Obsessive Compulsive Disorder: A Neuropsychological Approach

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Edited by: Pritha Mukhopadhyay & Sreemoyee Tarafder

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    Preface

    SAGE was founded in 1965 by Sara Miller McCune to support the dissemination of usable knowledge by publishing innovative and high-quality research and teaching content. Today, we publish over 900 journals, including those of more than 400 learned societies, more than 800 new books per year, and a growing range of library products including archives, data, case studies, reports, and video. SAGE remains majority-owned by our founder, and after Sara's lifetime will become owned by a charitable trust that secures our continued independence.

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    Acknowledgements

    To

    The Department of Psychology, University of Calcutta (estd 1916)where psychology started its journey in India more than 100 years ago

    Preface

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    List of Tables

    List of Abbreviations

    AVDTR

    audiovisual display time reproducer

    BDD

    body dysmorphic disorder

    BDI

    Beck Depression Inventory

    BGT

    Bender Gestalt Test

    BPD

    borderline personality disorder

    CBT

    cognitive behaviour therapy

    CCG

    community control group

    CGs

    control groups

    COWAT

    Controlled Oral Word Association Test

    CPEPA

    Centre with Potential for Excellence in Particular Area

    CS

    Conditional Stimulus

    CSTC

    cortico-striatal-thalamic-cortical

    DB

    Digit Backward

    DBS

    deep brain stimulation

    DEP

    depressive disorder

    DF

    Digit Forward

    DLPFC

    dorsolateral prefrontal-circuit

    DM

    decision-making

    DSM

    Diagnostic and Statistical Manual of Mental Disorders

    DZ

    dizygotic

    ECA

    Epidemiologic Catchment Area

    EF

    executive functions

    EEG

    electroencephalogram

    EHI

    Edinburgh Handedness Inventory

    EPQ

    Eysenck Personality Questionnaire

    ERP

    exposure and response prevention

    FDR

    first-degree relatives

    FSH

    follicle stimulating hormone

    FTMS

    failure to maintain set

    GHQ

    General Health Questionnaire

    GSR

    galvanic skin response

    HA

    harm avoidance

    HRSD

    Hamilton Rating Scale for Depression

    HYP

    hypochondriasis

    ICD

    International Classification of Disorders

    IGT

    Iowa Gambling Task

    IPD

    idiopathic Parkinson's disease

    IPDE

    International Personality Disorder Examination

    IWM

    internal working model

    LH

    luteinizing hormone

    LNS

    Letter Number Sequencing

    LOI

    Leyton Obsessional Inventory

    MCQ

    Metacognition Questionnaire

    MDD

    major depressive disorder

    MMSE

    Mini-Mental State Examination

    MRI

    magnetic resonance imaging

    MSE

    mental status examination

    MZ

    monozygotic

    NAOP

    National Association of Psychology

    NEO-FFI

    NEO Five Factor Inventory

    NEO-PI

    NEO Personality Inventory

    NOCC

    number of categories completed

    OBQ

    Obsessive Beliefs Questionnaire

    OCD

    obsessive compulsive disorder

    OCPD

    obsessive compulsive personality disorder

    OCPTs

    obsessive compulsive personality traits

    OCSD

    obsessive compulsive spectrum disorder

    OFC

    orbitofrontal cortex

    PCLR

    percent conceptual level response

    PE

    perseverative error

    PNPE

    percent nonperseverative error

    PPE

    percent perseverative error

    PPR

    percent perseverative response

    PR

    perseverative response

    PSI

    Processing Speed Index

    RT

    Reaction time

    SAPAS

    Standardized Assessment of Personality Abbreviated Scale

    SD

    standard deviation

    SEM

    structural equation modelling

    SMRA

    Stepwise Multiple Regression Analysis

    SNST

    Stroop Neuropsychological Screening Test

    SPSS

    Statistical Package for the Social Sciences

    S-REF

    Self-regulatory Executive Function

    SRIs

    serotonin reuptake inhibitors

    SSRIs

    selective serotonin reuptake inhibitors

    SST

    Serial Subtraction Test

    TAF

    thought-action fusion

    TCFC

    trials to complete first category

    TCI

    Temperament and Character Inventory

    TEF

    thought–event fusion

    TOF

    thought–object fusion

    TOL – DX

    Tower of London Drexel University

    UD

    unipolar depression

    US

    Unconditional Stimulus

    WAIS-III

    Wecshler Adult Intelligence Scale-III

    WCST

    Wisconsin Card Sorting Test

    WFD

    workforce development

    WHO

    World Health Organization

    WMI

    Working Memory Index

    YBOCS

    Yale Brown Obsessive Compulsive Scale

    YBOCS-SC

