Paul- before proceeding, I have to point out that the term "intractable" is  an illusional way of referring to an ineffective therapy - major source of the treatment difficulty is sloppy approach to research of brain biology- decades of advances in brain imaging confirm glitches in  brain systems that are implicated in OCD - most psychologists, social workers, counselors and others who practice psychotherapy have been content with shifting brain biology issues to medicine knows physicians - even undertake sometimes to encourage patients to comply with medication regimens- need to address the fact that  even the FDA  relies only on evidence that medications reduce the symptoms per DSM listings - no requirement to demonstrate corrections of brain impairments- I know of no evidence from any neuropharmaceutical that corrects defects in brain biology- We are all  aware, however, of the numerous examples of neurological damage like EPS and TD as well as serious endocrine disruptions- the only study I know that identifies brain pathology in mental illness, is the landmark project of Dr. Jeffrey Schwartz and his team in the UCLA  department of Psychiatry. They designed a psychotherapy protocol based on discoveries of neuroplasticity in the discipline of neuroscience-neuroplasticity refers to the process in which every learning experience includes biological brain changes. Part of therapy involved cognitive-behavioral methods for changing pathologies of thinking and behavior, which most psychotherapists will recognize.  (f)MRIs were applied to assess brain benefits .  Structures that were not doing what they are designed to do, were in overactive areas. Mindfulness skills ,along with other benefits, normalize activity levels. The resulting effects were that malfunctioning structures started working as designed.  Successful psychotherapy is always a learning experience - hundreds of studies of neuroplasticity confirm this phenomenon. A giant leap in the UCLA  project was designing a therapy where the brain changes came in the form of correcting defective functioning.  Highly recommend thew book describing the project- includes details of research references, which provides good update for modern advances in neuroscience

I'm also thinking that way in changes of structures and spots in the brain but more in function of pain and the change between acute pain to chronic pain

Possible are change in the brainstem responsible

Please Cf. harai.main.jp Here is some English papers as

Harai, H., Okajima, Miyo (2007). Termination with Japanese Clients. A Clinician’s Guide to the Theory and Practice of Termination in Psychotherapy. W. O'Donohue, Cucciare, Michael A. New York, Routledge.

DuPont, L. R., DuPont, C. M., Rice, D. P. (2002). . The American Psychiatric Publishing Textbook of Anxiety Disorders. D. J. Stein, Hollander, E. Washington. D.C., American Psychiatric Publishing. 不安障害，17章，35～37章　樋口 輝彦 (翻訳), 久保木富房 (翻訳), 貝谷 久宣 (翻訳), 坂野 雄二 (翻訳), 野村 忍 (翻訳), 不安抑うつ臨床研究会 (翻訳), ダン・J.スタイン, エリック・ホランダー 日本評論社.

Hays, S., C. (2005). Get out of your mind into your life. Oakland, New Harbringer.　〈あなた〉の人生をはじめるためのワークブック―「こころ」との新しいつきあい方アクセプタンス&コミットメント (単行本)　S.C.ヘイズ (著), S.スミス (著), 武藤 崇, 原井 宏明, 吉岡 昌子, 岡嶋 美代 　ブレーン出版　2008

Many thanks Kazoo, Paul

The article below may be a good place to start if you are interested in the neuro-physiology of OCD.  There has been much research since that time but this classic is what got me interested in clinical work with OCD patients.  My experience in the USA and in NZ is that many cases are considered intractable because patient's have not had access to quality cognitive behavioral therapy for this disorder.

All the best.

Baxter (1992)  Neuroimaging studies of OCD.  Psychiatric clinics of North America 15(4):871-. 

Hello Jon

Many  thanks for your interesting and important reflections, which I shall follow up. You provide a non-traditional but insightful directional focus. By that, I mean, there needs to be more focus on untreated, undertreated and wrongly treated OCD patients. I know that CBT is documented as an effective treatment. My very tentative hypothesis, however, is that CBT might not fully address the obsessive aspects of the disorder. Perhaps new medication and cautious surgery that modify communication messaging between the amygdala and associated structures might have something to offer here.

