Cognitive-behavioral therapy for obsessive–compulsive disorder: access to treatment, prediction of long-term outcome with neuroimaging

Figures & data

Figure 1 A pretreatment brain imaging predictor of long-term treatment response of OCD.

Notes: (A) Values of the resting-state fMRI (rsfMRI) graph theory parameter small-worldness (a metric of brain information transfer efficiency) in a pilot sample of 17 adult OCD patients within 1 week before (pre; open symbols) and 1 week after (post; filled symbols), 4 weeks of intensive daily CBT. Sixteen of 17 patients (2 minimally) exhibited pre-to-post increase in small-worldness (group-mean 7.5%, P<0.05 permutation testing). (B) For same sample, change in Y-BOCS total score measuring severity of core OCD symptoms, expressed as score at post-CBT follow-up minus score immediately after completing CBT. This is plotted as a function of pre-CBT small-worldness. Patients with higher pre-CBT small-worldness had worsening of OCD symptoms (positive change) at follow-up while patients with initially low small-worldness had improvement in symptoms (negative change) (r=0.65, P<0.005). Relapsers (≥5-point increase in Y-BOCS; triangles) had above-average pre-CBT small-worldness. Thus, rsfMRI graph theory may have some ability to predict long-term treatment response in OCD.
Abbreviations: AUC, area under the curve; BOLD, blood oxygen level-dependent; OCD, obsessive-compulsive disorder; rsfMRI, resting-state functional magnetic resonance imaging; fMRI, functional magnetic resonance imaging; CBT, cognitive-behavioral therapy; Y-BOCS, Yale-Brown Obsessive-Compulsive Scale.

Figure 2 Sagittal MRI of pregenual anterior cingulate and its proton magnetic resonance spectrum.

(A) Sagittal T1-weighted MRI of the human brain showing location of 15×15×15 mm³ proton magnetic resonance spectroscopy (MRS) acquisition voxel (yellow square) in the pregenual anterior cingulate cortex (pACC). (B) Sample raw (jagged gray), baseline (light gray), and fit (solid red) MR spectra acquired from the pACC. The MR spectrum is a plot of the intensity of radiofrequency signal (ordinate axis) vs signal frequency (abscissa) in parts-per-million (ppm). The size (area under the curve) of each peak in the spectrum is proportional to a different biochemical species (metabolite) or small family of chemically related metabolites in the MRS voxel. The peak marked “Cr+PCr” at 3.02 ppm represents the sum of the energetic neurometabolites creatine and phosphocreatine. In our OCD pilot sample, pretreatment Cr+PCr level in pACC was predictive of OCD core and other symptoms at post-treatment follow-up.

Abbreviations: Cr, creatine; OCD, obsessive-compulsive disorder; MR, magnetic resonance; MRI, magnetic resonance imaging; PCr, phosphocreatine.

Figure 3 Post-treatment (1–12 months) follow-up (f/u) clinical scores in a sample of 19 adult OCD patients (filled circles) who received 4 weeks of intensive daily CBT.

Notes: (A and B) Scores assayed core OCD symptoms on the Yale–Brown Obsessive Compulsive Scale (Y-BOCS, A) and Obsessive-Compulsive Inventory (OCI, B). (C and D) Scores assayed depressive symptoms on the Montgomery–Åsberg Depression Rating Scale (MADRS, C) and anxious symptoms on the Hamilton Anxiety Rating Scale (HAMA, D). All scores are plotted as a function of the combined level (corrected for cerebrospinal fluid [CSF] content of the acquisition volume) of the energetic neurometabolites creatine (Cr) and phosphocreatine (PCr) in the midline (left + right) pregenual anterior cingulate cortex (pACC), a brain region linked to positive affect, among other functions. Levels were acquired with proton magnetic resonance spectroscopy (MRS) at most 1 week prior to CBT. Higher pretreatment levels of Cr+PCr were significantly correlated (Spearman) with lower OCD, depressive, and anxious symptoms across the sample. Thus, elevated energetic metabolism may dispose toward retention of response to CBT. This suggests that brain imaging may be helpful in predicting long-term outcomes in OCD.
Abbreviations: CBT, cognitive-behavioral therapy; CSF, cerebrospinal fluid; IU, Institutional Units; OCD, obsessive-compulsive disorder.