Standardized assessment of personality disorders in obsessive-compulsive disorder

Obsessive-Compulsive Disorder With Co-Occurring Obsessive-Compulsive Personality Disorder: A Practice Focused Review

This review article addresses the frequently noted comorbidity between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). We begin by reviewing the recent empirical literature on the co-occurrence of these two conditions and the functional consequences of comorbid OCPD on OCD. We describe theoretical conceptualizations of the links between these disorders, including shared mechanisms that may drive the association between these two distinct conditions. We then provide an overview of diagnostic measures for OCPD and differential diagnosis. We also review data on the impact of comorbid OCPD on cognitive-behavioral treatment for OCD, including how to address potential treatment barriers through which OCPD may complicate OCD treatment. Lastly, we conclude with directions for future research.

Schizotypal personality disorder in clinical obsessive-compulsive disorder samples: a brief overview

Obsessive-compulsive disorder (OCD) is a chronic and disabling mental disorder characterized by the presence of obsessions and/or compulsions that cause major distress and impair important areas of functioning. About 9 out of 10 patients with OCD have comorbid psychiatric diagnoses. A high proportion of clinically diagnosed OCD patients fulfill diagnostic criteria of a schizophrenia spectrum disorder, to the point that significant evidence in the literature supports the existence and the clinical relevance of a schizo-obsessive spectrum of disorders, including schizotypal personality disorder (SPD) with OCD (schizotypal OCD). In this paper, we provide a brief but comprehensive analysis of the literature on the clinical coexistence between OCD and SPD. The clinical validity of the so-called schizotypal OCD is analyzed through a comprehensive investigation of the relationship between SPD features and obsessive-compulsive phenomena in clinical OCD samples. This review describes the potential connections between OCD and SPD on the epidemiological, sociodemographic, psychopathological, and clinical levels. SPD is commonly observed in OCD patients: about 10% of OCD patients have a full categorical diagnosis of SPD. Early clinical identification of SPD features-and, more generally, of psychotic features and personality disorders-in OCD patients is strongly recommended. In fact, a proper and early diagnosis with early treatment may have benefits for prognosis. However, although schizotypal OCD seems to have clinical and predictive validity, further neurobiological and genetic studies on etiological specificity are warranted.

General personality dimensions, impairment and treatment response in obsessive-compulsive disorder

General personality dimensions are associated with clinical severity and treatment response in individuals with depression and many anxiety disorders, but little is known about these relationships in individuals with obsessive-compulsive disorder (OCD). Individuals in the current study included 705 adults with OCD who had participated in family and genetic studies of the disorder. Participants self-completed the Neuroticism, Extraversion, Openness Personality Inventory or Neuroticism, Extraversion, Openness Five-Factor Inventory-3. Relationships between personality scores, and subjective impairment and OCD treatment response, were evaluated. The odds of subjective impairment increased with (unit increase in) the neuroticism score (odds ratio, OR = 1.03; 95% CI = 1.01-1.04; p < 0.01) and decreased with extraversion scores (OR = 0.98; 95% CI = 0.96-0.99; p < 0.01). The odds of reporting a good response to serotonin/selective serotonin reuptake inhibitors (OR = 1.02; 95% CI = 1.01-1.04; p < 0.01) or cognitive behavioural therapy (OR = 1.03; 95% CI = 1.01-1.05; p < 0.01) increased with the extraversion score. The magnitude of these relationships did not change appreciably after adjusting for other clinical features related to one or more of the personality dimensions. The findings suggest that neuroticism and extraversion are associated with subjective impairment, and that extraversion is associated with self-reported treatment response, in individuals with OCD. © 2019 John Wiley & Sons, Ltd.

The relationship between obsessive-compulsive personality and obsessive-compulsive disorder: data obtained by the Personality Disorder Examination

We administered the Personality Disorder Examination (PDE) to 31 patients meeting DSM III criteria for obsessive-compulsive disorder (OCD) and to an age-and sex-matched healthy control group. Seventeen patients (54.8%) and four controls (12.9%) met criteria for one or more DSM III Axis II diagnoses. The most frequent Axis II diagnoses in patients were avoidant, passive-aggressive and compulsive personality disorder. Compulsive personality disorder was diagnosed in 6 OCD patients (19.3%). The prevalence of this disorder did not change according to sex, age of onset or duration of OCD, and severity of obsessive-compulsive symptoms.

Psychopharmacological Treatment of Obsessive-Compulsive Disorder (OCD)

Background:

Obsessive-compulsive disorder (OCD) is associated with affective and cognitive symptoms causing personal distress and reduced global functioning. These have considerable societal costs due to healthcare service utilization.

Objective:

Our aim was to assess the efficacy of pharmacological interventions in OCD and clinical guidelines, providing a comprehensive overview of this field.

Methods:

We searched the PubMed database for papers dealing with drug treatment of OCD, with a specific focus on clinical guidelines, treatments with antidepressants, antipsychotics, mood stabilizers, off-label medications, and pharmacogenomics.

Results:

Prolonged administration of selective serotonin reuptake inhibitors (SSRIs) is most effective. Better results can be obtained with a SSRI combined with cognitive behavioral therapy (CBT) or the similarly oriented exposure and response prevention (ERP). Refractory OCD could be treated with different strategies, including a switch to another SSRI or clomipramine, or augmentation with an atypical antipsychotic. The addition of medications other than antipsychotics or intravenous antidepressant administration needs further investigation, as the evidence is inconsistent. Pharmacogenomics and personalization of therapy could reduce treatment resistance.

Conclusions:

SSRI/clomipramine in combination with CBT/ERP is associated with the optimal response compared to each treatment alone or to other treatments. New strategies for refractory OCD are needed. The role of pharmacogenomics could become preponderant in the coming years.

Obsessive-compulsive symptoms in schizophrenia: a review

OBJECTIVE

To review the available literature on obsessive-compulsive symptom (OCS)/obsessive-compulsive disorder (OCD) in patients with schizophrenia.

METHODOLOGY

Electronic searches were carried out to locate studies reporting various aspects of OCS/OCD in patients with schizophrenia.

