Cognitive training for neurocognitive and functional impairments in obsessive compulsive disorder: A case report

Journal Pre-proof Cognitive training for neurocognitive and functional impairments in obsessive compulsive disorder: A case report Himani Kashyap, Puneeth Reddy, Surekha Mandadi, Janardhanan C. Narayanaswamy, Paulomi M. Sudhir, Y.C. Janardhan Reddy PII:

S2211-3649(19)30088-0

DOI:

https://doi.org/10.1016/j.jocrd.2019.100480

Reference:

JOCRD 100480

To appear in:

Journal of Obsessive-Compulsive and Related Disorders

Received Date: 7 May 2019 Revised Date:

27 August 2019

Accepted Date: 16 September 2019

Please cite this article as: Kashyap H., Reddy P., Mandadi S., Narayanaswamy J.C., Sudhir P.M. & Reddy Y.C.J., Cognitive training for neurocognitive and functional impairments in obsessive compulsive disorder: A case report, Journal of Obsessive-Compulsive and Related Disorders (2019), doi: https:// doi.org/10.1016/j.jocrd.2019.100480. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.

Cognitive training for neurocognitive and functional impairments in obsessive compulsive disorder: a case report Himani Kashyap1, Puneeth Reddy2, Surekha Mandadi3, Janardhanan C Narayanaswamy4, Paulomi M. Sudhir1, Y. C. Janardhan Reddy4 1 - Department of Clinical Psychology, National Institute of Mental Health And Neurosciences, India 2 – Gutermann Technologies 3 – Cloud based Solutions 4 - Obsessive Compulsive Disorder Clinic, Department of Psychiatry, National Institute of Mental Health And Neurosciences, India

Address for correspondence: Dr. Himani Kashyap, Assistant Professor, Department of Clinical Psychology, Level 3, MVG Building, National Institute of Mental Health And NeuroSciences (NIMHANS), Bengaluru 560029, Karnataka, India Email: [email protected] Ph: 91-80-26995941 Manuscript word count: 4017 Abstract word count: 200 Number of tables: 4 Number of figures: 1

Cognitive training for neurocognitive and functional impairments in obsessive compulsive disorder: a case report

Manuscript word count: 4244 Abstract word count: 200 Number of tables: 4 Number of figures: 1

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Abstract Obsessive-compulsive disorder (OCD) is associated with impairments in neurocognition, especially on executive functioning and visuospatial memory, which tend to persist despite clinical improvement. Impairments in social and occupational functioning are likely related to neurocognition but are rarely targeted by existing treatments for OCD. Previous studies of cognitive training in OCD have been limited by narrow transfer of effects. We report a case of an individual referred for cognitive training in view of persisting cognitive and functional difficulties despite clinical improvement. The intervention consisted of therapist-guided sessions along with homework practice. A smartphone application was developed for cognitive stimulation, and used with other techniques for cognitive stimulation, strategy use, and generalization to achieve transfer of effects. Following 12 weeks of intervention, changes were observed on executive functions including verbal fluency and planning, and smaller changes across measures of attention and working memory. Notably, there was simultaneous reduction on severity of anxiety, depression, and obsessive-compulsive symptoms. Further, there was improvement in subjectively perceived cognitive difficulties as well as work, family and social functioning. The cognitive training intervention has promising implications for individuals with OCD with persisting cognitive and functional impairments despite clinical improvement.

Keywords: cognitive training; cognitive remediation; obsessive compulsive disorder; functional impairment

