may be edited for style and length.
Yi-Jie Zhao, Yingying Zhang, Qianfeng Wang, Luis Manssuer, Hailun Cui, Qiong Ding, Bomin Sun, Wenjuan Liu, Valerie Voon. Evidence Accumulation and Neural Correlates of Uncertainty in Obsessive-Compulsive Disorder. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 2023; DOI: 10.1016/j.bpsc.2023.05.011
Elsevier. “New neural insights into processing uncertainty in obsessive-compulsive disorder.” ScienceDaily. ScienceDaily, 12 September 2023. <www.sciencedaily.com/releases/2023/09/230912165659.htm>.
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