Are the symptoms of obsessive-compulsive disorder temporally stable in children/adolescents? A prospective naturalistic study

Stability and transition likelihood of primary symptoms in adults with obsessive-compulsive disorder: A 5-year prospective follow-up study

BACKGROUND

Obsessive-compulsive disorder (OCD) has a chronic course. However, limited longitudinal research exists on whether adults with OCD tend to maintain the same cluster of symptoms and how those symptoms may change over time. The present study aimed to examine the stability of primary OCD symptoms across 5 years and describe how symptoms change within individuals.

METHODS

107 treatment-seeking adults with primary OCD participated in a naturalistic prospective study on the course of OCD. Primary obsessions and compulsions were assessed using the Yale-Brown Obsessive Compulsive Scale at baseline, year 2, and year 5. Markov transition probabilities were calculated to assess the likelihood of symptom change from one of the nine primary obsession categories and seven compulsion categories to another at follow-up.

RESULTS

Symptom stability varied across categories. Contamination, hoarding, symmetry, and responsibility for harm obsessions were generally stable, along with hoarding, cleaning, and checking compulsions. Conversely, somatic, aggressive, religious, sexual, and miscellaneous obsessions tended to change, along with repeating, counting, and ordering/arranging compulsions. Aggressive, religious, and sexual obsessions most often switched to one of the other two categories at follow-up. Overall, OCD symptom stability decreased over longer follow-up periods.

LIMITATIONS

Symptom stability was only assessed between baseline and years 2 and 5. Therefore, possible changes between years 2 and 5 remain unclear.

CONCLUSIONS

OCD symptoms are relatively stable over time; however, specific symptoms may be more likely to vary. Future research should investigate factors underlying stable and unstable symptoms, as well as the impact of treatment on symptom stability.

Measuring symptoms of obsessive-compulsive and related disorders using a single dimensional self-report scale

BACKGROUND

Obsessions and compulsions are heterogenous but can be classified into obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder (HD), hair-pulling disorder (HPD), and skin-picking disorder (SPD). OCD is in itself heterogenous, with symptoms clustering around four major symptom dimensions: contamination/cleaning, symmetry/ordering, taboo obsessions, and harm/checking. No single self-report scale captures the full heterogeneity of OCD and related disorders, limiting assessment in clinical practice and research on nosological relations among the disorders.

METHODS

To provide a single self-report scale of OCD and related disorders that respects the heterogeneity of OCD, we expanded the DSM-5-based Obsessive-Compulsive and Related Disorders-Dimensional Scales (OCRD-D) so that is also includes the four major symptom dimensions of OCD. A psychometric evaluation and an exploration of the overarching relations among the dimensions were conducted using an online survey which was completed by 1,454 Spanish adolescents and adults (age span = 15-74 years). Approximately 8 months after the initial survey, 416 participants completed the scale again.

RESULTS

The expanded scale showed excellent internal psychometric properties, adequate test-retest correlations, known groups validity, and correlations in the expected directions with well-being, depression/anxiety symptoms, and satisfaction with life. The higher-order structure of the measure indicated that harm/checking and taboo obsessions formed a common disturbing thoughts factor and that HPD and SPD formed a common body-focused repetitive behaviors factor.

CONCLUSION

The expanded OCRD-D (OCRD-D-E) shows promise as a unified way to assess symptoms across the major symptom dimensions of OCD and related disorders. The measure may be useful in clinical practice (e.g., screening) and research, but more research on construct validity, incremental validity, and clinical utility is needed.

Towards a definitive symptom structure of obsessive-compulsive disorder: a factor and network analysis of 87 distinct symptoms in 1366 individuals

BACKGROUND

The symptoms of obsessive-compulsive disorder (OCD) are highly heterogeneous and it is unclear what is the optimal way to conceptualize this heterogeneity. This study aimed to establish a comprehensive symptom structure model of OCD across the lifespan using factor and network analytic techniques.

METHODS

A large multinational cohort of well-characterized children, adolescents, and adults diagnosed with OCD (N = 1366) participated in the study. All completed the Dimensional Yale-Brown Obsessive-Compulsive Scale, which contains an expanded checklist of 87 distinct OCD symptoms. Exploratory and confirmatory factor analysis were used to outline empirically supported symptom dimensions, and interconnections among the resulting dimensions were established using network analysis. Associations between dimensions and sociodemographic and clinical variables were explored using structural equation modeling (SEM).