RESULTS

Available evidence suggests that prevalence of OCS/OCD in patients with schizophrenia is much higher than prevalence in general population and it is seen in all the stages of schizophrenia, starting from at risk mental state to chronic/stabilisation/deficit phases. Symptom profile of OCS/OCD in schizophrenia is similar to that seen in patients with OCD only. Presence of OCS/OCD is associated with higher severity of symptoms of schizophrenia and more negative outcome. At present there is very limited data on the efficacy/effectiveness of various pharmacological measures and psychological interventions, for management of OCS/OCD in patients with schizophrenia. There is some evidence pointing towards beneficial effect of certain antipsychotics, antidepressants and cognitive behaviour therapy. Management of OCS/OCD in patients with schizophrenia involves proper assessment. If the OCS/OCD is related to use of particular antipsychotic use, initial attempt must be made to reduce the dose of antipsychotics, however, if this is not effective, than addition of a selective serotonin reuptake inhibitor (SSRIs) must be considered. If the OCS/OCD is not related to the use of antipsychotic medication, than depending up on the severity of psychotic symptoms, addition of SSRIs must be considered.

CONCLUSION

This review suggests that OCS/OCD is highly prevalent among patients with schizophrenia and there is limited good quality evidence to make any specific recommendations for management.

The Impact of Obsessive Compulsive Personality Disorder on Cognitive Behaviour Therapy for Obsessive Compulsive Disorder

BACKGROUND

It is often suggested that, in general, co-morbid personality disorders are likely to interfere with CBT based treatment of Axis I disorders, given that personality disorders are regarded as dispositional and are therefore considered less amenable to change than axis I psychiatric disorders.

AIMS

The present study aimed to investigate the impact of co-occurring obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) on cognitive-behavioural treatment for OCD.

METHOD

92 individuals with a diagnosis of OCD participated in this study. Data were drawn from measures taken at initial assessment and following cognitive-behavioural treatment at a specialist treatment centre for anxiety disorders.

RESULTS

At assessment, participants with OCD and OCPD had greater overall OCD symptom severity, as well as doubting, ordering and hoarding symptoms relative to those without OCPD; however, participants with co-morbid OCD and OCPD demonstrated greater treatment gains in terms of OCD severity, checking and ordering than those without OCPD. Individuals with OCD and OCPD had higher levels of checking, ordering and overall OCD severity at initial assessment; however, at post-treatment they had similar scores to those without OCPD.

CONCLUSION

The implications of these findings are discussed in the light of research on axis I and II co-morbidity and the impact of axis II disorders on treatment for axis I disorders.

Comorbid Personality Disorders in Obsessive-Compulsive Disorder and Its Symptom Dimensions

The current paper was aimed at: (1) investigating the comorbidity between obsessive-compulsive disorder (OCD) and personality disorders (PDs) using an OCD sample and clinician-administered structured interviews; (2) exploring the associations of different cluster comorbid PDs with the specific symptom dimensions of OCD; (3) analyzing the variables which could play a significant role in the probability of having at least one comorbid PD, controlling for confounding variables. The SCID-II and Y-BOCS, together with a series of self-report measures of OCD, depression and anxiety symptoms were administered to a clinical sample of 159 patients with a primary diagnosis of OCD. 20.8 % of the participants suffered from at least one comorbid PD; the most common was obsessive-compulsive PD (9.4 %), followed by narcissistic PD (6.3 %). In OCD patients with comorbid cluster C PDs, the percentage of responsibility for harm, injury, or bad luck symptoms was significantly greater than other OCD symptom dimensions (p < .005). Logistic regression found some evidence supporting the association between severity of OCD symptoms and comorbid PDs. PDs are prevalent among Italian people with OCD and should be routinely assessed, as comorbidity may affect help-seeking behaviour and response to treatment.

The correlates of obsessive-compulsive, schizotypal, and borderline personality disorders in obsessive-compulsive disorder

We assessed correlates of obsessive-compulsive (OCPD), schizotypal (SPD) and borderline (BPD) personality disorders in 110 obsessive-compulsive disorder (OCD) patients. We found OCD patients with OCPD (20.9%) to exhibit higher rates of hoarding and bipolar disorders, increased severity of hoarding and symmetry, lower prevalence of unacceptable thoughts involving sex and religion and less non-planning impulsivity. Conversely, OCD patients with SPD (13.6%) displayed more frequently bipolar disorder, increased severity of depression and OCD neutralization, greater prevalence of "low-order" behaviors (i.e., touching), lower low-planning impulsivity and greater "behavioral" compulsivity. Finally, in exploratory analyses, OCD patients with BPD (21.8%) exhibited lower education, higher rates of several comorbid psychiatric disorders, greater frequency of compulsions involving interpersonal domains (e.g. reassurance seeking), increased severity of depression, anxiety and OCD dimensions other than symmetry and hoarding, more motor and non-planning impulsivity, and greater "cognitive" compulsivity. These findings highlight the importance of assessing personality disorders in OCD samples.

The clinical characteristics of obsessive compulsive disorder associated with high levels of schizotypy

OBJECTIVES

This study aims to examine the characteristics of obsessive compulsive disorder (OCD) associated with high levels of schizotypy.

METHODS

Using the Schizotypal Personality Questionnaire (SPQ) with 177 individuals with OCD, patients with OCD and high levels of schizotypy (OCD-HS) were compared to patients with OCD and low levels of schizotypy (OCD-LS) on a range of clinical characteristics. Self-report and clinician-administered instruments were used. Results were adjusted for the severity of OCD symptoms, age, marital status and comorbidity using logistic regression.

RESULTS

Patients with OCD-HS were younger and less likely to have been married. OCD-HS was associated with higher rates of symmetry/order obsessions, ordering/arranging compulsions, checking compulsions, co-occurring major depression, post-traumatic stress disorder, substance use disorders and greater general psychopathology. Previously reported associations, such as higher total scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) were not significant when adjusted for differences in demographic variables and comorbidity.