    Yale Brown Obsessive Compulsive Scale Symptom Checklist

    5HIAA

    5-hydroxy-indole-acetic-acid

    Foreword

    For more than a century psychologists have been trying to understand OCD in terms of its diagnosis, aetiology and prognosis. It was since the case history of ‘Rat Man’ was reported by Freud in 1909 that OCD has remained a fertile area of research in clinical psychology. The Rat Man was indeed a lawyer fantasizing about being tormented by rats. The lawyer was very fearful that terrible things may happen to his father and his lady friend. Freud personally treated him regularly for three months and sporadically afterwards, using his method of psychoanalysis. The lawyer had partial relief but was never cured completely. Research in the area of OCD has come a long way from the days of Freud, who incidentally was the contemporary of Girindra Shekhar Bose, the first psychoanalyst in India. OCD is now taken as a spectrum of neuropsychological disorders treated by a combination of psychotherapy, cognitive behaviour therapy (CBT) and pharmacological drugs. There is a vast body of knowledge today about the role of cortico-striatal-thalamic-cortical circuit. Hollander (2013) while bringing out DSM-V expanded the scope of OCD as a spectrum of disorders, introducing the continuum of ‘compulsive-impulsive’ along which the disorders vary. Impulsivity implied deficient mental control and premature act at one end of the continuum, the other being rigidity and over-control. A term ‘obsessive compulsive spectrum disorder’ was introduced to cover a wide range of OCDs. That has given research a new direction in this area. But even today it is looked upon as a mysterious disease, and we have a long way to go in deciphering the origins and true character of this disorder. It is still considered, as in Freudian days, that OCD can be managed by psychotherapy and drugs, but there is no cure.

    The present book on OCD, edited by Professor Pritha Mukhopadhyay and Dr Sreemoyee Tarafder, is a comprehensive work comprising a series of studies. Professor Mukhopadhyay set up a neuropsychological laboratory in the Psychology Department of University of Calcutta in 2000, and the present book is the culmination of this team's research on OCD in the last 15 years. She and her students conducted a series of studies over this long period and have come out with salient findings on obsessive compulsive behaviour. This work has set a new direction and approach in the study of OCD. The implications of her findings are worth considering for the management of this disorder. In seven chapters of this book, the editors have examined OCD patients from psychological, physiological and neurological perspectives. The book also focuses on the prognosis and other ramifications of OCD.

    As many aetiological studies show, OCD is on rise in India. It should be noted that most of the aetiological studies are conducted in urban areas and few in rural areas. The reported studies are mostly clinical observation rather than demographic surveys. A gross estimation shows that around 2% to 3% of the population suffers from OCD in India, which includes both mild and severe cases. OCD often manifests in late adolescence, and the disorder continues for lifetime with intermittent remission. In recent decades, OCD has been on the rise, and we are still in the process of understanding its prognosis and various ramifications. One of the reasons for lack of reliable data about OCD is its overlap with obsessive compulsive personality, obsessive compulsive spectrum and related symptoms. Another difficulty is that children with OCD often hide their symptoms and are shy of talking about it. This leads to delay in diagnosis of the disorder.

    OCD is a chronic disorder and can only have symptomatic relief. Obsession implies repetition of the same thought, imagery or idea for long period of time and compulsion is repetition of some action over and over again. It becomes a disorder when patients have no control on their thinking and behaviour, and suffers distressing anxiety. Some of the important manifestations of obsession are fear of causing harm to someone else, fear of harm inflicted to self, fear of contamination, need for symmetry or exactness, sexual and religious fixation, fear of behaving unacceptably and anxiety of making a mistake. The consequent compulsive behaviour may be cleaning, hand washing, checking, ordering and arranging, hoarding, asking for reassurance and mental acts such as counting, silent word repetition and rumination. It is a mentally disabling condition, varying from person to person and severity varying even within the same person at different times. In most severe condition, it may completely take over the thinking faculty and activities, such as in case of a possessed person. As a mental health disorder, it should be understood that there is no treatment of the disease, only symptomatic relief is possible.

