Lecture 9: OCD 2 - The Role of Habits

Question 1

how are compulsions defined in the classical view of OCD

Answer 1

1) Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rigid rules
2) The behaviors/mental acts are aimed at preventing/reducing anxiety or distress, or preventing some dreaded event/situation; however these behaviors are not realistically connected to the thing they are meant to prevent/reduce
–> the DSM suggests that compulsions are goal-directed

Question 2

explain the cognitive theory of OCD

Answer 2

= compulsive actions are goal-directed, they prevent/reduce anxiety and are rational actions based on rational beliefs which stem from cognitive biases in OCD
–> compulsivity is mediated by dysfunction in the assignment of value to available alternatives; compulsive individuals may view the cost of cessation of behaviour to be higher than the benefits thereof

Question 3

explain the habit theory of OCD

Answer 3

= internal or external stimulus leads to obsessions and distress/anxiety and this leads to ritualised behaviour (compulsions); the temporary relief caused by performing compulsions may lead to reinforcement of habitual rituals associated with antecedent triggers –> negative reinforcement
–> compulsions are therefore driven by abberantly strong habits, and strong habit formation could lead to the experience of a compulsive urge (“I must do it exactly like this”)

Question 3

what are 3 multipliers within the cognitive theory of OCD

Answer 3

1. high perceived responsibility
2. high perceived probability of harm
3. high perceived seriousness of harm
   –> these together lead to intense and prolonged checking

Question 4

what are 3 arguments against compulsions as goal-directed behaviors

Answer 4

1 - in OCD, the behaviour is usually egodystonic, which means that a patient feels that the symptoms do not really belong to them –> they recognise that the compulsions are irrational/excessive
2 - patients recognize that the compulsions are irrational and excessive
3 - the relief that they experience upon performing the compulsive act is usually highly transient

Question 5

explain the C-O-D account of OCD

Answer 5

= obsessions may arise as a post hoc rationalisation of otherwise inexplicable compulsive urges in order to resolve cognitive dissonance (= unpleasant tension that arises from conflict between one’s behaviour and one’s beliefs –> people feel a strong urge to reduce dissonance by modifying or rationalising their beliefs/behavior)
E.g.: when people wash their hands a lot and feel like this does not make sense, they may start to believe that they are dirty and that is why they are doing this, to make sense of their behaviour

Question 6

which two areas are related to goal-directed control and which two are related to habitual control

Answer 6

goal-directed:
- caudate
- vmPFC

habitual:
- PMC
- posterior putamen

Question 7

what are 3 executive functions that people with OCD struggle with

Answer 7

1 - Cognitive flexibility; they make more perseverative errors on the Wisconsin card sorting test, suggesting that ability to modify responses on the basis of feedback is impaired
2 - Decision making on the basis of positive vs negative consequences; they exhibit an impaired ability to adjust their behaviour on the basis of monetary gains and losses in the Iowa gambling task (they choose worse decks)
3 - Decision making: Delay discounting; they are less inclined to resist an immediate small reward in order to obtain a delayed larger reward

Question 8

T/F: there is nothing that shows up in relatives of patients with OCD that could show vulnerability to the illness

Answer 8

false, executive dysfunction is also found in unaffected relatives of OCD patients, suggesting that it qualifies as an endophenotype candidate for OCD –> heritable

Question 9

T/F: studies have shown that no shift from goal-directed behaviour exists for people with OCD

Answer 9

false, there is a shift in balance from goal-directed behaviour to habits in OCD patients

Question 10

what are 3 causes of the shift from goal-directed behaviour to habits in OCD patients

Answer 10

1 - they may have deficits in action-outcome associative learning which causes them to rely excessively on habits that were preciously reinforced
2 - excessive habit learning in OCD might cause patients to lose their sensitivity to action-outcome links, producing deficits in explicit action-outcome knowledge
3 - rather than abnormalities in goal-directed/habitual control, in OCD the problem could lie in the arbitration of between these two controllers

Question 11

how is the compulsive brain tested and explain

Answer 11

= symptom provocation studies; they expose patients to triggers of obsessions/compulsions (images) inside a scanner and then study the areas that become active –> similar to cue reactivity studies

Question 12

what is the most consistent finding from symptom provocation studies

Answer 12

HYPERactivity in orbitofrontal cortex (OFC), ventromedial PFC and caudate compared to controls; based on this it was proposed that OCD is a disorder of the balance between goal-directed control and habits in line with the idea of enhanced ‘habit propensity’ (= tendency to develop habits)
–> in SUDs we often observe reduced activity in these areas

Question 13

what were the results of an outcome devaluation test that was done with the fabulous fruits game with people with OCD

Answer 13

OCD patients committed mor slips of action, which is evidence fro generally enhanced habit propensity –> severity of OCD symptoms predicted how vulnerable patients were to slips of action

Question 14

what other study was done that gave more evidence for habit propensity in OCD patients and what brain areas were connected to this study

Answer 14

Patients and controls were trained to press left and right foot pedals to avoid electric shocks to the left or right hand (a red or blue square signalled whether a left or right shock would be delivered).
After a brief training one of two electrodes was removed, and subjects were told they could no longer receive a shock to that hand and that their only taks thereafter was to continue avoiding shocks (one of the shocks was devalued) –> OCD patients were as able as control to stop pressing the devalued signal
Electrode was then reattached and subjects were given additional (extensive) training –> this timeOCD patients pressed more often to avoid the devalued shock then the healthy controls

brain areas:
- hyperactivation of the OBC during the learning phase, disappeared during the course of training
- hyperactivation of the caudate in patients who had formed habits
–> related to imbalance between goal-directed/habitual control

Question 15

explain the study done on memory confidence with OCD patients

Answer 15

An experimental group was training extensively to turn a stove on and off, compared to a control group who only did it a couple of times.
Results showed that the experimental group was much less confident in whether they had turned the stove off correctly in the last trial than the control group.
This shows that repetition leads to memory uncertainty, so perhaps habit propensity contributes to the memory uncertainty patients report.

Question 16

what kind of treatment is advised based on the cognitive account, and what treatment was proposed based on the habit account of OCD and explain

Answer 16

cognitive account; focus on cognitive biases –> Exposure Response Prevention (ERP) –> acceptability is low and many patients refuse to refrain

habit account; Habit Reversal Therapy (HRT)
two components:
1 - awareness training (e.g. daily monitoring go compulsions and antecedents/triggers)
2 - competing response training (physically incompatible response; replacing compulsive behaviors with other behaviors; e.g. instead of washing hands you sit down and brush off your hands)
–> was rated as highly acceptable and lead to significant reductions in OCD severity

Question 17

what are 2 problems with the current (cognitive) OCD framework

Answer 17

1 - compulsions are a secondary phenomena, but there is evidence that compulsive-like, automatic behaviors develop in OCD in the absence of any prior obsessions related to tasks
2 - OCD is an ego-dystonic disorder; patients have insight into irrationality of their actions –> cognitive models can’t account for this

Question 18

What are 2 arguments for compulsions as habits

Answer 18

1. some patients report that they have sometimes ‘suddenly’ without realising it themselves started the compulsion
2. It is also sometimes reported that the symptoms temporarily diminish in a new environment