CONCLUSIONS

Patients with OCD-HS were associated with specific OCD symptoms and comorbid conditions and may warrant a specific treatment approach.

The clinical characteristics of patients with obsessive compulsive disorder: a descriptive study of an Irish sample

Objective: To describe the clinical characteristics and demographic details of a sample of patients with a principal diagnosis of obsessive compulsive disorder (OCD). Method: A retrospective review of fifty patients with DSM-III-R OCD referred to the Department of Behaviour Therapy at St. Patrick's Hospital, Dublin, Ireland between 1990 and 1991. Standard clinical ratings were made before and after treatment. Ratings used included the Maudsley Obsessive Compulsive Inventory (MOCI), the Fear Questionnaire (FQ), and the Yale-Brown obsessive compulsive score (YBOCS). Results: The male to female ratio was almost equal and the mean duration of illness was 6.1 (SD 11 years). OCD presented in isolation in a minority of cases (14%). A life time history of at least one other DSM-III-R axis I diagnosis, especially depression, was found in 72% of patients. Co-morbid Gilles de la Tourettes syndrome or epilepsy was rare. The majority of patients were on medication prior to presentation (78%). Levels of symptomatology were reduced in 91% of patients who completed treatment. Conclusions: Epidemiological research into the mass aspects of this disorder is required.

Personality disorders in obsessive-compulsive disorder: a comparative study versus other anxiety disorders

Objective. The purpose of this paper is to provide evidence for the relationship between personality disorders (PDs), obsessive compulsive disorder (OCD), and other anxiety disorders different from OCD (non-OCD) symptomatology. Method. The sample consisted of a group of 122 individuals divided into three groups (41 OCD; 40 non-OCD, and 41 controls) matched by sex, age, and educational level. All the individuals answered the IPDE questionnaire and were evaluated by means of the SCID-I and SCID-II interviews. Results. Patients with OCD and non-OCD present a higher presence of PD. There was an increase in cluster C diagnoses in both groups, with no statistically significant differences between them. Conclusions. Presenting anxiety disorder seems to cause a specific vulnerability for PD. Most of the PDs that were presented belonged to cluster C. Obsessive Compulsive Personality Disorder (OCPD) is the most common among OCD. However, it does not occur more frequently among OCD patients than among other anxious patients, which does not confirm the continuum between obsessive personality and OCD. Implications for categorical and dimensional diagnoses are discussed.

Quality of life, family burden and associated factors in relatives with obsessive-compulsive disorder

OBJECTIVE

The aim of this study is to assess the quality of life (QoL), family burden and psychiatric disorders in first-degree relatives of patients with obsessive-compulsive disorder (OCD) and to compare them with healthy controls and their relatives.

METHODS

Forty patients with OCD and 47 of their first-degree relatives as well as 40 healthy subjects and 45 of their first-degree relatives were recruited in this study. OCD and comorbid anxiety or mood disorders were determined by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders. Comorbid Axis II disorders were diagnosed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition Personality Disorders. Type and severity of obsessive-compulsive symptoms were assessed with the Yale-Brown Obsessive-Compulsive Scale, and the disability of patients with OCD was evaluated with the WHO DAS II. Family burden and QoL in the relatives were evaluated with the Zarit Burden Interview (ZBI) protocol and the World Health Organization Quality of Life Assessment-Brief, respectively.

RESULTS

The mean ZBI score of family members of OCD patients was higher than the control relatives. Linear regression analysis indicated that the independent factors associated with ZBI were duration of OCD, comorbid major depressive disorder and poorer insight. Compared with those of control relatives, the QoL of relatives of patients with OCD was significantly lower in all domains. While the diagnosis of major depressive disorder in relatives of OCD patients was significantly higher than the control relatives, the diagnosis of any anxiety disorder did not differ.

CONCLUSIONS

Our study provides evidence that OCD not only affects the lives of patients but also their family members.

Comorbidity of personality disorders in anxiety disorders: a meta-analysis of 30 years of research

BACKGROUND

A comprehensive meta-analysis to identify the proportions of comorbid personality disorders (PD) across the major subtypes of anxiety disorders (AD) has not previously been published.

METHODS

A literature search identified 125 empirical papers from the period 1980-2010 on patients with panic disorders, social phobia, generalised anxiety, obsessive-compulsive (OCD) and post-traumatic stress disorder (PTSD). Several moderators were coded.

RESULTS

The rate of any comorbid PD was high across all ADs, ranging from .35 for PTSD to .52 for OCD. Cluster C PDs occurred more than twice as often as cluster A or B PDs. Within cluster C the avoidant PD occurred most frequently, followed by the obsessive-compulsive and the dependent PD. PTSD showed the most heterogeneous clinical picture and social phobia was highly comorbid with avoidant PD. A range of moderators were examined, but most were non-significant or of small effects, except an early age of onset, which in social phobia increased the risk of an avoidant PD considerably. Gender or duration of an AD was not related to variation in PD comorbidity.

LIMITATIONS

Blind rating of diagnoses was recorded from the papers as an indication of diagnostic validity. However, as too few studies reported it the validity of the comorbid estimates of PD was less strong.

CONCLUSIONS

The findings provided support to several of the proposed changes in the forthcoming DSM-5. Further comorbidity studies are needed in view of the substantial changes in how PDs will be diagnosed in the DSM-5.

Comorbid obsessive-compulsive personality disorder in obsessive-compulsive disorder (OCD): a marker of severity

INTRODUCTION

Comorbid obsessive-compulsive personality disorder (OCPD) is well-described in obsessive-compulsive disorder (OCD). It remains unclear, however, whether OCPD in OCD represents a distinct subtype of OCD or whether it is simply a marker of severity in OCD.

MATERIALS AND METHODS

The aim of this study was to compare a large sample of OCD subjects (n=403) with and without OCPD on a range of demographic, clinical and genetic characteristics to evaluate whether comorbid OCPD in OCD represents a distinct subtype of OCD, or is a marker of severity.