    It is characteristic of OCD that it often gets associated with other disorders such as depression, suicidal tendencies, eating disorders (such as bulimia), anxiety attack and sexual perversions. Then the situation becomes even more complicated and threatening. According to WHO, suicide will be the number one killer disease by 2030, and OCD will play an important contributory role in that. Containing OCD becomes all the more urgent in such cases. Children with autism have greater probability of developing OCD.

    The main thesis of the work reported in this book is that repetitive thinking along with associated faulty neural network leads to multiple cognitive deficits. It contends that there is a symbiotic connection between brain and behaviour. Neurological dysfunctioning is both cause and consequence of OCD. It is reported that OCD patients are slow in responding to conflicting and noncon-flicting situations. They follow their internal rule—disregarding external instructions—and this choice does not arouse any guilt. Information processing speed is found to be the potent predictor of severity of the disorder. Higher-order cognitive activities such as planning, intention, coordination and integration (called executive functions) are severely impaired in the condition of OCD. These and other findings reported in this book render it a valuable contribution in the field of OCD.

    Ajit Kumar Dalal Retd Professor of Psychology, University of Allahabad

    Acknowledgements

    Pritha Mukhopadhyay

    Throughout my life, I have acknowledged to myself that the only best friend of my life is my mom. My mother, Mrs Pranati Mukherji, who is no more with me, but is always there. It is she who made me what I am today. But for the first time in my life I am formally acknowledging, ‘Mom, I have no words to express the insight, love and support you've given me’.

    My sincere gratitude to my department, the Department of Psychology, University of Calcutta, for providing me with all the facilities to carry out my research work with my students and research scholars. I am thankful to Centre with Potential for Excellence in Particular Area (CPEPA) for providing me with the infrastructure to do the research and also with an academic impetus to disseminate knowledge in a greater sphere by providing a peaceful ambience.

    I have no words to express my thanks to Professor Ajit Dalai who has given me inspiration and guidance from the time I communicated to him about this attempt to write a book based on our own research. I am thankful to all the doctors, Professor Gautam Bandyopadhyay, Dr Jai Ranjan Ram, Dr Satyajit Ash and Dr Abhijit Hazra, who have sent patients to us and helped us as and when necessary. We continuously felt their support throughout the course of our work. I am delighted to mention that my students and research scholars—Ms Ananya Mondal, Ms Piya Saha, Ms Ayoleena Ray, Mr Kaustav Manna and Ms Doyel Ghosh—helped me at every step in making tables, formatting texts, charting graphs and correcting typographic errors.

    To Sreemoyee, I will just say that the comfort of cognitive symbiosis that you have provided to me cannot be expressed in words—if I would start a thought, you'd finish it for me and that is perhaps the reason why we worked so well together. I am thankful to all the authors who have contributed to the book— Mrs Suvosree Bhattacharya, Dr Sujata Das, Professor Shyamal Kumar Das, Dr Dinaz Bilimoria, Ms Parmeet Soni and Mrs Nilanjana Chatterjee. Without their contribution and cooperation, the book would not have been possible. I extend my thanks to the editorial and production teams of SAGE India for their continuous guidance and monitoring for publication of the book.

    This work could not be made complete with all the workload I have to undertake as academic and administrative responsibilities of the department and the university. But I am ever so grateful to my husband, Professor S. K. Ghoshal, who always stands beside me in any of my academic endeavours and helps me to improve my knowledge at every step. My daughter, Ms Sayari Ghoshal, her concern for me, her tolerance and her ability to never place her need before mine and always smiling. I do not know how to say my thanks to her.

    Sreemoyee Tarafder

    An absence that makes its presence felt at every juncture of my life is that of my mother. When I graduated from college, my mother had gifted me a book, and on its inside cover she had written words of encouragement for me that I cherish till date. When our book is being published, she is not around to hold it in her hands, but I know what she would have said, and I know what I would have felt. So, to begin with, I thank her—my mother, Sanghamitra Tarafder—a woman of immense wisdom and empathy who taught me all about unconditional love and instilled in me the love for academia. This is your dream, Maa.

    I know that this book would not have been possible without the driving force of my supervisor and mentor Professor Pritha Mukhopadhyay. The book is the result of her tireless efforts and rigour that made all of us put in our best. She is my co-editor for the book, and I feel honoured to share the title credits with her. I remain ‘limbically yours, Mamie’. It was good to work at the CPEPA lab over endless cups of tea and food (being supplied by Ananya and Pia), interspersed by some invigorating conversations with Ma'am, her students and scholars.