RESULTS

Thirteen first-order symptom dimensions emerged that could be parsimoniously reduced to eight broad dimensions, which were valid across the lifespan: Disturbing Thoughts, Incompleteness, Contamination, Hoarding, Transformation, Body Focus, Superstition, and Loss/Separation. A general OCD factor could be included in the final factor model without a significant decline in model fit according to most fit indices. Network analysis showed that Incompleteness and Disturbing Thoughts were most central (i.e. had most unique interconnections with other dimensions). SEM showed that the eight broad dimensions were differentially related to sociodemographic and clinical variables.

CONCLUSIONS

Future research will need to establish if this expanded hierarchical and multidimensional model can help improve our understanding of the etiology, neurobiology and treatment of OCD.

Health anxiety symptoms in pediatric obsessive-compulsive disorder: patient characteristics and effect on treatment outcome

The aim was to explore the potential clinical role of health anxiety (HA) symptoms in children and adolescents diagnosed with obsessive-compulsive disorder (OCD). The study investigated differences in demographic and various clinical variables between young people with OCD, with and without HA symptoms, and the effect of HA symptoms on overall OCD treatment outcome. The study sample comprised 269 children and adolescents with OCD (aged 7-17 years) from the large Nordic Long-term OCD Treatment Study. OCD symptoms and severity were assessed with The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS), which includes one item regarding HA-like obsessions and one item regarding HA-like compulsions that were used to define the HA group. Several other instruments were used to assess comorbidity and other clinical aspects. All participants were treated with 14 weekly protocolled sessions of exposure-based cognitive behavioral therapy (CBT). HA symptoms were present in 31% of participants. Other anxiety symptoms and comorbid anxiety disorders were more prevalent among those with HA symptoms. These patients also presented with significantly more types of OCD symptoms. HA symptoms were reduced following OCD treatment with CBT and having HA symptoms did not affect CBT outcome. Results suggest that pediatric OCD with HA symptoms is characterized by more anxiety symptoms and a more heterogeneous OCD symptom profile. Standardized CBT seems equally effective in treating child and adolescent OCD with or without HA symptoms.Clinical trials registration: Nordic Long-term Obsessive-Compulsive Disorder Treatment Study: www.controlled-trials.com ; ISRCTN66385119.

Cognitive Beliefs Across the Symptom Dimensions of Pediatric Obsessive-Compulsive Disorder: Type of Symptom Matters

The cognitive model of obsessive-compulsive disorder (OCD) posits that dysfunctional cognitive beliefs are crucial to the onset and maintenance of OCD; however, the relationship between these cognitive beliefs and the heterogeneity of OCD symptoms in children and adolescents remains unknown. We examined how the major belief domains of the cognitive model (inflated responsibility/threat estimation, perfectionism/intolerance of uncertainty, importance/control of thoughts) and dysfunctional metacognitions were related to OCD symptoms across the following dimensions: doubting/checking, obsessing, hoarding, washing, ordering, and neutralization. Self-report ratings from 137 treatment-seeking youth with OCD were analyzed. When cognitive beliefs and symptom dimensions were analyzed in tandem, inflated responsibility/threat estimation and dysfunctional metacognitions were uniquely related to doubting/checking, obsessing, and hoarding and perfectionism/intolerance of uncertainty to ordering. Cognitive beliefs explained a large proportion of variation in doubting/checking (61%) and obsessing (46%), but much less so in ordering (15%), hoarding (14%), neutralization (8%), and washing (3%). Similar relations between cognitive beliefs and symptom dimensions were present in children and adolescents. Cognitive beliefs appear to be relevant for pediatric OCD related to harm, responsibility, and checking, but they do not map clearly onto contamination and symmetry-related symptoms. Implications for OCD etiology and treatment are discussed.

A dimensional perspective on the genetics of obsessive-compulsive disorder

This review covers recent findings in the genomics of obsessive-compulsive disorder (OCD), obsessive-compulsive symptoms, and related traits from a dimensional perspective. We focus on discoveries stemming from technical and methodological advances of the past five years and present a synthesis of human genomics research on OCD. On balance, reviewed studies demonstrate that OCD is a dimensional trait with a highly polygenic architecture and genetic correlations to multiple, often comorbid psychiatric phenotypes. We discuss the phenotypic and genetic findings of these studies in the context of the dimensional framework, relying on a continuous phenotype definition, and contrast these observations with discoveries based on a categorical diagnostic framework, relying on a dichotomous case/control definition. Finally, we highlight gaps in knowledge and new directions for OCD genetics research.