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Theoretical and Research Basis for the Treatment Neurocognitive deficits, in particular in the domain of executive functions and non-verbal memory are well-established in obsessive compulsive disorder (OCD) (Kashyap, Kumar, Kandavel, & Reddy, 2013; Snyder et al., 2016). These deficits are known to be trait-like, precede symptom onset, and persist in remission (Menzies et al., 2007; Rao, Reddy, Kumar, Kandavel, & Chandrashekar, 2008). Research has highlighted the importance of neurocognitive functioning in predicting OCD outcomes. For example, certain aspects of executive functioning have been shown to predict poorer treatment outcome, for cognitive-behaviour therapy (Flessner et al., 2010), pharmacotherapy (Cavedini, 2009), or both (McNamara et al., 2014). However, there is limited literature on the relationship between neurocognitive and functional difficulties, and role of cognitive remediation in improving functional outcomes in persons with OCD, unlike in depression (Bain & Stroud, 2015; McIntyre et al., 2015; Woo, Rosenblat, Kakar, Bahk, & McIntyre, 2016); and schizophrenia (Aghotor, Pfueller, Moritz, Weisbrod, & Roesch-Ely, 2010; Fett et al., 2011; Twamley, Jeste, & Bellack, 2003). Cognitive training has shown significant outcomes in schizophrenia in the form of alterations on fMRI, durable changes maintained over time, and improved social and functional outcomes (Patel et al., 2010; Wykes, Reeder, Corner, Williams, & Everitt, 1999; Wykes et al., 2003, 2002). As in other psychiatric disorders, it is crucial that the cognitive dysfunction be addressed through specific interventions to achieve full functional recovery in OCD. At present, there are no established treatment protocols for cognitive training / remediation in OCD; to the best of our knowledge, there are only a handful of published efforts. In the first study (Buhlmann et al., 2006), a single-session training on improving organizational strategies resulted in better organization scores on the Rey Complex Figure, and although recall showed some improvements, the main effects of training were not evident. In the second study (Park et al., 2006), pre-post assessments following training on organizational strategies and problem solving showed statistically significant improvements in the treatment group compared to controls on non-verbal memory, but no evidence of transfer of training to the task of verbal memory. The treatment group showed significant reductions on the Yale-Brown Obsessive Compulsive Scale (YBOCS), which were attributed by the authors to improved organizational strategies following problem-solving training. 3

Another study (Calkins & Otto, 2013) investigated the effect of a three-session computerised cognitive control training intervention (CCT) on obsessive-compulsive symptoms in a community sample randomized to either CCT or a computerised control task. Although decreses in negative affect were found for the CCT group, the obsessive-compulsive scores did not differ significantly between groups post-intervention. Other ongoing efforts include a published protocol for a recently initiated study in OCD (van Passel et al., 2016) which is reportedly based on a program developed for anorexia nervosa (Tchanturia, Davies, & Campbell, 2007) with a focus on set shifting and central coherence, as a method to enhance cognitive flexibility and holistic rather than detailoriented attention. Further, previous studies have a predominant focus on drill-and-practice approaches which do not demonstrate much evidence (Tate et al., 2014), and a lack of transfer and generalization techniques (Harvey & Bowie, 2012). Frequently noted impairments in OCD include response inhibition, cognitive flexibility and nonverbal memory (Chamberlain et al., 2007; Kashyap et al., 2013; Penadés, Catalán, Andrés, Salamero, & Gastó, 2005; Rao et al., 2008; Savage et al., 2000; Viswanath, Janardhan Reddy, Kumar, Kandavel, & Chandrashekar, 2009). Performance on these tasks requires overcoming habitual responses, correcting errors, storage and manipulation of information in working memory, strategy use, and adjustments of behavior in line with goals – which by definition are essential components of cognitive control (Crone, Ridderinkhof, Nieuwenhuis, & Ullsperger, 2004; MacDonald, Cohen, Stenger, & Carter, 2000). Some neuroimaging studies have also provided evidence for cognitive control difficulties in OCD (Cocchi et al., 2012). In view of the above, it has been hypothesised that the core deficit in OCD is not of a single domain, but a broader difficulty with executive control of lower-order cognitive abilities (Kashyap et al., 2013; Snyder et al., 2016), otherwise referred to as cognitive control. Cognitive control deficits are likely to underpin many aspects of neurocognitive and everyday functioning, and in such a case, it appears that the domains targeted in existing OCD interventions (organisational strategies / setshifting / problem solving) may be too narrow to achieve transfer to everyday life. It has been suggested that the oft-reported problem of narrow transfer in cognitive training (Owen et al., 2010) could be attributed to training being content/stimulus-specific, whereas process-specific training is associated with improvement on untrained tasks and domains (Slagter, Davidson, & Lutz, 2011). Cognitive control has been proposed to be particularly amenable to process-specific training, as the processes are fundamental to higher cognitive 4