Best wishes Paul 

Paul - Appreciate your response.  I agree that CBT is not a utopia for all OCD patients and certainly there are some patient's that may benefit from the addition of neurosurgical or medical interventions.  It is probably important to keep in mind that behaviorally defined disorders such as OCD likely capture a range of neural pathologies so what is effective for one proportion of the population may not work for others.  My experience is that obsessive thinking patterns that are driven primarily by anxiety networks are amenable to behavioral interventions for the most part.  The thing I found fascinating about the Baxter review was that it references research that showed normalization of brain activation patterns with effective therapy - whether that was medication therapy or behavioral intervention.  Just another pointer to alert us to the fact that the brain is a very dynamic system and can be impacted by many therapeutic modalities.  Naturally there are limits to the extent of current therapeautics on the brain which probably results in the intractable cases that your question initially references.

Thank you once again, Jon. You clearly are an expert in this field. I was particularly interested in the normalization of brain activation patterns in the wake of effective therapy. That finding alone offers huge hope and might, one day, make the adjective "intractable" redundant. Professor Keith Matthews at Ninewells Hospital in Dundee, Scotland,  is one of the leading UK psychiatrists in the OCD field, and his team includes a neurosurgeon. Surgical interventions, however, are last resort and I think that a decision has been made not to continue with them except in very exceptional circumstances, notably, in research and with robust ethical protocols in place. All the best. Paul

At our clinic we have had some success with a combination of cymbalta and lithium carbonate for chronic OCD.

Edward, I will try the combination of cymbalta　and lithium carbonate.

Read books therapy might be helpful. And, of course most important is how we could tune with the patient’s agony and understand what is the problem now, to vibrate with patient’s wave.

Paul, have a look on the Researchgate profile of Damiaan Denys. He has interesting and partly good results with deep brain stimulation for intractable OCD patients. For instance: https://www.researchgate.net/publication/281552071_Effects_of_Deep_Brain_Stimulation_on_the_Lived_Experience_of_Obsessive-Compulsive_Disorder_Patients_In-Depth_Interviews_with_18_Patients

Article Effects of Deep Brain Stimulation on the Lived Experience of...

Paul, have a look on the Researchgate profile of Damiaan Denys. He has interesting and partly good results with deep brain stimulation for intractable OCD patients. For instance: https://www.researchgate.net/publication/281552071_Effects_of_Deep_Brain_Stimulation_on_the_Lived_Experience_of_Obsessive-Compulsive_Disorder_Patients_In-Depth_Interviews_with_18_Patients

Article Effects of Deep Brain Stimulation on the Lived Experience of...

Thank you very much Peter. These are very interesting leads and I shall follow them up. My best guess, and I might be wrong here, is that there are no large randomized studies of patients that compare  placebo or medication with neurosurgical interventions for intractable OCD. The neurosurgical option appears to be under constant attack for good or spurious reasons. Best wishes, Paul

I have been reading the qualitative study available via the link you kindly sent me, Peter. It is refreshing to see qualitative research in a field that appears to be dominated by quantitative approaches. It rounds the circle to some extent, so to speak. The experience of a patient´s likening of OCD to having no option other than to surface from deep water is powerful. I think that another metaphor, that of being on a battlefield and constantly hearing "Incoming", also captures some of the pain. Such data can only be captured through qualitative research. Best wishes Paul

Shannahoff-Khalsa DS, Kundalini Yoga meditation techniques in the treatment of obsessive compulsive and OC spectrum disorders, Brief Treatment and Crisis Intervention, 3:369-382 (2003) (by invitation).

Shannahoff-Khalsa, DS, Ray LE, Levine, S, Gallen, CC, Schwartz, BJ, Sidorowich, JJ, Randomized Controlled Trial of Yogic Meditation Techniques for Patients with Obsessive Compulsive Disorders, CNS Spectrums: The International Journal of Neuropsychiatric Medicine, vol 4, no. 12, pp. 34-46, 1999.

Shannahoff-Khalsa, DS, Yogic Techniques are Effective in the Treatment of Obsessive Compulsive Disorders, In: Eric Hollander & Dan Stein, eds., Obsessive-Compulsive Disorders: Diagnosis, Etiology, and Treatment, Marcel Dekker Inc., New York, pp. 283-329, 1997.