    I have received a lot of help from Dr Dinaz Jeejeebhoy—my co-author and guardian angel. Rupam Banerjee, Navnita Bose, Priyanka Roy, Parmeet Soni, Suvosree Bhattacharya—I really appreciate their inputs and comments at various stages of the work. Had it not been for Professor Gautam Bandyopadhyay, Dr Jai Ranjan Ram, Dr Satyajit Ash and my teachers—Professor P. K. Chattopadhyay, Debabrata Biswas, late Saugato Basu, Professor Nilanjana Sanyal, Prasanta Kr. Roy among others—I would have perhaps not acquired an insightful understanding of OCD.

    I thank my inner circle of love—DJLPS (my soul sisters Dona Pal, Jayshree Sarda, ‘Lalti’, Priyanka Bhattacharyya and Priyanka Thapar)—for keeping the dream alive in me. My friends kept me afloat through difficult times and the last two years have not been easy; hence, a big thanks to ‘Mangsho-Mishti-More’, Trina, Srinayana, Priyanka, Pushpita, Sayantan, Souvik, Anuttama and Jhuma for your hand-holding. I am also indebted to my workplace—West Bengal State University, the Honb'le Vice Chancellor Prof. Basab Chaudhuri and all my departmental colleagues for ensuring that I could devote time to the book. My students at WBSU are my source of sustenance, they provide me with immense joy and satisfaction. I feel humbled by the love that they shower on me and they must be thanked for keeping my spirits high. My friends from work— ‘Mureer Tin’, especially Dr Kausik Bandyopadhyay, needs special mention for guiding me about the publication process. I am especially thankful to Abhijit Baroi, Guneet Kaur Gulati and team SAGE for beautifully guiding us all through the journey.

    Words cannot express the admiration that I feel for my father Sri Apurba Kumar Tarafder, who always inspires me with his infectious workaholism. And my family—brother Abhishek, his wife Gargi, niece Aritri, uncle Sameer Mitra and father-in-law, Sri Aditya Kr Chatterjee—for providing the holding environment.

    I thank my husband, Dr Siddhartha Chattopadhyay, for being my cherished friend and for making the frame of my life so beautiful with his steady and nurturing presence, encouraging me to become the best that I can be.

  • About the Editors and Contributors

    Editors

    Pritha Mukhopadhyay is Professor at the Department of Psychology, University of Calcutta. She has been a brilliant and meritorious student right from the beginning of her student life. She was awarded national scholarship by the Government of India for her performance at higher secondary and graduation examinations. She was the recipient of the gold medal at the postgraduation level at the Department of Psychology, University of Calcutta in 1980. She went on to join the Department of Psychology, University of Calcutta as a lecturer in 1986. She was awarded her doctoral degree in 1991. For her postdoctoral work, she received the J. William Fulbright Scholarship and visited the School of Medicine at Temple University, USA in 1994. She is an avid researcher and her primary interests lie in the areas of psychophysiology and neuropsychology. She is the Coordinator of the UGC-funded Centre with Potential for Excellence in Particular Area, University of Calcutta, since 2011, and is carrying out cutting-edge work at her laboratory there with quantitative electroencephalogram and brain training programmes. She has received several research projects awarded by University Grants Commission, Indian Council of Social Science Research, All India Council for Technical Education and Department of Science & Technology. She has around 60 journal publications to her credit, both at national and international levels, and has authored 10 book chapters in various publications. She lives in Kolkata with her husband and daughter and loves reading books and travelling. Former head of the Department of Psychology, University of Calcutta, she is widely acclaimed and respected for her academic and administrative brilliance.

    Sreemoyee Tarafder is at present an Assistant Professor and Coordinator of the Department of Psychology, West Bengal State University, Barasat. A promising student of psychology right from her undergraduate days, she is a gold medalist in MPhil in Clinical Psychology from the University of Calcutta where she also received the G. G. Prabhu Award for topping her class. She completed her PhD from University of Calcutta, under Prof. Pritha Mukhopadhyay and was felicitated with the Durganand Sinha Memorial Award for her doctoral work on OCD from the National Association of Psychology (NAOP). She is also a corporate trainer and a consultant clinical psychologist who is specialized in areas related to personality disorders and anxiety disorders with specific expertise in OCD. She has established scientific liaisons with University of Haifa, Israel, BRAC University and Dhaka University in Bangladesh and University of Bath, UK. She has published around 20 papers in journals of national and international repute. She is a known face on mass media and frequently appears for mental health-related shows on regional and national channels of television and radio to promote awareness of mental health at community level. She lives in Kolkata with her husband and family, and apart from her passion for films, art, theatre and dance, she loves travelling, reading and socializing.