processes (Slagter et al., 2011). Several factors have been proposed as critical to process-specific learning, including complexity of the training setting, task variability and difficulty, training of core cognitive processes including focusing and switching abilities, and metacognitive monitoring (Slagter et al., 2011). Further, the use of techniques for metacognitive strategy training, enhancing self-awareness, and generalization is emphasized as a ‘practice standard’ in evidence-based recommendations of cognitive training (Cicerone et al., 2011; Tate et al., 2014). In this context, we report a case study of cognitive training intervention for OCD, with a focus on training core processes involved in cognitive control. It is expected that enhancement of cognitive control may result in transfer of effects to other neurocognitive, as well as functional domains.

Case Introduction The participant was a 29-year-old male with 14-years of OCD. He was evaluated using the MINI (David V. Sheehan et al., 1998) and the diagnosis of OCD was confirmed by an experienced clinician (YCJR) after reviewing all the available information. He had no other comorbid conditions as per the MINI. His main symptoms were in the domains of harm, scrupulosity and somatic preoccupation, with checking and reassurance seeking compulsions. Clinically, he had reported significant improvement, and had been stable for the previous four months (YBOCS score obsessions 9, compulsions 7, total 16) on a combination of medications (Fluoxetine 60 mg, Quetiapine 200mg and Clonazepam 1mg) and cognitive-behavior therapy (20 sessions, completed). Due to subjective report of significant problems in attention and concentration and resultant poor performance at work, he was referred by the clinical team for intervention. He described himself as an academic topper until onset of symptoms at age 15, but had with difficulty graduated as a software engineer and obtained employment. Persisting attentional difficulties (due to mind-wandering and ruminations) and resultant slowness and inefficiency (often staying late into the night at work, but unable to meet deadlines) had resulted in two job losses; he had been unemployed for 3 months, and was living in rented accommodation on his savings (his family lived in another state). There were no treatment changes during the course of intervention. Assessments 5

Initial assessments consisted of the Structured Clinical Interview for DSM-5 (SCID-5;(First, 2014)), the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; (Goodman et al., 1989)), the Hamilton Anxiety Rating Scale (Hamilton, 1959) and the Montgomery-Asberg Depression Rating Scale (MADRS; (Montgomery & Asberg, 1979)). We assessed metacognitions, perceived cognition and functionality pre- and post-intervention using the Metacognitions Questionnaire (MCQ 30; (Wells & Cartwright-Hatton, 2004)), the Perceived Deficits Questionnaire (Fehnel et al., 2013), and the Sheehan Disability Scale (Dv Sheehan, Harnett, Sheehan, & Raj, 1983). The neurocognitive assessments included - Wechsler Digit Span and Spatial Span for attention and working memory (Gurappa, 2009); Colour Trails Test for cognitive flexibility (D’Elia, Satz, Uchiyama & White, 1996); Wechsler Block Design for intelligence (Wechsler, 2011); Controlled Oral Word Association and Animal Names Test for verbal fluency (Spreen & Strauss, 1998); Behavioural Assessment of Dysexecutive Syndrome (BADS) Zoo Map Test and Rule Shift Cards respectively for planning and set shifting (Wilson, Alderman, Burgess, Emslie, & Evans, 2003); Rey Complex Figure Test (Meyers & Meyers, 1995) and Auditory Verbal Learning Test (Maj et al., 1994) for memory.

Case conceptualization Given the patient’s significant attentional difficulties contributing to poor occupational functioning in daily life, and the literature pointing towards broad difficulties in executive control of lower-order abilities in OCD (Kashyap et al., 2013; Snyder et al., 2016), an intervention focusing on cognitive control was conceptualized. Cognitive control includes processes common to many tasks, such as monitoring of ongoing actions and performance outcomes, adjustments of behavior in line with goals, modulation of attention, overcoming habitual responses, and correcting errors (MacDonald et al., 2000). The focus in the current study was on process rather than content of training, with considerations relating to core cognitive processes, complexity and variability of tasks, integration of mindfulness techniques, strategic monitoring, and generalization to everyday life (Cicerone et al., 2011; Harvey & Bowie, 2012; Slagter et al., 2011; Tate et al., 2014).