RESULTS

Our findings suggest that OCD with and without OCPD are similar in terms of gender distribution and age at onset of OC symptoms. Compared to OCD-OCPD (n=267, 66%), those with OCD+OCPD (n=136, 34%) are more likely to present with the OC symptom dimensions which reflect the diagnostic criteria for OCPD (e.g., hoarding), and have significantly greater OCD severity, comorbidity, functional impairment, and poorer insight. Furthermore there are no differences in distribution of gene variants, or response to treatment in the two groups.

CONCLUSION

The majority of our findings suggest that in OCD, patients with OCPD do not have a highly distinctive phenomenological or genetic profile, but rather that OCPD represents a marker of severity.

Comorbidity of obsessive-compulsive disorder with obsessive-compulsive personality disorder: Does it imply a specific subtype of obsessive-compulsive disorder?

The present study examined whether the comorbidity of obsessive-compulsive personality disorder (OCPD) and obsessive-compulsive disorder (OCD) constitute a specific subtype of OCD. The study sample consisted of 146 consecutive outpatients with a DSM-IV diagnosis of OCD. Diagnoses were established using MINI, IPDE, YBOCS and YBOCS-SC. OCD patients with comorbid OCPD were compared with OCD patients without OCPD on various sociodemographic and clinical variables. Almost one third of the OCD subjects met criteria for comorbid OCPD. OCD+OCPD patients had a significantly earlier age at onset of initial OC symptoms, earlier age at onset of OCD and more obsessions and compulsions than pure obsessions compared to the patients with OCDOCPD. OCD+OCPD patients also had a higher rate of comorbidity with avoidant personality disorder and showed more impairment in global functioning. There were not differences between the two sub-groups on severity of OCD symptoms and also on type of OCD onset. Our results indicate that the comorbidity of OCD with OCPD is associated with a number of specific clinical characteristics of OCD. These findings in conjunction with of current clinical, family and genetic studies provide some initial evidence that OCD comorbid with OCPD constitute a specific subtype of OCD.

Obsessive-compulsive disorder with poor insight: a three-year prospective study

Available evidence about the relationship between poor insight and other clinical characteristics in patients with obsessive-compulsive disorder (OCD) is inconclusive and conflicting. There is also a paucity of data on the long-term course and treatment outcome of OCD patients with poor insight. The present study reports the findings of a relatively large sample (n=106) of outpatients fulfilling DSM-IV criteria for OCD, treated with serotonin reuptake inhibitors (SRIs) and prospectively followed up for 3 years. Baseline information was collected on demographic and clinical characteristics, using standardized instruments. Insight was assessed by means of the Brown Assessment of Beliefs Scale (BABS). Eighty-three patients were followed prospectively and evaluated systematically by validated measures of psychopathology. Compared to their good insight counterparts, the OCD patients with poor insight (22%) showed a greater severity of obsessive-compulsive and depressive symptomatology; an earlier age at onset; a higher rate of schizophrenia spectrum disorder in their first-degree relatives; a higher comorbidity with schizotypal personality disorder. During the follow-up period, poor insight OCD patients were less likely to achieve at least a partial remission of obsessive-compulsive symptoms; required a significantly greater number of therapeutic trials; received more frequently augmentation with antipsychotics. The results suggest that the specifier "poor insight" helps to identify a subgroup of patients at the more severe end of OCD spectrum, characterized by a more complex clinical presentation, a diminished response to standard pharmacological interventions, and a poorer prognosis. Further research is needed to identify alternative strategies for the management of these patients.

Psychological interventions for obsessive-compulsive personality disorder

This is the protocol for a review and there is no abstract. The objectives are as follows: To evaluate the potential beneficial and adverse effects of psychological interventions for people with obsessive-compulsive personality disorder and to make recommendations for future areas of research.

Predictive Factors in the Treatment of Obsessive-Compulsive Disorders with Fluvoxamine and/or Behaviour Therapy

Fisher's stepwise discriminant analysis was carried out on 10 baseline variables searching for posterior prediction of success in a sample of sixty DSM-III obsessive-compulsive patients. The patients' median score on Hamilton rating scale of depression was 19. In a controlled study they were randomized into three groups: fluvoxamine with antiexposure, fluvoxamine with exposure, or placebo with exposure. In the whole sample, five variables accounted for 76% of the correctly classified patients: avoidance score of the behavioural avoidance test, behaviour therapy expectations, fluvoxamine expectations, Beck depression inventory and rituals repetition. High avoidance score predicted 68% of the correctly classified patients in the whole sample. The discriminant function classified correctly 70% of the patients in the antiexposure with fluvoxamine group, versus 75% in the exposure with fluvoxamine group, and 85% of the patients receiving exposure with placebo (χ2, d.f.2, NS).

Temperament features in adolescents with ego-syntonic or ego-dystonic obsessive-compulsive symptoms

The present study evaluated whether different patterns of temperament may predict a different threshold of acceptability of obsessive-compulsive (OC) symptoms in adolescents. OC symptomatology was detected with the Leyton Obsessional Inventory-Child Version (LOI-CV) and temperament was assessed using the tridimensional personality questionnaire in 2,775 high-school students. According to the LOI-CV scores, the adolescents were classified as high interference (interfering, ego-dystonic symptoms) (HI), supernormal (noninterfering, ego-syntonic symptoms) (Sn) and controls (C) HI were 119 (4.3%), Sn 85 (3.1%) and C 2,571 (92.6%). The best predictor of belonging to HI or Sn groups was the temperament configuration of high Harm Avoidance (HA) and high Persistence (P). The feature that mainly distinguishes the two symptomatic groups were Novelty Seeking (NS) levels. Our data suggest that people characterized by pessimistic worry in anticipation of future problems, passive avoidant behaviour, rapid fatigability (high HA) and irresoluteness, ambitiousness, perseverance, perfectionism, enduring feelings of frustration (high P) might develop OC symptoms. Whether OC symptoms become ego-syntonic or ego-dystonic seems to mainly depend on NS levels: low NS might protect people (with the prevention of "exploratory and active behaviours" that may elicit loss of control on symptoms) from the development of interfering OC symptoms.

