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October 2018

Neuroscientifically Informed Formulation and Treatment Planning for Patients With Obsessive-Compulsive Disorder: A Review

Author Affiliations
  • 1Division of Neurotherapeutics, Massachusetts General Hospital, Boston
  • 2Obsessive-Compulsive Disorder Institute, McLean Hospital, Belmont, Massachusetts
  • 3Obsessive-Compulsive and Related Disorders Program, Massachusetts General Hospital, Boston
  • 4Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
  • 5Biological Psychiatry Laboratory, McLean Hospital, Belmont, Massachusetts
  • 6BC Mental Health & Addictions Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
  • 7Picower Institute for Learning and Memory, Massachusetts Institute for Technology, Cambridge
JAMA Psychiatry. 2018;75(10):1081-1087. doi:10.1001/jamapsychiatry.2018.0930

Importance  Obsessive-compulsive disorder (OCD) is a common and often debilitating psychiatric illness. Recent advances in the understanding of the neuroscience of OCD have provided valuable insights that have begun to transform the way we think about the management of this disorder. This educational review provides an integrated neuroscience perspective on formulation and treatment planning for patients with OCD. The article is organized around key neuroscience themes most relevant for OCD.

Observations  An integrated neuroscience formulation of OCD is predicated on a fundamental understanding of phenomenology and symptom dimensions, fear conditioning and extinction, neurochemistry, genetics and animal models, as well as neurocircuitry and neurotherapeutics. Symptom dimensions provide a means to better understand the phenotypic heterogeneity within OCD with an eye toward more personalized treatments. The concept of abnormal fear extinction is central to OCD and to the underlying therapeutic mechanism of exposure and response prevention. A framework for understanding the neurochemistry of OCD focuses on both traditional monoaminergic systems and more recent evidence of glutamatergic and γ-aminobutyric acid–ergic dysfunction. Obsessive-compulsive disorder is highly heritable, and future work is needed to understand the contribution of genes to underlying pathophysiology. A circuit dysregulation framework focuses on cortico-striato-thalamo-cortical circuit dysfunction and the development of neurotherapeutic approaches targeting this circuit. The impact of these concepts on how we think about OCD diagnosis and treatment is discussed. Suggestions for future investigations that have the potential to further enhance the clinical management of OCD are presented.

Conclusions and Relevance  These key neuroscience themes collectively inform formulation and treatment planning for patients with OCD. The ultimate goal is to increase crosstalk between clinicians and researchers in an effort to facilitate translation of advances in neuroscience research to improved care for patients with OCD.