Course of Treatment and Assessment of Progress 6

The cognitive training program included once-weekly therapist-guided and additional homework sessions over two months, and a further four therapist-guided booster sessions following a twomonth break as the client had to travel inter-state to attend to a family crisis. The postintervention assessment was done at the end of five months. The initial intervention sessions (weeks 2-7) focused on feedback of assessments, education about cognition, mindfulness practice, and cognitive stimulation using exercises. As part of the training, a smartphone application named CogTrain for visuospatial working memory was developed. This was done following a review of the literature regarding the neurocognitive deficits in OCD, games used for cognitive training, and commercially available brain training applications. Based on the task requirements of cognitive control including focused attention, working memory load, inhibitory control for irrelevant information, strategy use for problem solving, and progressive difficulty levels, several potential tasks were generated through brainstorming, and discussed for gamification with game designers. Criteria for increasing levels of difficulty, positive and negative scores, success/failure, and progression through the levels were defined. The app was developed using the libgdx platform which allowed development of the application and deployment on multiple platforms like Android, iOS and browser. Android studio was used as a development environment, and the algorithm/ user interface was written in Java. The game (single-player) involved windows glowing briefly on a house front and/or side, with the user required to tap the windows in the order in which they had been lit up. Progressive difficulty levels relating to speed (of lights glowing on and off) and span length (number of windows glowing) could be pre-set by the user/therapist. After each trial, verbal feedback as well as a change on the scoreboard (5 points for every correct trial) appeared on screen. Each game ended when the user achieved a score of 100 with a summary of time spent, and number of successful attempts (depending on length of sequence and player performance, approximately 3-7 minutes might be required to achieve a score of 100). The task was designed such that once 60% success was achieved, the user would move up to the next span length, else, would remain at the previous level of difficulty in order to reduce frustration and allow gaining of points. To elaborate, if the user did not get a sequence correct, it was repeated for three attempts, before moving on to a different sequence of same length. In a 7-window sequence, if the player did not get a minimum 3 out of 5 sequences correct, the game would return to the previous span of 6 windows). Figure 1 shows a screenshot of the application. 7

Although it was originally planned that the smartphone application would include several games with progressive difficulty levels, this was not possible at this stage due to available time and funds. Hence the cognitive training program included CogTrain along with additional tasks and games in a face-to-face performance format. The tasks chosen were broadly relating to cognitive control processes, involving focused attention, working memory load, monitoring current states and goal states, planning moves, adapting behavior to changing rules, and flexibly shifting attention to several aspects of the task. Some tasks were selected from popular games of strategy, and others were developed for the program. Since some of the popular games were also available as free smartphone applications, they were curated for the client to use for homework practice. The smartphone applications were chosen after careful review and trial runs to ensure the games ran smoothly. In each session, a record was maintained of scores and time, along with strategies used, and difficulties faced. While the client was asked to spend not more than about 30 minutes in total on the apps each day (in order to minimise the risk of technology abuse), he was encouraged to gradually increase other tasks relevant to his occupation such as reading, watching instructional videos, and writing programs, upto the duration of a usual workday, i.e., 6-8 hours. A description of the tasks follows: Mental counting (addition and subtraction) of two parallel piles of cards (requiring working memory and set shifting) with progressive levels of difficulty. Brainvita (available as ‘Peg Solitaire’ app, single-player) - a game of eliminating marbles on a tray based on certain rules ; requires sustained attention, planning of moves, working memory, learning, applying and shifting strategy. Connect 4 (available as ‘4 in a row King’ app, two-player) - getting four disks in a row while blocking opponent moves ; requires focused attention, planning moves, attention to opponent moves, strategy use. Sudoku (available as ‘Learning Sudoku’ app, single-player) -completing a grid of numbers based on certain rules; requires sustained attention, working memory, strategy use. From week 5 onwards, there was increasing focus on awareness and monitoring of one’s cognitive processes, use of strategies, and shifting set flexibly to maximize performance.

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Generalization was achieved through ongoing discussion, role plays, and practice of real-world tasks, in line with practice standards for cognitive training. The details of the sessions are provided in Table 1.