Risk factors for obsessive-compulsive symptoms. Follow-up of a community-based youth cohort

Environmental factors are at least as important as genetic factors for the development of obsessive-compulsive symptoms (OCS), but the identification of such factors remain a research priority. Our study aimed to investigate the association between a broad scope of potential risk factors and OCS in a large community cohort of children and adolescents. We evaluated 1877 participants and their caregivers at baseline and after 3 years to assess various demographic, prenatal, perinatal, childhood adversity, and psychopathological factors. Mean age at baseline was 10.2 years (SD 1.9) and mean age at follow-up was 13.4 years (SD 1.9). Reports of OCS at baseline and follow-up were analyzed using latent variable models. At preliminary regression analysis, 15 parameters were significantly associated with higher OCS scores at follow-up. At subsequent regression analysis, we found that eight of these parameters remained significantly associated with higher follow-up OCS scores while being controlled by each other and by baseline OCS scores. The significant predictors of follow-up OCS were: lower socioeconomic status (p = 0.033); lower intelligence quotient (p = 0.013); lower age (p < 0.001); higher maternal stress level during pregnancy (p = 0.028); absence of breastfeeding (p = 0.017); parental baseline OCS (p = 0.038); youth baseline anxiety disorder (p = 0.023); and youth baseline OCS scores (p < 0.001). These findings may better inform clinicians and policymakers engaged in the mental health assessment and prevention in children and adolescents.

Obsessive-compulsive symptoms and their links to depression and anxiety in clinic- and community-based pediatric samples: A network analysis

BACKGROUND

Symptoms of depression and anxiety are common in children with obsessive-compulsive disorder (OCD) and associated with more severe OCD, greater impairment, and worse treatment outcome. Beyond twin studies showing that genetic factors contribute to the high co-occurrence, few studies have examined how OCD, depression, and anxiety are linked in youth, and current studies often fail to account for OCD and anxiety heterogeneity.

METHODS

Network analysis was used to investigate how OCD were linked to depression and anxiety in multinational youth diagnosed with OCD (total n = 419) and in school-recruited, community-based samples of youth (total n = 2 991).

RESULTS

Initial results aligned with earlier work showing that severity of obsession-related symptoms are important in linking OCD to depression in youth with OCD. However, when symptom content of OCD (e.g., washing, ordering) was fully taken into account and when measures of anxiety were included, specific OCD symptom dimensions (primarily obsessing and doubting/checking) were linked to specific anxiety dimensions (primarily panic and generalized anxiety) which in turn were linked to depression. These results were replicated in three separate community-based samples from Chile, Italy, and Spain using different measures of anxiety and depression.

LIMITATIONS

Cross-sectional data were analyzed which precludes causal inference. Self-report measures were used.

CONCLUSIONS

Youth with OCD with symptoms related to doubting/checking and obsessing should be carefully assessed for symptoms of panic and generalized anxiety. Non-responders to standard OCD treatment may benefit from interventions targeting panic and generalized anxiety, but more research is needed to test this hypothesis.

Obsessive-Compulsive Symptomatology in Community Youth: Typical Development or a Red Flag for Psychopathology?

OBJECTIVE

Obsessive-compulsive symptoms (OCS) are common throughout development and often considered developmentally appropriate. We evaluated the prevalence and phenotypic heterogeneity of self-reported OCS in a large community youth sample not ascertained for seeking mental-health help. We aimed to identify patterns in OCS that are associated with serious psychopathology and may thus represent a "red flag" that merits psychiatric evaluation.

METHOD

Data were analyzed from youth from the Philadelphia Neurodevelopmental Cohort (N = 7,054, aged 11-21 years, 54% female). Participants underwent structured psychiatric interviews, including screening for OCS (8 obsessions, 8 compulsions, and hoarding) and other major psychopathology domains. Factor analysis was conducted to identify clustering of OCS presentation. Regression models were used to investigate association of OCS with threshold lifetime diagnoses of obsessive-compulsive disorder (OCD), depressive episode, psychosis, and suicide ideation.