Demographic and clinical characteristics associated with treatment status in family members with obsessive-compulsive disorder

This study investigated the demographic and clinical factors that influence treatment status in family members with obsessive compulsive disorder (OCD). Six hundred and two subjects from the OCD Collaborative Genetics Study were interviewed using the Structured Clinical Interview for DSM-IV (SCID) to diagnose Axis I disorders, and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) for assessment of OCD symptoms. The demographic and clinical data were compared between subjects who had received treatment and those who had not. A precipitous onset of symptoms, severe illness, multiple obsessions and compulsions, and co-morbid affective disorders were all positively associated with receiving treatment. Older age and the presence of obsessive compulsive personality disorder (OCPD) or OCPD traits were negatively associated with treatment. Gender and age at onset of symptoms did not predict treatment history. The mean duration from onset of symptoms to receiving treatment was 13.8+/-SD 11.9 years, but there was a direct relationship between current age and time to treatment, with younger subjects receiving treatment sooner. Clinical factors are predominant in predicting treatment status in family members with OCD. Although the mean duration from onset of symptoms to treatment was long, younger family members appear to receive treatment sooner.

Clinical considerations for the treatment of body dysmorphic disorder with cognitive-behavioral therapy

Although cognitive behavior therapy has been found to be very effective in the treatment of body dysmorphic disorder (BDD), there still remain a number of challenges that clinicians face in the treatment of individuals with BDD. In this article, we discuss issues related to comorbid depression, suicidality, substance use disorders, personality disorders as well as the role of early life experiences, delusional intensity of beliefs, and motivation to change. The aim of this review is to provide a treatment aid to clinicians by offering specific recommendations for improved care based on the available literature as well as our clinical experience.

Utility of the Leyton Obsessional Inventory to distinguish OCD and OCPD

The Leyton Obsessional Inventory (LOI) is a self-report questionnaire that assesses obsessional symptoms. The ability of the LOI to distinguish between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) has not been adequately addressed. Our purpose is to identify dimensions of obsessional symptoms from the LOI and determine how well they distinguish between OCD and OCPD. The LOI was completed by 488 participants diagnosed by trained clinicians. Factor analysis was performed on responses to the interference items of the LOI. The relationship between the factors, OCD and OCPD was evaluated using logistic regression. Five factors underlying the LOI were identified: (I) obsessional ruminations and compulsions, (II) ordering and arranging, (III) organizing activities, (IV) contamination, and (V) parsimony. Factors I, III, and IV were strongly associated with OCD. Only Factor II was associated with OCPD. Factor IV was negatively associated with obsessive-compulsive personality traits. LOI factors are useful in discriminating between OCD and OCPD. Obsessional ruminations and compulsions, organizing activities, and contamination fears may indicate OCD, and ordering and arranging symptoms may indicate OCPD rather than OCD. Parsimony may indicate neither disorder, and contamination, the absence of OCPD traits compared with the other LOI factors. These findings may contribute to effective diagnosis and treatment by allowing the LOI to screen for OCD and OCPD in a population exhibiting obsessional symptoms and traits.

Bipolar obsessive-compulsive disorder and personality disorders

OBJECTIVES

Relatively few systematic data exist on the clinical impact of bipolar comorbidity in obsessive-compulsive disorder (OCD) and no studies have investigated the influence of such a comorbidity on the prevalence and pattern of Axis II comorbidity. The aim of the present study was to explore the comorbidity of personality disorders in a group of patients with OCD and comorbid bipolar disorder (BD).

METHODS

The sample consisted of 204 subjects with a principal diagnosis of OCD (DSM-IV) and a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score>or=16 recruited from all patients consecutively referred to the Anxiety and Mood Disorders Unit, Department of Neuroscience, University of Turin over a period of 5 years (January 1998-December 2002). Diagnostic evaluation and Axis I comorbidities were collected by means of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Personality status was assessed by using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). Socio-demographic and clinical features (including Axis II comorbidities) were compared between OCD patients with and without a lifetime comorbidity of BD.

RESULTS

A total of 21 patients with OCD (10.3%) met DSM-IV criteria for a lifetime BD diagnosis: 4 (2.0%) with BD type I and 17 (8.3%) with BD type II. Those without a BD diagnosis showed significantly higher rates of male gender, sexual and hoarding obsessions, repeating compulsions and lifetime comorbid substance use disorders, when compared with patients with BD/OCD. With regard to personality disorders, those with BD/OCD showed higher prevalence rates of Cluster A (42.9% versus 21.3%; p=0.027) and Cluster B (57.1% versus 29.0%; p=0.009) personality disorders. Narcissistic and antisocial personality disorders were more frequent in BD/OCD.

CONCLUSIONS

Our results point towards clinically relevant effects of comorbid BD on the personality profiles of OCD patients, with higher rates of narcissistic and antisocial personality disorders in BD/OCD patients.

Does obsessive-compulsive personality disorder belong within the obsessive-compulsive spectrum?

It has been proposed that certain Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I disorders share overlapping clinical features, genetic contributions, and treatment response and fall within an "obsessive-compulsive" spectrum. Obsessive-compulsive personality disorder (OCPD) resembles obsessive-compulsive disorder (OCD) and other spectrum disorders in terms of phenomenology, comorbidity, neurocognition, and treatment response. This article critically examines the nosological profile of OCPD with special reference to OCD and related disorders. By viewing OCPD as a candidate member of the obsessive-compulsive spectrum, we gain a fresh approach to understanding its neurobiology, etiology, and potential treatments.