INSERT TABLE 1 ABOUT HERE

Clinically significant changes were calculated based on pre- and post-intervention data (Blanchard and Schwarz, 1988) to assess the efficacy of the intervention. The formula used was Pre score – post score x 100 Pre score

His scores on other clinical measures pre- and post-intervention are noted in Table 2.

INSERT TABLE 2 ABOUT HERE

The changes from pre- to post-intervention across raw scores on neurocognitive domains are summarized in Table 3. It is evident that there were improvements on most neurocognitive domains from pre- to post-intervention, except for Block Design, Colour Trails Time 1, COWAT, and Rule Shift. INSERT TABLES 3 AND 4 ABOUT HERE

The client’s feedback regarding the intervention summarizes the components he found helpful – “When I first came, I could not focus for even a few minutes. I could not even read and understand mobile game instructions. My thoughts would keep wandering at work, even during an interview, or when I went for a walk, or watched TV. But if I played a difficult game of sudoku 9

in the morning it made me calm, focused - after that I could actually read for some time. Mindfulness helped me to anchor my thoughts, to bring my mind back to the task. I stopped worrying about my thoughts, because I understood thoughts are natural, and just started focusing on what I am doing. I began to read and watch videos on many subjects online. I realized there are so many ways of earning money, I don’t have to be employed in an office. Now I think, if this doesn’t work, it’s ok, I’ll try something else – it’s a roadblock, not a dead-end. In the past I used to take someone shopping with me because even choosing a t-shirt was too hard. Now when I have to take a decision, my mind feels clear, I can see the paths forward very clearly.” Prior to the intervention, he did not routinely play videogames, and had never practiced mindfulness. Table 4 shows sample game scores on one of the games used for training. Through therapist-aided game play focused on metacognitive awareness and monitoring as well as mindfulness practice, he was assisted in ‘tuning in’ to natural fluctuations in attention, awareness of mind-wandering, ignoring task-irrelevant information, redirecting attention to task, recognition of strategies used, difficulties faced, and strategy planning for future. The Pomodoro technique (Cirillo, 2006) for effectively using short bursts of attention was used. By the 8th week, he was able to study and prepare for interviews for 2-4 hours with breaks. As his awareness of his own attention improved, in his daily schedule he was able to utilize his ‘peak’ times of focus, relax during periods of reduced concentration, and expressed confidence about his ability to redirect attention to task when required. Importantly, the client, who had been unemployed for close to six months, had, by the end of the training program, started a web services consultancy on his own, and was able to work upto 6 hours a day.

Treatment implications Following a cognitive training program consisting of 12 weekly therapist-guided sessions along with homework practice, changes were observed in relation to baseline on executive functions including verbal fluency and planning, and smaller changes observed across measures of attention and working memory. Notably, there were reductions on severity of anxiety, depression, and obsessive-compulsive symptoms as compared to baseline. Furthermore, there were reductions on subjectively perceived cognitive difficulties, as well as improved 10

functionality across work, family and social domains. Importantly, the client initiated selfemployment after nearly 6 months of unemployment. A long-standing criticism for cognitive training interventions has been the lack of transfer effects to untrained tasks, even when tasks are cognitively closely related (Owen et al., 2010). Extensive reviews have attempted to identify the components of cognitive remediation with the most robust evidence. Lauenroth et al (2016) in a review recommended that 1 to 3 hours of weekly training for 12 to 16 weeks (or more) is more likely to lead to detectable improvements in cognitive performance than other training schemes, with a minimum being 10 hours of training. Further, training in metacognitive strategies and transfer/generalization techniques have been proposed as crucial elements of training (Harvey & Bowie, 2012) and recommended as ‘practice standards’ for attention and executive functions training (Cicerone et al., 2011; Tate et al., 2014). In line with these recommendations, the current study included 3 hours of training per week across 12 weeks, with a combination of cognitive exercises for stimulation; training in identification, selection and modification of strategies; and techniques for generalization to everyday life. It has been hypothesized that factors contributing to transfer of training to untrained domains include task variability and difficulty; training of core cognitive processes including focusing and switching abilities; and metacognitive monitoring (Slagter et al., 2011). The latter two capture the essence of cognitive control processes which were the foci in the current program, i.e., the monitoring of ongoing actions and goals, inhibition of task-irrelevant information, shifting mental set, and flexible adjustments of behaviour in line with goals (Crone et al., 2004; MacDonald et al., 2000). This was attempted in the study through enhancing focused attention and working memory capacity via mindfulness practice and graded difficulty levels on games, monitoring of attention and strategy use, and enhancing ability to redirect attention to task through metacognitive awareness and application to everyday situations. It appears that our client benefited most from improved focussed attention through the use of difficult games and mindfulness, better awareness of mind-wandering, use of short bursts of attention to resume focus on task, and ability to shift strategy when stuck on a task. This also seemed to enhance his self-efficacy and reduce catastrophizing about rumination. It has also been recommended that cognitive training should involve tasks which are adequately challenging to provoke effortful thinking (Lauenroth et al., 2016). From the client’s feedback, the most challenging tasks were the