RESULTS

OCS were common in non-mental health-seeking individuals (38.2%), although only 3% met threshold OCD criteria. OCS were more common in female participants and postpuberty. Factor analyses resulted in 4 factors: F1 - Bad Thoughts; F2 - Repeating/Checking; F3 - Symmetry; F4 - Cleaning/Contamination; and Hoarding as a separate item. All OCS were associated with higher rates of OCD, depression, psychosis, and suicide ideation. However, endorsement of F1 symptoms, prevalent in more than 20% of the sample, showed the most substantial associations with major psychiatric conditions.

CONCLUSION

OCS are common in community youth. Although for most youths OCS symptoms may be benign, some patterns of OCS are associated with major psychiatric conditions. These findings may help to identify youth at risk for serious psychopathology.

Validation of an interview-only version of the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) in treatment-seeking youth with obsessive-compulsive disorder

There is a growing body of evidence suggesting that individuals with obsessive-compulsive disorder (OCD) may be sub-typed along different symptom dimensions. These dimensions may help explain responsiveness to current treatments. The Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) is a validated instrument involving a self-report screening tool followed by a structured interview in which the presence/absence and severity of OCD symptom dimensions are assessed and rated. The present study investigated the validity of a briefer, interview-only version of the DY-BOCS modified for use in routine care. Clinically-referred children and adolescents (N = 119) with OCD were administered the DY-BOCS along with other measures of OCD, anxiety, depression, and overall functioning and a subset (N = 100) were reassessed on average 14 months after initial assessment. This briefer, interview-only version of the DY-BOCS demonstrated high levels of internal consistency and correlated in the moderate to strong range with alternative measures of OCD severity and OCD symptom dimensions. Change scores on the DY-BOCS from baseline to follow-up were significantly correlated with change scores on the alternative measures of OCD and clinician-rated improvement, suggesting that this brief version of the DY-BOCS is valid and sensitive to the effects of treatment for OCD delivered in routine clinical care.

A multilevel longitudinal study of obsessive compulsive symptoms in adolescence: male gender and emotional stability as protective factors

The severity of obsessive compulsive symptoms (OCS) is suggested to be normally distributed in the general population, and they appear to have an impact on a range of aspects of adolescent development. Importantly, there are individual differences regarding susceptibility to OCS. In the present repeated measures study, OCS were studied in relation to gender and emotional stability (as a personality trait) using a normative sample of 515 adolescents at ages 16 and 18 years. OCS were assessed with the relevant subscale of the SCL-90-R and emotional stability with the Five Factor Questionnaire. A three-level hierarchical linear model was calculated to longitudinally assess the over time variations of OCS and their over time links to gender and emotional stability, while controlling for random effects due to the nesting of the data. Experiencing OCS increased with age (between 16 and 18 years). Additionally, male gender and higher emotional stability were associated with lower OCS at 16 years and these remained stable over time. Results indicate age-related and between individual differences on reported OCS that need to be considered for prevention and intervention planning.

Children with Obsessive-Compulsive Symptomology in the General Population: Different Subtypes?

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a moderately prevalent neurodevelopmental disorder, and many children suffer from subclinical obsessive-compulsive (OC) symptoms. The disorder is heterogeneous and has high comorbidity rates. In early disease stages of psychiatric disorders, symptoms are typically hard to attribute exclusively to specific disorders. The authors investigated whether profiles of neuropsychiatric symptoms can be distinguished within a large population-based study of school-aged children (7-10 years) scoring high on OC symptoms.

METHODS

OC symptoms and comorbid symptoms common in pediatric OCD were assessed: symptoms of attention-deficit hyperactivity disorder, oppositional defiant disorder, autism, and anxiety. Latent profile analysis was performed on the subgroup of children scoring high on OC symptoms (high-OC sample, n = 209, i.e., 4.5% of total sample, n = 4632) using the z scores of the measures of comorbid symptoms as indicators.

RESULTS

Three distinguishable profiles were found within the high-OC sample. The first subgroup ("OC-specific"; 81.3%, 3.7% of total sample) had only OC-specific problems, the second subgroup ("Comorbid OC"; 11.0%, 0.5% of total sample) had high scores on all measures of comorbid symptomology, and the third subgroup ("Autistic OC"; 7.7%, 0.3%, of total sample) scored especially high on autism.

CONCLUSION

The findings show that profiles based on neuropsychiatric symptoms can be distinguished within a population-based sample of school-aged children scoring high on obsessive-compulsive symptoms. These profiles may be useful in establishing patterns of symptom course during development. Longitudinal follow-up is necessary to ascertain whether at a later age these subgroups still differ in their symptom profile and neuropsychiatric trajectory.