[ESEEEEE Theoretical Foundations of Obsessive-Compulsive and Related Disorders
waa A Transdiagnostic Approach to Obsessions,
Compulsions and Related Phenomena
Leonardo F Fontenelle and Murat Ycel
Introduction Posie Ses ee eng
Obsesvecompulive dioder (OCD) cancer. Su
inte symptoms include obsessions (persistent and” predominantsite of Disorder
‘unwanted thoughts, imagescrurges) and compulsions regan
(tepettive behavior that are performed in response to
ttvesions or acordng to gd ul). OCD i both Noma} Teves aoe
frequent and dling tacts to ofthe general Spat tr that
population and leas to deeaed productivity snd ra
Substantial decreases in quality of lie. However, the rtegtnieee
fmpact of OCD’ consituert symptoms (obsessions,
compulsions and related phenomena) may be greater
‘than the one associated with the disorder per se. For Fesiv sian pay
instance, obsessions and compulsions are frequently optic vit caicton
Sound in sub-theeshold yet Impact forme. They (tram)
also occur in conditions ofically classed by the rea
Diagnose and ttitical Manual of Mental Disorders,
‘th edition (DSM-5) [1] andthe 1Ith Revision ofthe Caen rion
International Classification of Disease (ICD-11) [2] a8 Woe veram
‘obsesive-compulsive and reed disorders(OCRDS)._Feralatoercgutie. Sve
“Te fact that obsessive thoughts and compulsive srst@npoalicbe
behaviors may occur arossa number af newropeychi- sain conten
atric conditions has been wall known since Kraepelin
(foralistof conditions presenting OCD symptoms, sce Rooeawon ei et,
Table 11), However itisonlyafter the end ofastrongly Etec
herarchical approach to pychitric diagnosis that Gewolmdton uve malay
clinicians have been abe o offically diagnose OCD ostunton
inthe presence of conditions such ae schizoph
isjor depressive disorder or Tourette’ disorder. The en
‘ecogiton that neuropsychiatric disorders could be 7
omorbid with one another hasbeen a major advance P#CwECHI Seton
in the field. 1 prompted clinicians not only to iden Dapeng tpl)
Ly but also to teat comorbid OCD, this leading
to better outcomes. However, this is not exactly the
teanadignostic approach we del with inthis chapter,
Obsesions and compulsions are linia!
anstructs, Unt ove they have proven tobe reliable
And useful. They are reliable for being consistent over being remediate by a series of strategie that, des-
"ime and between dierent clinicians, and useful for Pit Rot being efectve in some cases can alleviateSection 1-Theortical Foundations of CROs
symptoms in many. However, rather than existing as
“natural kinds" obsessions and compulsions may be
the final products of multiple intrelting dysfune:
tional cognitive affective proceses and corresponding
neurobiological systems. Faure to recognize these
The RDOC svgges the newophysoiogcl underpinning
of cnet detection to be ERN, lead adresse in tht
hapter ander cognitive contol
L
the caper f xine na dtd uo he
a Gohang need bi ermtonn OCRDS
ss ech duced more depth ner
sos boa eg. Chapter 8 Hove lee
Mend neal et brn et
1 Pet comple deter we ought
Aerob apyopt aden ersoe es
tethering ehh could lp
‘petiecanplvy or ke
Ti insane bounce stone ave been
ceased angstrom drag
SESS has tat eden by poste ence
seas The me migit At for ther
atl dons aches anling order
Macrae tes gunes tmigntnt em cay ee
che OGD wih he ab formaton model ne OCD
Stave denser aden by pte,
Soran ponte ehecomen Yr ple
‘eb teadedoped gee avian haba
San onl ins shock Since ok died fo
Induce hatte through wertraing (0) Al
ple of 72 patents ith OCD: ve hve ound
fan thie Saloon Hat Indes SRE) ones
tried poate wh nds of OCD seve
{Goer Comp ment sr eon td
{co tnd the le Bown Obese Compue
Sas conplaons ioc) ee ie etna
Siu tems ere eed [the tater Say
there wr sh craton tetven duton of es
tric acting promt and ntsc of
other pons 1)" atom between has
tnd ching hs been ihe tone
‘aly th nine cn and deere fret