Paul- before proceeding, I have to point out that the term "intractable" is  an illusional way of referring to an ineffective therapy - major source of the treatment difficulty is sloppy approach to research of brain biology- decades of advances in brain imaging confirm glitches in  brain systems that are implicated in OCD - most psychologists, social workers, counselors and others who practice psychotherapy have been content with shifting brain biology issues to medicine knows physicians - even undertake sometimes to encourage patients to comply with medication regimens- need to address the fact that  even the FDA  relies only on evidence that medications reduce the symptoms per DSM listings - no requirement to demonstrate corrections of brain impairments- I know of no evidence from any neuropharmaceutical that corrects defects in brain biology- We are all  aware, however, of the numerous examples of neurological damage like EPS and TD as well as serious endocrine disruptions- the only study I know that identifies brain pathology in mental illness, is the landmark project of Dr. Jeffrey Schwartz and his team in the UCLA  department of Psychiatry. They designed a psychotherapy protocol based on discoveries of neuroplasticity in the discipline of neuroscience-neuroplasticity refers to the process in which every learning experience includes biological brain changes. Part of therapy involved cognitive-behavioral methods for changing pathologies of thinking and behavior, which most psychotherapists will recognize.  (f)MRIs were applied to assess brain benefits .  Structures that were not doing what they are designed to do, were in overactive areas. Mindfulness skills ,along with other benefits, normalize activity levels. The resulting effects were that malfunctioning structures started working as designed.  Successful psychotherapy is always a learning experience - hundreds of studies of neuroplasticity confirm this phenomenon. A giant leap in the UCLA  project was designing a therapy where the brain changes came in the form of correcting defective functioning.  Highly recommend thew book describing the project- includes details of research references, which provides good update for modern advances in neuroscience

I have had some success with an MTHFR protocol with marked increases in NAC and the addition of Li2co3 in the 150-300mg range

Many thanks for this update Edward.

 Herman

You have certainly got my attention. The idea that mental events (or mental physiology, so to speak) affect brain anatomy seems logical to me. I had another RG post a few months ago along the lines of what you propose. One researcher likened the dance between the anatomy and function as somewhat like the particle-wave phenomenon in physics. Have you studied metacognitive theory, by the way?

This mental disorder exists and aggravated by school teachers and colleagues. We must think about it.

a little addendum,Paul- important that logic supports idea that mental events affect

brain- however neuroscience observations confirm that the mental acts of decision to  

engage in mindfulness exercise and deliberate conscious acts of focusing attention

normalize electrical and biochemical processes-  

That is an important and, crucial this, clinically significant finding. I wonder if those mental acts you refer to Herman, could validly be described as examples of neurophysiology. Or are these events - including the decision to become more mindful - not explainable in terms of physiological function?

neurons firing and networks of neurons firing are easy for me to describe as neurophysiology- neuronal activation of biochemical hormonal processes also fits- these are material events that can be independently observed by 2 or more persons- what boggles the mind for material determinists is that even the most convoluted mental gymnastics cannot avoid the realities of conscious experience, a real world reality that is not confirmable by dispassionate independent observers-understanding the principles of some aspects of consciousness requires a kind of relationship involving trust and skills of mindful awareness that promote reality-focused communication-  I'd   expect much better predictability asking somebody what flavor ice-cream cone they will choose than finding the answer with the highest tech most  advanced brain imaging technology- (also a lot less costly).  I know of no proposed study to pursue how neurophysiology explains the conceptual work involved in designing the automobile, airplane or rocketship ,  - 

Dear all who are interested in this project.

I have had not studied OCD from the stand point of vibration, quantum theory.

Now I am somewhat exhausted with a OCD patient with dysmorphism. 

My patient is struggling with photobooth. To begin with, he could not look at the terminal,

But these days he can gaze the photo, but is still troublesome with others’ behavior, who react at

His appearance or expression. He looks with tension and darkness. He insists that passers-by make U-turn at his appearance. 

Now I make it to the treatment takes much weeks and months with make my stand point as high as the patient. Iguess his amygdala is so pathological that it takes so much period to normalize. It is ok taking such a long time, but important point is, to make our eye level as high as the patient’s mindfully with consciousness vibration with quantum theory. It is possible from the experience with forest qigong.