Battling OCD in Real-Time: Live brain imaging helps patients attack anxiety at the source

We all, occasionally, feel anxious. For most people, anxiety strikes at specific moments — when turbulence rocks the plane or when your professor says, “we need to talk.” But imagine if even in the most ordinary of moments, every thought and experience you had was challenged by crippling anxiety — anxiety that has minimal basis in reality.

In fact, 3.3 million Americans suffer from obsessive compulsive disorder, commonly abbreviated as OCD. The disease is characterized by unsubstantiated fear that leads to time-consuming, distressing repeated rituals. Someone with OCD might have to wash her hands in a perfectly timed routine for fear of her own death, or the death of a loved one, or the destruction of her home and possessions. Despite ongoing research into the disorder, OCD continues to puzzle psychiatrists and agonize patients.
But new treatments may be on the horizon, thanks in part to a study by researchers at Yale University. A collaboration between the department of radiology and biomedical imaging and the Yale OCD Research Clinic, the study utilizes brain imaging to provide neural feedback to OCD patients in real time. The recently developed technology, known as real-time functional magnetic imaging (rt-fMRI), presents an effective therapy for OCD symptoms. In the new era of personalized medicine, it seems the answer to treating OCD is to show patients their own brain.

Exposing true compulsion

The most recognizable symptom of OCD is the obsessive conduct of apparently irrational actions. This might include repetitive hand washing (think Leonardo DiCaprio in The Aviator) or hoarding (think the psychiatric patient whose stash of chicken bones is discovered by Angelina Jolie in Girl, Interrupted). Many people experience so-called “compulsive” behaviors. Without rhyme or reason, we may prefer our books alphabetically organized or our notes color-coded, or we may have pre-game rituals that we follow religiously in preparation for athletic competitions, dates, or job interviews. But quirky habits do not a disorder make.

Yes, OCD patients exhibit an unyielding compulsion to move through specific routines. But these rituals are prompted by a relentless, obsessive, and irrational internal message that terrible consequences will follow unless certain behaviors are performed in a precise sequence. A ritual like hand washing can temporarily silence the obsessive message, something along the lines of “my grandmother will die if I don’t wash my hands the proper way.” These actions are not rational reactions to real fear, but rather, are attempts to stave off an all-consuming and often debilitating anxiety.
Surprisingly, someone with OCD can — when prompted — admit that such beliefs are irrational. Yet they cannot help but feel, often urgently, that their fears, random rituals, and potential consequences are all linked. The connection between unrelated events is cemented in their brain circuitry. Without targeted effort, the brain is impossible to rewire.

A malleable brain

The good news: our brains are not static. One of the key features of the human brain is neuroplasticity: Our brains consist of infinitely interconnected neurons that are interwoven into an extraordinarily complex system. But with each new experience, these neural connections can be dissolved and made anew.
This exciting premise of plasticity gives hope to neurofeedback, or the idea that people can learn by watching their brain in action. The treatment tested by the Yale team relies on real time-fMRI, which unlike traditional fMRI gives patients on-line feedback regarding their neural activity while they are in the scanner. With this feedback information, patients can potentially train their brains to correct exaggerated and unfounded responses to particular stimuli. The Yale researchers were inspired by the possibility that rt-fMRI could help the millions of people afflicted by OCD.

Anxiety-heavy disorders are particularly well suited to treatment by neurofeedback. “Anxiety is partly induced by environmental experiences,” said Michelle Hampson, assistant professor and director of rt-fMRI at the Yale School of Medicine. “The brain is obviously plastic in that circuitry can learn to become more anxious or less anxious,” she said.

In other words, if anxiety can be learned, perhaps it can also be unlearned.

The power of real time feedback

OCD manifests in many ways, but the Yale study led by Hampson focused on the type of OCD that is characterized by contamination anxiety, or a fear of coming into contact with dirt or germs. This anxiety is linked to a particular area of the brain known as the orbitofrontal cortex (OFC) — hyperactivity in this region is consistently correlated with the severity of OCD symptoms.
Flashing certain images to subjects while scanning their brains, the researchers were able to locate a specific anxiety-related region within the OFC, where activity levels rose and fell in response to dirty and clean images, respectively. Before treatment began, subjects met with a clinical psychologist who helped them create an individualized strategy for controlling contamination anxiety and activation of the OFC. Armed with these mind control techniques, subjects were then asked to mentally raise or lower OFC activity depending on the image shown. Because subjects were given fMRI feedback while trying to regulate this brain area, they were able to see the effect of their intended anxiety control in real time.
Half of the subjects in this study underwent neurofeedback treatment, while the other half received a placebo, or sham treatment. The sham biofeedback treatment mimics neurofeedback in almost every way, but instead of viewing their own OFC activity, people were shown activity from another subject of the same age and gender.

Before and approximately half a week after their neurofeedback sessions, each subject’s anxiety responses were assessed. The neurofeedback group showed a lessening of anxiety, but the sham group did not. Following the treatment, neurofeedback subjects also demonstrated an improved ability to control their OFCs compared to the sham group.