Obsessive-compulsive disorder: boundary issues

The boundaries between obsessive-compulsive disorder (OCD) and other neuropsychiatric disorders remain unresolved and may well differ from one disorder to another. Endophenotypes are heritable, quantitative traits hypothesized to more closely represent genetic risk for complex polygenic mental disorders than overt symptoms and behaviors. They may have a role in identifying how closely these disorders are associated with another and with other mental disorders with which they share major comorbidity. This review maps the nosological relationships of OCD to other neuropsychiatric disorders, using OCD as the prototype disorder and endophenotype markers, such as cognitive, imaging, and molecular data as well as results from demographic, comorbidity, family, and treatment studies. Despite high comorbidity rates, emerging evidence suggests substantial endophenotypic differences between OCD and anxiety disorders, depression, schizophrenia, and addictions, though comparative data is lacking and the picture is far from clear. On the other hand, strong relationships between OCD, Tourette syndrome, body dysmorphic disorder, hypochondriasis, grooming disorders, obsessive-compulsive personality disorder, and pediatric autoimmune neuropsychiatric disorders associated with streptococcus are likely. Studies designed to delineate the cause, consequences, and common factors are a challenging but essential goal for future research in this area.

Clarifying the convergence between obsessive compulsive personality disorder criteria and obsessive compulsive disorder

In this study we examined the convergence between obsessive-compulsive personality disorder (OCPD) criteria and obsessive-compulsive disorder (OCD). Baseline assessments of 629 participants of the Collaborative Longitudinal Personality Disorders Study were used to examine the associations between OCPD criteria and diagnoses of OCD. Three of the eight OCPD criteria--hoarding, perfectionism, and preoccupation with details--were significantly more frequent in subjects with OCD (n = 89) than in subjects without OCD (n = 540). Logistic regressions were used to predict the probability of each OCPD criterion as a function of Axis I diagnoses (OCD, additional anxiety disorders, and major depressive disorder). Associations between OCD and these three OCPD criteria remained significant in the logistic regressions, showing unique associations with OCD and odds ratios ranging from 2.71 to 2.99. In addition, other anxiety disorders and major depressive disorder showed few associations with specific OCPD criteria. This study suggests variability in the strength of the relationships between specific OCPD criteria and OCD. The findings also support a unique relationship between OCPD symptoms and OCD, compared to other anxiety disorders or major depression. Future efforts to explore the link between Axis I and Axis II disorders may be enriched by conducting analyses at the symptom level.

Obsessive compulsive personality disorder and obsessive compulsive disorder: clinical characteristics, diagnostic difficulties, and treatment

BACKGROUND

The overlap between obsessive compulsive personality disorder (OCPD) and obsessive compulsive disorder (OCD) has received increasing recognition and continues to be a source of much debate. With the advent of new research methodologies, researchers have attempted to distinguish whether OCPD and OCD are two distinct phenomena that can co-occur or whether they are similar, overlapping constructs.

METHODS

MEDLINE was used to systematically review the OCPD and OCD literature published between 1991 and 2004.

RESULTS

Using the more stringent DSM-IV criteria, results from OCD clinical samples suggest that the majority of individuals with OCD (75%) do not have OCPD. Similarly, results from personality disorder samples suggest that the majority of individuals with OCPD (80%) do not have OCD.

CONCLUSIONS

While there is evidence that OCD and OCPD are linked, the literature does not support either one as a necessary or sufficient component of the other.

Obsessive-compulsive disorder (OCD) with schizotypy vs. schizophrenia with OCD: diagnostic dilemmas and therapeutic implications

Although schizophrenia and obsessive-compulsive disorder (OCD) are distinct diagnostic entities, there are substantial areas of overlap between the two disorders in clinical characteristics, affected brain areas and pharmacotherapy. Though OCD patients apparently do not have increased risk for developing schizophrenia, schizotypal personality disorder has consistently been found in OCD patients. Compelling evidence also points to an increased rate of OCD in schizophrenia patients. Accurate diagnosis of both disorders in their "pure" and overlapping forms is necessary in order to evaluate etiological mechanisms underlying schizophrenia and OCD, and to provide adequate treatment and prognosis. In this review, we address some aspects of the current status of research pertinent to the OCD-schizophrenia interface and suggest further steps towards the clinical and etiological identification of homogeneous subgroups on the putative OCD-schizophrenia axis.

DSM-IV obsessive-compulsive personality disorder: prevalence in patients with anxiety disorders and in healthy comparison subjects

The relationship between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) has not yet been fully clarified. The aim of the present study was to analyze DSM-IV OCPD prevalence rates in OCD and panic disorder (PD) patients to test for the specificity of the OCPD-OCD link, and to compare them to OCPD prevalence in a control group of subjects without any psychiatric disorder. A total of 109 patients with a principal diagnosis of DSM-IV (SCID-I) OCD and 82 with PD were interviewed using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) in order to assess the prevalence of OCPD. All patients with a coexisting axis I diagnosis were excluded from the study to eliminate confounding factors when evaluating the association between prevalence rates of OCPD and anxiety disorder diagnoses. An exclusion criteria was also a Hamilton Depression Rating Scale (HAM-D) score >/=16. A sample of comparison subjects (age 18 to 65 years) without any psychiatric disorder was recruited from people registered with two general practitioners (GPs), whether or not they consulted the doctor, in order to evaluate OCPD prevalence rate in the community. A significant difference was found between the prevalence of OCPD in OCD (22.9%) and in PD (17.1%) on one hand, and that in the comparison sample (3.0%) on the other. No differences were found between the two psychiatric groups, even when splitting the samples according to gender. Our study failed to support the hypothesis of a specific relationship between OCPD and OCD; we confirmed the higher prevalence rate of this personality disorder in OCD subjects with regard to the general population, but we also confirmed the higher rate of OCPD in another anxiety disorder which is phenomenologically well characterized and different from OCD, such as PD.

