Understanding treatment response and resistance in obsessive compulsive disorder in the context of cognitive neuropsychological model

Abstract

Cognitive-behavioral therapies, antidepressants and neuromodulation techniques are current treatment options used in various stages of the treatment procedure for obsessive-compulsive disorder (OCD). The factors that disparate treatment options-from psychological approaches to invasive surgical techniques-in a psychiatric disorder have in common have scarcely been described in the relevant literature. The cognitive neuropsychological model (CNM) is a novel approach that offers a common framework in which psychological and neurobiological models of different psychopathologies are reconciled by means of impaired emotional processing. In this paper, an integrated approach of disrupted top-down and bottom-up emotional processing is described to understand the efficacy of the different treatment modalities for OCD. In this model, 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 patients with OCD, and many 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 are discussed in the context of CNM.