    Contributors

    Suvosree Bhattacharya MPhil (Clinical Psychology) is clinical psychologist and Assistant Professor at the Department of Applied Psychology, The Neotia University, Kolkata. She obtained her MPhil in Medical and Social Psychology from Central Institute of Psychiatry, Ranchi, in 2006. After obtaining her MPhil, she worked at the Memory Disorder Research Group, Department of Neurology, Copenhagen University Hospital, Denmark, and at the Goodwill Industries of East Texas (USA) as a counsellor and workforce development trainer in the workforce development (WFD) department. After she returned to India, she worked as clinical psychologist at the Department of Clinical Psychology, Institute of Psychiatry, IPGMER, Kolkata. She also has wide teaching experience, having taught as a visiting faculty at the Department of Psychology, West Bengal State University and Department of Applied Psychology, University of Calcutta. She knows Danish and Japanese languages, and learning new languages is her passion.

    Nilanjana Chatterjee is a school psychologist and refers to herself as a health and wellness teacher at South Point High School. She obtained her master's degree from the Department of Psychology, University of Calcutta. She is also associated with different organizations as a psychologist and trainer. She is an avid photographer, with a keen interest for photography and travelling.

    Sujata Das is consultant neuropsychologist at Fortis Hospital, Kolkata. She obtained her doctoral degree in 2009, having studied cognitive functions in obsessive compulsive disorder (OCD), paranoid schizophrenia and idiopathic Parkinson's disease. She is a sincere researcher and practitioner, with over 15 publications in peer-reviewed journals, both national and international. She was associated with the Department of Psychology, West Bengal State University, as a visiting faculty, teaching courses on biopsychol-ogy and cognitive studies. She loves to read and travel and has a special interest in folk music, especially baul gaan.

    Shyamal Kumar Das MBBS, MD, DM, is professor and head of the Department of Neurology, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education & Research (IPGMER), Kolkata. He is a renowned researcher with over 150 international and national publications in indexed journals. He received a movement disorder fellowship from University of Calgary, Canada. He specializes in neurodegenerative disorders, clinical sciences, neurogenetics, neuromedicine and neurophysi-ology. He has undertaken significant research projects related to dementia and dystonia. He is known for his avid interest in research and academic rigour.

    Dinaz R. Jeejeebhoy MPhil (Clinical Psychology), PhD, is Assistant Professor, Loreto College, Kolkata, and also a practising clinical psychologist. She has been a meritorious student all through her academic career. She was awarded with the national scholarship for achievement at BSc level by the University of Calcutta to pursue MSc in psychology for the batch 2003–2005. She was the recipient of the Debarpita Mukhopadhyay Book Prize for 2003 (for topping BSc examination) and the Dr G. Bose Memorial Prize for 2002 (for topping BSc Part I examination), awarded by the Department of Psychology, University of Calcutta. She has presented a number of papers at seminars and conferences and was recently awarded the S. C. Gupta Best Paper Award in 2015 by the Indian Association of Clinical Psychology for her work on borderline personality disorder. She is actively involved with an NGO that works for the upliftment of women and children. An avid sportswoman, she continues to play basketball at the club level and trains guides and bulbuls.

    Parmeet Kaur Soni MSc, MPhil (Clinical Psychology), is consultant clinical psychologist at Mental Health Foundation, Kolkata. She is a registered clinical psychologist, qualified in 2010, and has been working in mental health and research settings since 2012. She works mainly with children, adolescents and young adults in the area of emotional and behavioural disorders and has extensive experience in conducting psychodiagnostic assessments and providing psychotherapy using evidence-based methods. She provides parent training as well as works in liaison with schools to recommend viable management solutions for children. She has a special interest in clinical training and supervision, participating in clinical-based research, and in the area of substance abuse disorders and dual diagnosis in adolescents and young adults.


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