tmengton
The bi sem may alo be involved in nathr
tere deem cv rte irl dares
{Oc and SAD, mandy te nese eh
lr compety alae nh mot OCRD eta
Ing wang cen nd odsing behave
Although the ttn earch amin
‘ton bs cmpbaded ie semen he ly
{prom eompler mot sore (Le eton
‘ora In coptive driers Sapper
Peg he pouty at compen OCD ra
‘ress: mie phemnenan at nan xe
ecto «soe copes mee et es
behavioral roatnes tha a enaplatd in chun
United by ston ound, epg en
sigs om the rain athe rental core)
Ua Smith and Geni [6] edt ta hse
behaviors could results from chunking-rlted activity
In the dorsolateral striatum or infralimbic cortex oss
‘of erorcorrectve signaling in the dorsolteral sti
‘zum or inflexibily in the infalimblc related ha
promoting process
Synthesis of the Transdiagnostic
Approach to Obsessions and
Compulsions
We baleve that an indepth dicasion on the
tranlagnovcaspetsofobsssonsand compulsions
{eather than one tht focuses on al Blown DSM 3
‘OCD) poses sigan challenges For stance, we
Scknowedge tht as advocated by the RDWC mate
dine and vbtieshold forms of pyhopatology
actly to share the sane undeing newrbilogy
tia tie sce Chapter 13). However cles
Sil speciy wit iscsiiable or dogronble and
‘ha oe ot eed ny spect spec ern
Son. Although diagnostic contact ean be dimen
sonal and obcsonliy and compalsy are dear
trample of thee sorts uf symptoms te
sion of eating or nt tetng a patent remains
‘gore ne Ta dentin! approach poet
Prete and ethical question, sch ahee tenes
Should be dawn an the aneciated ris of over oF
{mderteniment hs denna bs ben faced by pre
vows prychiatrc csifeatory schemes and should
tbe ignored
Yeu it one wants to discus the impliations
cf the trnuiaraatc aspects of obsetons and
Compulsion ont shuld operational the concepts
Of obvesionaty and comput. In ly tere,
tuendonality cold be simply dvribed a he ten
dency to think excniven while compuly cou
be dine at popeatytvard sibling beter
‘aces Hower thee wommon sen non
dnt sce to have much clin tty as they
cncopse several elated opie. depee
‘ination and behavior eg, pychomotr og
on syptoms. Also, thy cannot gue trestnen a
theresnotherapetcapronchthatsablet remediate
Al anormally perstentcopns and exesive
Behaviors indisinintl Howevertes we propose
lesional and compas arecostaedas ls
that paral ove wth wht has been techy
in a cbssons and compulon, we believe
that a few advance an be mae at est he et
ial component ofthe ater conivut ae entedSection 1: Theoretical Foundations of OCRDs
and described. Thus, there may be different type and
Aefnitions of obsessionality and compulsivty This
‘was our approach in this chapter, where we refer to
diferent RDoC dimensions. Symptoms that could be
subsumed under obsesionality and compulsvty are
listed in Tables 1.2 and 1.3, respectively.
Deconstructing obsessions and compulsions into
their key components has theoretical (pathophysio-
logical) and practical (diagnostic and therapetic)
‘nmpications. First, DSM-5 OCD may have diferent
neurobiological ystems implicated in is pathopays-
‘logy depending on whetheraspecifisetofeympioms
(eg, obsessions, compulsions or bath) predominates,
For instance, obsessive images may be more trauma
Felted 36}, whereas compulsive behaviors may be
‘more neurodevelopmentlly based [73]. Notably, this
‘pproach mighthave implications for other conditions
that share features with OCD; for example, OCD
obsessive images and PTSD intrusive images may
both eslt fom dysfunction in similar brain ercuits
(able 1.2) (74), Second, atransdiagnostic approach io
‘obsessions and compulsions may also have diagnostic
consequences, a the diferential diagnosis of OCD
‘may be more precisely performed if cognitions (eg
thought alienation) or behaviors (eg. stereotypes)
that characterize other disorders (eg, schizophrenia)
are disentangledfeom obsessional thoughts or com-
pulsve ritual that are core to OCD.