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ones that helped him reduce ruminative thinking and enhance task focus. This is in line with the finding that individuals with high anxiety show increased attention control, under conditions of high cognitive load (Najmi, Amir, Frosio, & Ayers, 2015). Further, the client’s emphasis on ‘awareness of mind-wandering’ highlights an important aspect of the training, i.e., the use of mindfulness and metacognitive strategy training. Recommendations based on the highest level of evidence, i.e., practice standard, are for approaches involving strategy training (Cicerone et al., 2011; Tate et al., 2014). Bowie and colleagues (Harvey & Bowie, 2012) have suggested a three-pronged approach to cognitive training including cognitive activation, metacognitive strategy training, and generalization / transfer. Several studies have demonstrated that mindfulness enhances cognitive control (Li, Liu, Zhang, Liu, & Wei, 2018) and is an excellent example for process-specific training producing broad-level transfer to untrained tasks and domains (Slagter et al, 2011). Mindfulness in itself is known to produce improvements in sustained attention and working memory in some, but not all reviewed studies, although most studies are on healthy participants (Chiesa, Calati, & Serretti, 2011). It may be argued that mindfulness alone may produce changes in cognitive control. Furthermore, cognitive behaviour therapy (CBT) for OCD has also been associated with improvements in nonverbal memory encoding (Kuelz et al., 2006), and set-shifting and verbal fluency (Bolton, Raven, Madronal-Luque, & Marks, 2000), although the latter were not correlated with improvements in anxiety, depression or YBOCS scores; and other studies have showed that improvements are not significant after controlling for practice effects (Vandborg, Hartmann, Bennedsen, Pedersen, & Thomsen, 2015). While CBT may have produced some neurocognitive changes which were not documented pre-post in this case, our client had already undergone approximately 20 sessions of CBT, but had continued to complain of significant cognitive and functional impairments. Other studies have used combined mindfulness and goal management training and shown improvements on measures of working memory, response inhibition, and decision-making, in comparison to standard psychotherapeutic intervention in abstinent polysubstance users (Alfonso, Caracuel, Delgado-Pastor, & Verdejo-García, 2011). The effects of CBT and mindfulness in comparison to the current intervention cannot be satisfactorily answered in a single case report, and require further investigation with a control group.

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We postulate that a combination of mindfulness, cognitive stimulation, metacognitive monitoring, and generalization techniques is critical to facilitate neurocognitive and functional improvements in individuals with OCD. While more data is needed to understand the mechanism of action, we propose that the combination of mindfulness practice and cognitive stimulation through games enhances (i) sustained attention, (ii) focused attention, and (iii) working memory to optimum capacity; (iv) assists with training in strategy monitoring and modification - to increase awareness of effective strategies, and to shift mental set when stuck; generalization techniques such as role plays and real-world practice may be critical to bridge the gap and facilitate transfer in order to reduce functional impairments. This may be particularly important in individuals with impaired cognitive control such as those diagnosed with a psychiatric disorder.

