Categorised as Obsessive Compulsive Disorder and Related Disorders (OCD&RD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Obsessive Compulsive Disorder (OCD) is the fourth most prevalent psychiatric illness and causes a tenth of all disability cases worldwide (Association, 2013; Ferreira et al., 2019). A pattern of recurrent thoughts, known as obsessions or ruminations, accompanied by high anxiety is a defining feature of OCD, which often leads to compulsion -repetitive behaviours or mental acts aimed at alleviating anxiety- also called rituals (Ferreira et al., 2019).
Neurophysiologically, anxiety symptoms in patients with OCD are associated with an overactive orbitofrontal-striatal circuit, anterior cingulate, and thalamus, which present as dysregulated autonomic nervous system, resulting in increased heart rate, elevated skin electrodermal activity, and augmented breathing rate (Seibell & Hollander, 2014). Psychologically, patients with OCD suffer from dysregulation in data processing and display marked distress when making value-based judgments, seeking extra information to make choices, which outwardly manifests as indecisiveness, doubt, and behavioural inflexibility, which, coupled with behavioural inflexibility, shapes a neuro-cognitive endophenotype of OCD (Cheon et al., 2015).
The primary treatments for OCD&RD are cognitive-behavioural therapy (CBT) and antidepressants; however, these interventions only provide symptomatic remission to a limited number of patients, with other patients requiring alternative therapies, one of which is biofeedback (Ferreira et al., 2019; Seibell & Hollander, 2014). Biofeedback, as a general term, involves inhibiting excessive or reinforcing impaired physiological signals, which aim to teach the patient to regulate their emotions, thoughts, or behaviours in response to specific stimuli, helping patients manage their symptoms (Ferreira et al., 2019; Schoenberg & David, 2014). In the case of psychiatric disorders such as anxiety, depression, and schizophrenia, biofeedback is applied with a specific type of feedback from neural activity in target brain regions, i.e., neurofeedback (Schoenberg & David, 2014).
Initially, neurofeedback was described as a method in which specific frequency bands of the electroencephalograph (EEG) are used to select operant brainwave frequencies by giving real-time audio and/or visual feedback cues (J.H. Begemann et al., 2016; Micoulaud-Franchi et al., 2015a). Because the technique is non-invasive and side effects such as headache or fatigue due to attentional demands are minimal, EEG neurofeedback is generally considered a viable alternative, nonmedical treatment option.
Consistent patterns of OCD-related activity have been identified through quantitative EEG (qEEG) of patients OCD, with some showing an excess of alpha brain waves across most regions of the brain and other increased theta activity, primarily in frontal and posterior temporal areas (Hammond, 2005) .Clinical experiences from qEEG assessments of patients with OCD have demonstrated excess beta activity in the midline and cortical areas located approximately over the anterior cingulate, based on clinical experience (Hammond, 2005). Using fMRI as an alternative to EEG, the effectiveness of neurofeedback was demonstrated by showing that patients learned to modulate brain regions (the anterior insula and orbitofrontal cortex) through which later studies have suggested reductions in rumination and anxiety, which has demonstrated a superior effect compared with sham neurofeedback (false feedback signal used as placebo) with similar effectiveness to medication, particularly in reducing compulsion (J.H. Begemann et al., 2016; Micoulaud-Franchi et al., 2015a).
Rationale and Objectives
Rumination generally refers to passive thinking about the causes and consequences of problems without taking proactive steps to resolve the source of the problem, an approach that only exacerbates anxiety and often precedes and potentially fuels obsessive-compulsive behaviour. Cognitive Avoidance (CA) — defined as the tendency to repress unwanted thoughts and avoid disturbing thoughts/images — has been argued to be a principal component of anxiety-related conditions by acting as a mediator of rumination and has been illustrated to be a crucial mechanism in OCD. The strategy of avoiding upsetting internal events, including obsessive thoughts, often leads to excessive cognitive loads and is associated with disruptions in the processing of multiple cortical and subcortical regions, which have been demonstrated to be a significant predictor of autonomic neural responses to threats. This results in brief moments of reduced fear and anxiety, which subsequently give way to further rumination and worry.
While the number of treatment sessions in qEEG-assisted neurofeedback is limited, and the effects are short-lasting in the initial sessions, the changes become more permanent as the brain learns to self-regulate, similar to how skills are learned and habits are shaped. Previous studies on the underlying psychological mechanism of neurofeedback’s effectiveness on OCD have illustrated that rumination is one of the key predictors of anxiety, which is reduced through treatment sessions. Considering the cyclical interaction between rumination — which might better be conceptualised as disengagement or avoidance of one’s specific problems — and OCD symptoms, it can be valuable to assess changes in the severity of rumination and CA during neurofeedback treatment, providing a better understanding of the psychological underpinnings of OCD treatment using qEEG neurofeedback. Thus, the current study aimed to determine the effectiveness of qEEG-assisted neurofeedback on rumination and cognitive avoidance in patients with OCD.