Perceived parental rearing style in obsessive-compulsive disorder: relation to symptom dimensions

Obsessive-compulsive disorder (OCD) runs in families, but the specific contribution of genetic and environmental factors to its development is not well understood. The aim of this study was to assess whether there are differences in perceived parental child-rearing practices between OCD patients and healthy controls, and whether any relationship exists between parental characteristics, depressive symptoms and the expression of particular OCD symptom dimensions. A group of 40 OCD outpatients and 40 matched healthy controls received the EMBU (Own Memories of Parental Rearing Experiences in Childhood), a self-report measure of perceived parental child-rearing style. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and the Hamilton Depression Rating Scale (HDRS) were used to assess the severity of obsessive-compulsive and depressive symptoms. The Y-BOCS Symptom Checklist was used to assess the nature of obsessive-compulsive symptoms, considering the following five symptom dimensions: contamination/cleaning, aggressive/checking, symmetry/ordering, sexual/religious and hoarding. Logistic and multiple linear regression analyses were conducted to study the relationship between parental style of upbringing, depressive symptoms and OCD symptom dimensions. Severe OCD (Y-BOCS: 27.0+/-7.4) and mild to moderate depressive symptoms (HDRS: 14.0+/-5.4) were detected in our sample. Compared with healthy controls, OCD patients perceived higher levels of rejection from their fathers. No differences between the groups with respect to perceived levels of overprotection were detected. The seventy of depressive symptoms could not be predicted by scores on any perceived parental characteristics. Hoarding was the only OCD symptom dimension that could be partially predicted by parental traits, specifically low parental emotional warmth. Social/cultural variables such as parental child-rearing patterns, in interaction with biological and genetic factors, may contribute to the expression of the OCD phenotype.

Patterns of Axis-II comorbidity in a Turkish OCD sample

OBJECTIVE Obsessive-compulsive disorder (OCD) patients frequently present with Axis-II disorders, particularly Cluster C (anxiety spectrum) and Cluster A (schizophrenic spectrum) personality disorders. The present study examined patterns of Axis-II comorbidity in a Turkish OCD sample. In addition, we explored the impact of personality disorder symptoms on OCD-symptom severity and symptom profile. METHOD Structured psychiatric interviews and self-report measures of OCD symptoms and Axis-II disorders were administered to patients with OCD and control subjects. RESULTS Patients with OCD obtained significantly higher scores on measures of Cluster A and Cluster C personality disorders. Patients with OCD also achieved significantly higher scores on the BPD Subscale; however, they did not obtain significantly higher scores on other Cluster B subscales. Group differences on measures of Cluster A and C disorders were marked. CONCLUSIONS Findings are consistent with prior work demonstrating an increased incidence of Axis-II disorders among patients with OCD.

Assessment of DSM-IV personality disorders in obsessive-compulsive disorder: comparison of clinical diagnosis, self-report questionnaire, and semi-structured interview

In patients with obsessive-compulsive disorder, personality disorders are not many times assessed according to DSM-IV criteria. The purpose of the present study is to examine the prevalence of personality disorders diagnosed according to the DSM-IV in a severely disordered OCD population (n=65) with three different methods of assessing personality disorders (structured interview, questionnaire, and clinical diagnoses). Furthermore, correspondence between these different methods was investigated and their construct validity was examined by relating the three methods to external variables. Each method resulted in a predominance of Cluster C personality disorders, and obsessive-compulsive personality disorder had the highest prevalence. However, there was generally low correspondence regarding which patient had which personality disorder. Results concerning the relation of external variables were the most promising for the structured clinical interview.

Fixity of belief, perceptual aberration, and magical ideation in obsessive-compulsive disorder

Clinicians and researchers have pondered the intersection of obsessive-compulsive disorder (OCD) and psychosis. We examined the records of 395 individuals seeking treatment for OCD and classified participants according to their most frequent or distressing obsession and compulsion. All participants completed measures of fixity of belief, perceptual distortions, magical ideation, and psychotic symptoms. Results indicated that individuals who reported fear of harming self or others via overwhelming impulse or by mistake, and those with religious obsessions, had poorer insight and more perceptual distortions and magical ideation than did individuals with other types of obsessions. These results did not appear to reflect mere differences in OCD severity. Results are discussed in light of previous findings showing that psychotic-like symptoms are associated with attenuated treatment outcome in OCD. More research is needed to assess the absolute magnitude of psychotic-like features in OCD patients with impulse/mistake and religious obsessions and to examine whether these features interfere with standard cognitive-behavioral therapy.

The Parma High School Epidemiological Survey: obsessive-compulsive symptoms

OBJECTIVE

This study was undertaken to assess the prevalence of obsessive-compulsive symptoms in a population of Italian adolescents.

METHOD

A sample of 2877 high-school students, 1463 males (51%) and 1414 females (49%), aged 16-21 years were assessed with the Leyton Obsessional Inventory--Child Version (LOI-CV). Two groups of subjects were defined as 'positive' on the screen: the high interference (HI) (i.e. all subjects who scored 25 or more in the interference score), and the supernormals (Sn).

RESULTS

Females scored higher than males both on yes and interference scores. One hundred and nineteen (4.1%) and 87 (3.0%) constitute, respectively, the HI and the Sn groups. The most interfering symptoms were obsessions linked to dirt phobia, rumination and nail biting.

CONCLUSION

The prevalence estimates of OCD symptoms confirmed the recent data of the literature that adolescent OCD symptoms are more frequent than was believed previously. Females showed more symptoms and more interference on personal functioning than males.

An update on obsessive-compulsive disorder

It is now recognized that obsessive-compulsive disorder (OCD) affects almost 3% of the world's population and is a major worldwide health problem. Much has been learned in the past 2 decades about the treatment of these disorders. Recent developments in neuroimaging techniques have led to a better understanding of the biology of OCD and the brain circuits that may be involved in the production of symptoms. The most effective treatment approaches, based on controlled data, are behavior therapy consisting of exposure and response prevention and specific medications. Although controversial, more invasive neurosurgical and neurostimulation approaches may hold some promise for severely disabled patients. Despite impressive research efforts, a small minority of patients remain refractory to treatment. Future clinical research should focus on this refractory group.

Onset of obsessive-compulsive disorder: premorbid conditions and prodromal phase

This article focuses on the clinical onset of obsessive-compulsive disorder (OCD), specifically addressing the age of onset, gradual and acute onset, and whether there are some types of premorbid conditions or a prodromal phase that predispose individuals to the onset of OCD. Clinical and epidemiological studies have come to different conclusions regarding age at onset as well as regarding differences between the sexes. Data gleaned from research to date have demonstrated a relationship between OCD and obsessive-compulsive personality disorder (OCPD), although OCPD does not appear to be the more prevalent personality disorder among patients with OCD. Preliminary research has suggested that Axis I disorders may predispose individuals to OCD onset; however, the significance of this relationship remains to be clarified. Evidence of the association between OCD and subthreshold obsessive-compulsive syndrome suggests that these disorders lie on a continuum of severity, with some cases developing OCD while others do not.