These results are of course exciting, but more work is needed to tell if anxiety regulation and changes in brain circuitry can be maintained over longer time spans. In order for rt-fMRI to be a truly promising, long-term treatment for OCD, patients must be able to carry what they learn in the lab into the real world.
Subjects in the Yale study underwent an assessment before and after training by resting state, or rs-fMRI, which examines brain connectivity by detecting areas of the brain that activate synchronously.

Connectivity, which is exhibited even in a resting brain, indicates that two brain areas have a tendency to work in tandem. This phenomenon is an active area of study for neurobiologists today.

Between the initial and final rs-fMRI tests, researchers noted several startling changes in their subjects’ brain connectivity. First, in all subjects who underwent real neurofeedback therapy, there was a significant decrease in the connectivity of regions in the brain associated with emotional generation and processing, but an increase in connectivity of regions in charge of the regulation and control of emotion. These people, once victims of exaggerated emotional reactivity, were now better able to regulate their emotions with the help of an experimental neurofeedback intervention.

Secondly, subjects who saw a marked decrease in anxiety symptoms also showed a global decrease in connectivity between the OFC and the rest of the brain. Strong coupling between the OFC and other brain regions has long been associated with OCD. According to Hampson, perhaps too much coupling causes overstimulation of the OFC, increasing anxiety to unbearable heights. “Anxiety levels could be higher because you’re always tapping into this anxiety circuitry, which is triggered by and linked to a lot of different things,” Hampson said.

Neurofeedback treatment offers an escape from this cycle, a way for patients to rewire their own brain circuitry.

A less anxious future

Though strides have certainly been made in understanding OCD, a complete model of its causes and symptoms has yet to be formalized. Without a strong consensus from the medical and research communities, effective treatments for OCD will remain out of reach. Most patients currently diagnosed with the anxiety disorder rely on a system of trial and error for treatment, experimenting with psychiatric drugs and other therapies that offer limited or no symptom relief for many individuals. Many patients still await a reliable treatment for their disorder. With strong supporting results from the recent Yale study, rt-fMRI neurofeedback may be part of the long sought-after breakthrough in combatting OCD.


Neutral image used in visual display and arrow pointing to the right, indicating to patients that they should maintain state of OFC. The time course of activity in the orbitofrontal cortex is shown below the neutral image.
Neutral image used in visual display and arrow pointing to the right, indicating to patients that they should maintain state of OFC. The time course of activity in the orbitofrontal cortex is shown below the neutral image. Image courtesy of Prof. Hampson and her team.

Nevertheless, Hampson’s study is — more than anything — a stepping off point. The results show great promise for rt-fMRI neurofeedback treatment, but further research must be done on a larger subject pool with a greater number of OCD patients before any definitive conclusions are made.

Still, Hampson is hopeful that neurofeedback will help sufferers of OCD, and that it will perhaps help patients with other anxiety disorders as well. She is collaborating with researchers at the Veterans Administration to investigate the application of rt-fMRI feedback for treating post traumatic stress disorder, or PTSD.

Neurofeedback presents a scaffold for personalized medicine — what better way to take charge of your own treatment than to peer into your own brain? The intervention at the center of Hampson’s study serves as a scaffold on which patients can practice individualized strategies for unlearning anxiety. The same plasticity that allows for the onset of an anxiety disorder may present the perfect opportunity for a lasting OCD treatment.

About the author: Marguerite Epstein-Martin is a junior Physics major in Saybrook college.
Acknowledgements: This author would like to thank Prof. Hampson for her time, energy, and unabated enthusiasm throughout the writing process.

More to Read:
Hampson, Michelle, Teodora Stoica, John Saksa, Dustin Scheinost, Maolin Qiu, Jitendra Bhawnani, Christopher Pittenger, Xenophon Papademetris, and Todd Constable. “Real-time fMRI biofeedback targeting the orbitofrontal cortex for contamination anxiety.” Journal of visualized experiments: JoVE 59 (2012).

Scheinost, Dustin, Teodora Stoica, Suzanne Wasylink, Patricia Gruner, John Saksa, Christopher Pittenger, and Michelle Hampson. “Resting state functional connectivity predicts neurofeedback response.” Frontiers in behavioral neuroscience 8 (2014).

Scheinost, D., T. Stoica, J. Saksa, X. Papademetris, R. T. Constable, C. Pittenger, and M. Hampson. “Orbitofrontal cortex neurofeedback produces lasting changes in contamination anxiety and resting-state connectivity.”Translational psychiatry 3, no. 4 (2013): e250.

Christopher deCharms, R., Kalina Christoff, Gary H. Glover, John M. Pauly, Susan Whitfield, and John DE Gabrieli. “Learned regulation of spatially localized brain activation using real-time fMRI.” Neuroimage 21, no. 1 (2004): 436-443.