Conclusion and recommendations Our client had been stable on treatment for approximately 4 months prior to the current intervention, with persistent cognitive and functional impairments. The parallel improvements on neurocognitive, functional and clinical measures following the intervention provides some preliminary evidence for this training program, including transfer of training effects to everyday life, a significant issue in studies of cognitive training. Cognitive control training may enhance one’s ability to defocus from irrelevant information (including obsessions) and enhance task focus, and hence everyday functioning. The cognitive training intervention tested in this study has significant implications for individuals with OCD who often continue to demonstrate cognitive and functional impairments despite clinical improvement. One potential limitation of the study is the use of commercially available games and applications along with the other exercises and techniques. Nevertheless, it represented an economical and easily accessible solution to the problem of homework practice, since only a single smartphone game could be developed as part of the study. Another limitation is the possibility of practice effects on repeat testing, however the literature indicates that improvements in performance due to practice effects are prominent with high-frequency (e.g., weekly or fortnightly) testing in the initial phase, and plateau off beyond three months (Bartels et al., 2010). Further, obsessivecompulsive symptoms were only assessed at two time points in this study; a mid-term 13

assessment may have shed light on the course of the symptoms during the intervention. Also, functioning was not formally assessed in this study using methods such as the International Classification of Functioning, Disability and Health (ICF). Furthermore, the premise of the study is that cognitive stimulation through the use of tasks and games is only one component of the training, and may be used mainly to enhance attention and working memory processes. It is suggested that critical aspects of the training may comprise training in the broad ability to regulate lower-order functions, including sustaining, shifting and modulating attention; facilitating metacognitive reflection on strategy selection, modification and use; and generalization to everyday tasks in the individual’s life. The relative utility of different components of the program, as well as comparison to other interventions, needs to be examined in future with control groups. While the single case design has generated encouraging results, efforts are ongoing to test the intervention on a larger sample (particularly with different subtypes of OCD, as this individual was ‘predominantly obsessional’), to establish the efficacy of the intervention. The study participant was not severely symptomatic; our report shows that the intervention may be suitable for individuals with mild / remitted OCD who report persisting cognitive and functional difficulties. We are not sure if a similar strategy would be effective in individuals with severe and distressing OCD as symptoms may potentially hinder patients’ ability and motivation to participate and benefit from this type of intervention. Future studies may test the intervention in both symptomatic and remitted individuals with cognitive difficulties.

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21

Figure 1 – screenshot of the application showing player response by tapping the windows in the order in which they lit up

Table 1 – Details of intervention sessions

Week

Tasks

Postulated Mechanisms

Issues addressed and outcomes

1

------- Baseline assessments ---------

2

Feedback of assessment; model of cognitive control Understanding of cognitive Client’s discomfort with continuous thoughts validated. control.

(TG).

Significant reassurance seeking addressed.

Mindfulness practice including sitting meditation and Enhanced

3-7

colouring (TG & HW; 3-7 mins)

attention.

Discussion of attention and cognitive control (TG).

Enhanced

Tasks including Mental counting, Brainvita/Peg Solitaire,

Connect4/4

in

a

row

King,

focused

focused

sustained

approximate total 20-30 minutes). Activity schedule including physical exercise (HW).

of

awareness

of

mind-wandering,

attention, expectations of success / failure on tasks, and impact

working memory.

Sudoku/Learning Sudoku, and CogTrain (TG & HW; Metacognitive

and Discussion

on performance. Generalization to work scenarios.

monitoring Reflection on successful / unsuccessful strategies in

of attention and strategy games and redirection when ‘stuck’. use.

Therapist redirection to defocus from anxiety while on task. Client found difficult levels of Sudoku improved focus. Began to use everyday.

Week

Tasks

Postulated Mechanisms

5-8

Mindfulness practice including activities of daily Enhanced

focused

living (ADLs) (approximately 20 minutes; TG & sustained

and Able to study 2-4 hours per day with short breaks.

attention,

working memory.

HW).

Continued difficult levels of Sudoku (HW; 5-10 Metacognitive minutes).

of

Graded reading tasks with metacognitive monitoring

Attended several job interviews -shortlisted, but not selected, leading to hopelessness. Concern about

monitoring unemployment, financial situation, parents’ ill-health

attention,

wandering,

Issues addressed and outcomes

and

mind- and disability validated. strategy

(HW); preparation for job interviews (TG roleplays use. & HW).

