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“Understanding Excess” at the Cambridge Science Festival
“Understanding excess” was a neuropsychiatry seminar hosted by the University of Cambridge on the 14th of March 2012, one of the many free events, to celebrate the Cambridge Science Festival with the theme “breaking boundaries”, reflecting the year of the Olympic and Paralympics games, showcasing, the boundaries that are being broken in science, technology, engineering and mathematics.
Professor Barbara Sahakian (Dept. of Psychiatry) chaired the event. The panel members included, Professor Trevor Robbins (Dept of Experimental Psychology and Behavioural and Clinical Neurosciences Institute), Professor Naomi Fineberg (Consultant Psychiatrist, Hertfordshire Partnership Foundation Trust and Visiting Professor, University of Hertfordshire) and Mr Dominic Blyth, a service user with a long history of obsessive compulsive disorder (OCD).
One of the aims of this seminar was to highlight the convergence of two disorders, obsessive compulsive disorder and addictions, both associated with compulsive urges to perform behaviours of a ritualised and habitual nature. The seminar was well attended with around 200 people packed into the auditorium.
Professor Barbara Sahakian opened the seminar by introducing the panel members and talked about the need for a paradigm shift from treatment to prevention of mental disorders, since, symptoms of most (75%) mental disorders start at an early age. With OCD and addictions, symptoms start early, then, tend to “creep up” and evolve into habits. She described the concept of “mental capital” to illustrate the role that emotional and cognitive resources play in offering resilience under stress. She also talked about the need for screening instruments which would enable early detection of mental disorders thus aiding early treatment. Prevention and early treatment in mental health, she felt, should be a priority in keeping with the Department of Health’s strategy of “No health without mental health”
Professor Robbins, an expert in cognitive neuroscience, lectured about the “brain” behind the “excess”. Inability to change behaviour in OCD and addictions is known to be related to reduced cognitive flexibility. Whilst an fMRI study suggests that there is reduced activity in subjects with OCD and their first degree relatives in the orbitofrontal cortex (an area associated with reversal learning), another study comparing subjects with OCD to those with cocaine dependence showed diminished connectivity of the same area with other brain regions. To illustrate that behaviours in OCD could be “habits”, Professor Robbins described an experiment using the “fabulous fruit test” wherein patients with OCD unlike control participants did not seem to understand the outcome of their actions leading to senseless repetition of learned behaviour that is familiar to the subject. According to him, bias towards habitual behaviour may underlie the drive to perform compulsions. Moreover he felt that in subjects with OCD, there seems to be an imbalance between habitual and goal directed behaviour. It was interesting to note that reversal of goal directed behaviour is regulated by the orbitofrontal cortex and basal ganglia, the circuits between which are fundamentally noted to be dysfunctional in OCD and related disorders.
Following Professor Robbins, it was Professor Naomi Fineberg’s turn to lecture on the clinical aspects of OCD. She was of the opinion that whilst OCD and addiction are theoretically diverse, some degree of convergence is also notable. In other words whilst they are both repetitive and ritualistic, compulsions in OCD are distressing for the individual, whereas addictive behaviour is experienced as pleasurable. However the convergence is demonstrated by the fact that whilst compulsions (in OCD) like addictions evolve into habits, in the long run, addictive behaviours induce withdrawal symptoms which are distressing thereby neutralising any pleasure experiences. Professor Fineberg highlighted the need for “research enhanced health care” - healthcare that balances patients’ needs with research evidence based treatment. She talked about the cornerstones of treatment in OCD- pharmacotherapy and exposure and response prevention, with outcomes generally being better in those receiving both. Professor Fineberg also talked about the “stepped care” model of treatment provision to cater to the needs of service users with a broad range of severity/complexity of OCD. She described how the revision of DSM (DSM-V) has acknowledged the concept of obsessive compulsive spectrum disorders by revising the nosological status of OCD and putting it together with disorders such as Body Dysmorphic Disorder (BDD), thereby moving away from the earlier concept of OCD as an anxiety disorder. Professor Fineberg illustrated this concept with a case vignette demonstrating the spectrum of obsessive compulsive and related disorders including alcohol addiction in a patient. She also discussed the neurobiological mediation of OCD with an example of a SPECT study wherein reduced orbitofrontal cortex activity was associated with good response to citalopram, a selective serotonin reuptake inhibitor that is known to be effective in the treatment of OCD.
Finally it was the turn of Mr Dominic Blyth, a service user, to discuss his experiences of suffering from OCD. His description of the onset of symptoms following the tragic death of his brother in a car accident and subsequent periodic relapses illustrated how symptoms of OCD are often triggered by life stresses. His report of onset of symptoms in childhood mirrored Professor Sahakian’s introductory remarks about early onset of symptoms in OCD. He described himself as a “checker”-one of the commonest subtypes of OCD. The “military style” regimental rearing influences of his grandfather (a personality who insisted that he gets everything exactly right) and a strict routine in boarding school illustrated how nature and nurture influence the onset of many psychiatric disorders including in this case, OCD. He then went on to talk about the long and difficult path towards treatment. In keeping with the status of OCD in the 80’s he was passed off as a “neurotic”. He also discussed the wide disparity in the provision of services across the country. Mr Blyth started noticing consistent improvement after receiving treatment at the National OCD service at Welwyn Garden City followed by in-patient treatment (intensive CBT), thus, highlighting the dependence on tertiary services for quality care in OCD
When asked about the relevance of “social capital” in OCD, Mr Blyth felt that due to stigma, sufferers of OCD are reluctant to discuss their illness such that this leads to disruption of their family and social support systems. In keeping with the typical course of this disabling disorder, Mr Blyth considered OCD to be a lifelong struggle for him. From a service user’s perspective, he felt that, beating the stigma and developing better drugs for treatment should be the priority for clinical services and research in OCD.
Following the panel presentation, the floor was open for a question and answer session. Several interesting questions ranging from those pertaining to the delayed recognition of OCD as a disorder with disability, to the treatment of paediatric OCD, the relationship between OCD, anorexia nervosa and depression, and the role of CBT in Autism/Asperger’s syndrome. The panel were equally enthusiastic about answering and discussing the queries.
The forum also offered an opportunity for Mr Daniel Nabarro, one of the invited guests to the seminar to highlight his role as the chairperson of “OCD ACTION”- a UK national charity for sufferers of OCD. He gave an overview of the charity, listing, some of the available support programmes, which included advocacy, employment support, not to mention, around 50 support groups up and down the country and programmes in schools which provide education and support.
Professor Sahakian closed the seminar by thanking the speakers for their contribution. That the seminar had captivated the attention of the audience was demonstrated by the fact that the 1 ½ hour programme went on for a further 45 minutes, with members of the audience clustering around the panellists asking more questions and the panellists in turn were noted to patiently answer their queries. The “excesses” of the day had to be “extinguished” by the caretaker of the building who was overheard politely reminding the lingering few that it was time to shut shop!
Dr Samar Reghunandanan MD MRC Psychiatry
ST4 Registrar in Psychiatry & Honorary Research Fellow
North Essex Partnership NHS Foundation Trust & National OCD and BDD services,
Hertfordshire Partnership NHS Foundation Trust
Welwyn Garden City
Posted on 11/04/2012
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