Clinical features of obsessive-compulsive disorder

The past decade has seen tremendous strides in the knowledge about the cause, epidemiology, and treatment of OCD. Research on clinical characteristics of the disorder have focused on several areas, including identification of subtypes, the role of insight, and patterns of comorbidity. Several studies looking at course of illness in OCD have found that, for adults with this disorder, the course is usually chronic, but increasing evidence shows that a subtype of OCD characterized by an episodic course may exist, and research is focusing on delineating that subtype more specifically. Another hypothesized subtype, which may be related to rheumatic fever, involves patients with both OCD and chronic tic disorders. Certain obsessions and compulsions are more common in patients with these two disorders; together with the familial transmission and treatment data, this suggests that these patients may represent a meaningful subtype. Another area of focus over the past 10 years has been the role of insight. Increasing evidence shows that a range of insight exists in patients with OCD. Whether patients with poor insight have a different treatment response or different course than do patients with better insight remains to be seen. Finally, comorbidity between OCD and schizophrenia has been an area of interest. Emerging evidence shows that obsessions and compulsions are more common in patients with schizophrenia than was previously thought. The effect of obsessions and compulsions on schizophrenia in terms of treatment response and course is being investigated. Despite tremendous advances in treatment of this potentially debilitating disorder, a significant percentage of patients do not respond to standard treatment. Continued research to identify meaningful subtypes in OCD is necessary to unravel important questions concerning cause and to develop specific treatment strategies for refractory patients.

The internal and external boundaries of obsessive-compulsive disorder

OBJECTIVE

This study aims to explore the internal and external boundaries of obsessive-compulsive disorder (OCD).

METHOD

Selected literature is reviewed.

RESULTS

Prevalence and incidence estimates for OCD vary markedly according to diagnostic criteria applied. External boundaries of the disorder are permeable, with a large degree of overlap with other psychiatric disorders, and an association with certain neurological disorders. Some cases of OCD appear to have a neurodevelopmental origin.

CONCLUSIONS

Further delineation of disorders characterised by obsessional and compulsive symptoms can inform models of aetiology, pathophysiology and treatment.

Obsessive-compulsive disorder subgroups: a symptom-based clustering approach

Although obsessive-compulsive disorder (OCD) is often considered a heterogeneous condition, there is no generally accepted subtype typology. Cluster analysis was used to identify definitive symptom-based groupings of 106 OCD patients. A stable cluster solution was achieved and five patient subgroups were identified based on their pattern of symptoms on the Yale-Brown (Y-BOCS) symptom checklist: harming, hoarding, contamination, certainty and obsessionals. The five subgroups were characterized by dominant symptom patterns and significant secondary concerns reflecting the symptom heterorgenaity often seen in the clinical presentation of obsessional patents. Between cluster differences on multiple symptom measures were evaluated and several meaningful differences were identified. Cluster analytic procedures may prove to be a useful tool for identifying a functional taxonomy of OCD subtypes.

Diagnosis of obsessive-compulsive illness

Obsessive-compulsive illness has long been subject to diagnostic neglect. Moreover, obsessive-compulsive features often underlie or are intercurrent with other symptom pictures and may be quite debilitating. Diagnostic dilemmas are discussed regarding obsessive-compulsive illness and its relation to eating disorders, generalized anxiety disorder, mood disorders, alcohol abuse, and adult attention deficit disorder. Some difficulties in eliciting and recognizing obsessive-compulsive illness are presented. These include patient secrecy, shame, and social and personality features of health professionals. Specific pharmacologic and therapeutic interventions are effective when directed at the intercurrent or underlying obsessive-compulsive illness.

Personality disorders in patients with obsessive-compulsive disorder in Japan

A total of 75 patients with obsessive-compulsive disorder (OCD) were studied in order to investigate the characteristics of OCD symptoms and the comorbidity of personality disorders (PD). Contamination obsessions and checking compulsions were most commonly found in patients, of whom 53% met the criteria for at least one PD. Among comorbid PD, the anxious-fearful (cluster C) PDs, such as avoidant, obsessive-compulsive and dependent PD, were most prevalent, followed by the odd-eccentric (cluster A) PDs, such as paranoid and schizotypal PD. The patients with PD had more severe social maladaptation and concurrent depressive and anxious symptoms than the patients without any PD, despite the similar severity of OCD symptoms. These results are consistent with those reported in the Western world, and are considered to be relatively stable cross-culturally.

Obsessionality in anorexia nervosa: the moderating influence of exercise

OBJECTIVE

Research has confirmed substantial links between OCD and AN. Not only are there psychopathological similarities between the two syndromes, but a marked neurochemical correspondence. Extensive exercising is a common feature of AN and also has relevance in its links with OCD. There is evidence from the exercise-induced weight-loss syndrome in animals that exercise and caloric restriction, in combination, tend to increase serotonergic activity in a synergistic manner. This syndrome has been proposed as a valid model of OCD as well as for AN. To date, little research has directly tested this theory in the human condition.

METHOD

Fifty-three AN patients were categorized as high-level exercisers (N = 22) or moderate/nonexercisers (N = 31) based on the frequency of their physical activity over the year before assessment.

RESULTS

Exercisers scored significantly higher on a measure of OC personality characteristics, OC symptomatology, and perfectionism--a personality factor associated with the development of Obsessive-Compulsive Personality Disorder. On the other hand, there were no group differences on other salient eating disorder characteristics such as body esteem, self-esteem, or weight preoccupation. There were also no differences in degree of emaciation as indicated by Body Mass Index.

CONCLUSIONS

Findings suggest that among AN patients obsessional personality characteristics are linked to high-level exercising, and that exercising is associated with a greater degree of OC symptomatology. Results are discussed in the context of current theories of AN, OCD, and some biological mechanisms.