Generalization to routine tasks.

-------- Break for client to attend to family crisis ---------

9-17

18 -21 Problem solving training for everyday life (TG & Enhanced awareness.

HW). Discussion

metacognitive Client generated ideas for self-employment. Began a

of

decision

making,

worry

about Generalization

consequences, and perfectionism; normalization of variable rumination as ‘default mode’; anxiety about anxiety practice. (TG). Mindful ADLs (HW).

web services consultancy working from home 5-6 hrs through real-world

per day at his peak times.

Journaling for internalization of techniques (HW). 22

-------- Post-intervention assessment ---------

Note: Therapist Guided – TG; Homework – HW

Table 2 – Pre- and post-intervention clinical measures Measure

Pre-intervention score Post-intervention score Change score

YBOCS

16

7

56.25

HAM-A

29

6

79.31

MADRS

19

3

84.21

MCQ

95

68

28.42

PDQ

40

15

62.5

SDS- work

10

1

90

SDS - social

10

4

60

SDS- family

6

2

66.67

SDS - total

26

7

73.08

SDS – days lost

7

0

100

SDS – days unproductive

7

0

100

Note: YBOCS: Yale Brown Obsessive Compulsive Scale; HAM-A: Hamilton Anxiety Scale; MADRS: Montgomery-Asberg Depression Rating Scale; MCQ: Metacognitions Questionnaire total score; PDQ: Perceived Deficits Questionnaire total score; SDS: Sheehan Disability Scale

Table 3 – pre- and post-intervention neuropsychological measures

Test

Variable

Pre-intervention

Post-intervention

Raw scores

Raw scores

(percentile scores)

(percentile scores)

Change score (percentage)

Block Design

Total

20 (9)

20 (9)

0

Digit Span

Total

18 (60)

22 (80-85)

-22.22*

Spatial Span

Total

16 (25-30)

17 (40)

-6.25*

Colour Trails

Time 1

82 (11-14)

107 (8-11)

-30.49

Time 2

174 (3-5)

103 (68-70)

40.80

COWAT

Average

11 (50-60)

11 (50-60)

0

ANT

Total

6 (<5)

15 (70-75)

-150*

ZooMap

Total

1 (10)

3 (69)

-200*

Rule Shift

Total

4 (71)

4 (71)

0

AVLT

Total

59 (60)

62 (80-85)

-5.08*

13 (50-60)

14 (70-80)

-7.69*

Delayed Recall

12 (25-40)

14 (75-80)

-16.67*

Copy

35 (10)

36 (15-95)

-2.86*

20 (10-15)

29 (60)

-45*

22 (15)

28 (50-60)

-27.27*

Immediate Recall

CFT

Immediate Recall Delayed Recall

Note: Change score = (pre-post/pre)x100; * - higher scores on asterisked variables represent better performance, hence negative change scores are indicative of improvements from pre to post. COWAT – Controlled Oral word Association Test; ANT – Animal Names Test; AVLT – Auditory Verbal Learning Test; CFT – Complex Figure Test

Table 4 – sample game scores on Connect 4

Time till game

Win / lose

Interference*

Strategy monitoring

60

Lose

8/10

“I am not able to plan ahead”

90

Lose

8/10

“I made same mistakes”

347

Lose

8/10

“I was trying to block opponent, scanning the patterns”

48

Lose

7/10

“I had better focus this time”

117

Lose

8/10

“I’m not able to track opponent moves”

159

Lose

3/10

“I managed to block opponent for many moves”

245

Win

7/10

“I was planning my next move”

137

Lose

6/10

“I didn’t worry about win/lose”

end (seconds)

Week 5

Week 7

Note: * - 10=maximum interference from thoughts / anxiety

Highlights •

Neurocognitive deficits in OCD are broad-ranging, persistent, and impact functioning and treatment outcome.

•

Neurocognitive and functional deficits are not addressed by existing interventions for OCD.

•

A combination of techniques for cognitive stimulation, strategy monitoring, and generalisation to everyday life shows promise in reducing neurocognitive and functional impairments in a single case design.