Most critically, however, a transdiagnostic
approach to obsessions and compulsions could help
‘0 illuminate the neurobiology of diferent psychi
atric disorders, thus leading to beter treatment in
line with RDOC guidelines. For instance, patients
with OCD recognize obsessions, along with several
other cognitive symptoms that share the feature of
being persistent and distressing as their own exper
ence, and not as someone else as in thought alien
ation. Thus, it makes sense to conttast OCD with
Schizophrenia samples to clarify the biology thet
‘underlies abnormal agency. Similar, compared
with delusions, which are prereflexive phenomens
(delusional patents express conviction and cer
{ainty about certain statements rather than admit
that these statements may be subject to discussion
and inquiry” (75), obsessions involve an Intense
Internal dialog, thus suggesting that patients with
OCD can be contrasted with psychotic patient to
iluminate the biology ofinsight and sel-knowlecge.
Further, like many obsessions, the preoccupations
‘of GAD include doubt, elements that are lacking in
J
auditory hallucinations and parapilic fantasies and
‘ould be studied under the construct of cognitive
control and suitaned threat
Al behaviors listed in Table 1.3 can be executed
with a certain degree of automaticity but compul
sive, avoidant and addictive behaviors are the only
‘ones more clearly performed to decrease fear and dis
tees. Thus, it seems reasonable to contrast patents
with the later conditions to samples with other
sulomatic behaviors to daify the biological bass of
sustained threat and to develop ant-fear treatment,
tis also interesting that behaviors associated with
the so-called sensory phenomena, such as OCD
compulsions, Tourettes tes and tichotillomania
grooming behaviors have been shown to be genet.
ically linked [76]. Further, thas been demonstrated
‘that impulsivity isa risk factor fr addiction, and both
ray be related to poor cognitive contol and lack
of foresight. Finally, while additive, grooming and
unding behaviors are all well known tobe associated
with reward valuation expectancy and responsive-
nes, it has been increasingly recognized that OCD
‘compulsions and ansety disorder avoidance can also
be associated with reward processing abnormalities,
“Thus, It seems sensible to tet approaches targeting
anticipatory (dopaminergic) and/or consummatory
(opioidergc) transmission in the later conditions
‘We must acknowledge that, instead of resulting
from the combination of multiple dysfunctional
neurobiological systems, OCD may be ascribed to
8 tll unrecognized and broad obsessionality and!
‘or compulsivity RDOCconstruct/sub-construct
However, there is yet no fll consensus on how these
‘concepts should be understood: that a symptom
phenomena, as personality traits or a8 neue.
peychological constructs [77]. Although the RDoC
‘spproach is particulary interested in addressing
the abnormal biology underlying symptoms (rather
than on obsessions or compulsions per se), it it
conceptually difficult to disentangle absessionality
and compulsvity from the concept sith which i
1s intcnsicaly intermingled (ke. & symptom com:
plex). In other words, searching for the biology
‘of obsessionality and. compulsivity and not for
‘obsesionsand compulsions could beamere semantic
exercise that does not capture the underlying biology
‘of OCRDs. However, only future therapeutic studies
willbe able to clarify whether concentrating on dys
functional RDO systems underlying absessionalty
and compulsivity will prove more beneficial 10
Table 1.2 Overiewf penn and ening cave rms shang eee hese
Preaccputons Ruminatons Obseine Obsesve Fentalee shu alucaond
Pte
asstin! ererioed
ocCamters Symotm —Thowght
hoogeager
ferere
er
racy
i
Ee
A
somos
8
Sure RDO. esetch Domain
(0b bey mmc cer GAS geese oete than concentrating on obsesions and 13, Sing GE, Tantomor dela concen
pate In Recard M, eur general y pea
Madrid tori Gres 19567282
14. Denys. Obeesonaty and compulviys
Pempulsions Pe
behaviors behaviors
Compulsive Avoidant
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