The use of antibody D8/17 to identify B cells in adults with obsessive-compulsive disorder

The Psychopharmacology of Obsessive-Compulsive Disorder: A Preclinical Roadmap

This review evaluates current knowledge about obsessive-compulsive disorder (OCD), with the goal of providing a roadmap for future directions in research on the psychopharmacology of the disorder. It first addresses issues in the description and diagnosis of OCD, including the structure, measurement, and appropriate description of the disorder and issues of differential diagnosis. Current pharmacotherapies for OCD are then reviewed, including monotherapy with serotonin reuptake inhibitors and augmentation with antipsychotic medication and with psychologic treatment. Neuromodulatory therapies for OCD are also described, including psychosurgery, deep brain stimulation, and noninvasive brain stimulation. Psychotherapies for OCD are then reviewed, focusing on behavior therapy, including exposure and response prevention and cognitive therapy, and the efficacy of these interventions is discussed, touching on issues such as the timing of sessions, the adjunctive role of pharmacotherapy, and the underlying mechanisms. Next, current research on the neurobiology of OCD is examined, including work probing the role of various neurotransmitters and other endogenous processes and etiology as clues to the neurobiological fault that may underlie OCD. A new perspective on preclinical research is advanced, using the Research Domain Criteria to propose an adaptationist viewpoint that regards OCD as the dysfunction of a normal motivational system. A systems-design approach introduces the security motivation system (SMS) theory of OCD as a framework for research. Finally, a new perspective on psychopharmacological research for OCD is advanced, exploring three approaches: boosting infrastructure facilities of the brain, facilitating psychotherapeutic relearning, and targeting specific pathways of the SMS network to fix deficient SMS shut-down processes. SIGNIFICANCE STATEMENT: A significant proportion of patients with obsessive-compulsive disorder (OCD) do not achieve remission with current treatments, indicating the need for innovations in psychopharmacology for the disorder. OCD may be conceptualized as the dysfunction of a normal, special motivation system that evolved to manage the prospect of potential danger. This perspective, together with a wide-ranging review of the literature, suggests novel directions for psychopharmacological research, including boosting support systems of the brain, facilitating relearning that occurs in psychotherapy, and targeting specific pathways in the brain that provide deficient stopping processes in OCD.

Individualized Immunological Data for Precise Classification of OCD Patients

Obsessive⁻compulsive disorder (OCD) affects about 2% of the general population, for which several etiological factors were identified. Important among these is immunological dysfunction. This review aims to show how immunology can inform specific etiological factors, and how distinguishing between these etiologies is important from a personalized treatment perspective. We found discrepancies concerning cytokines, raising the hypothesis of specific immunological etiological factors. Antibody studies support the existence of a potential autoimmune etiological factor. Infections may also provoke OCD symptoms, and therefore, could be considered as specific etiological factors with specific immunological impairments. Finally, we underline the importance of distinguishing between different etiological factors since some specific treatments already exist in the context of immunological factors for the improvement of classic treatments.

Markers of susceptibility to acute rheumatic fever: the B-cell antigen D8/17 is not robust as a marker in South Africa

BACKGROUND

Acute rheumatic fever and its chronic sequelae, rheumatic cardiac disease, and neuropsychiatric movement disorders, remain major public health problems in South Africa. Early identification and treatment of streptococcal pharyngitis in susceptible individuals would prevent rheumatic cardiac disease. The B-cell antigen D8/17 is a marker of susceptibility to rheumatic fever in some populations.

METHODS AND RESULTS

We assessed the significance of the D8/17 marker in a group of South Africans. Blood was collected from 107 individuals; 40 patients had previous confirmed rheumatic fever, 20 were first-degree relatives, and 47 were controls. The expression of D8/17 in each sample was analysed by flow cytometry. The mean proportion of B-cells that were D8/17 positive was 0.5% in the index cases, 0.47% in their relatives, and 0.27% in the controls. There was a significant difference between the index cases and the controls, p = 0.03, but the mean percentage positive in each group was very low.

CONCLUSIONS

Patients with a history of rheumatic fever had statistically increased expression of the D8/17 marker. However, the actual percentages in this observational study were markedly lower than in other populations, ranging from 0.14%-1.53% compared to 11.6%-39.3%. The D8/17 marker would be an impractical screening tool in the South African population.

Sydenham's chorea

Sydenham's chorea (SC) is the neurologic expression of acute rheumatic fever (ARF). Despite the declining incidence of ARF worldwide, it remains the most common cause of acute chorea in children. It is characterized by a combination of motor and nonmotor features. In addition to chorea, among the first are decreased muscle tone and tics. Nonmotor features include obsessions, compulsions, attention deficit, emotional lability, decreased verbal fluency, and executive dysfunction. Most patients present with nonneurologic features of ARF, such as carditis and arthritis. The pathogenesis is thought to involve streptococcus-induced antibodies which cross-react with antigens of the basal ganglia. The diagnosis is made on purely clinical grounds since there is no biological marker of the illness. The management is based on use of antichoreic agents, such as valproic acid and neuroleptics, and prophylaxis of new bouts of streptococcus infection with antibiotics. Although the motor features of SC come into spontaneous remission in the majority of patients, a significant proportion of individuals remain with persistent chorea.

Normalisation of immune cell imbalance after pharmacological treatments of patients suffering from obsessive-compulsive disorder

Recent data have shown the presence of immunological alterations in adult patients suffering from obsessive-compulsive disorder (OCD). The objective of this study was to examine the possible effects of 12 months of treatment with different serotonergic drugs, such as clomipramine and selective serotonin reuptake inhibitors (SSRIs) on peripheral immunological cells of 18 OCD patients. Both the absolute number and percent of CD4+, CD8+, CD3+, CD19+ and CD56+ cells were measured in peripheral blood before and after treatment by means of a Facstar Flow Sorter apparatus. At baseline, all patients showed a significant increase of CD8+ and decrease of CD4+ lymphocytes when compared with a similar group of healthy control subjects; after the treatment, CD8+ and CD4+ cells, respectively, decreased and increased significantly, and the CD4+/CD8+ ratio increased, when compared with baseline values, in parallel with the clinical improvement. These data suggest that the alterations of immune cells reported in patients with OCD at baseline may be reverted by treatment with SRIs and should be considered a state-dependent marker, perhaps related to a condition of stress.

Obsessive-compulsive disorder and immunology: a review

Interest in the possibility of an immune-mediated pathophysiology of obsessive-compulsive disorder and related disorders has increased. In the late 1980s, the National Institute of Mental Health reported an increase in obsessive-compulsive symptoms (OCS) in patients with Sydenham chorea (SC). Subsequently, a precipitating streptococcal infection in children with sudden onset of OCS but no chorea led to the coining of PANDAS (Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection). This association has furthered interest in biological measures for immune and genetic susceptibility in non-PANDAS obsessive-compulsive disorder patients (OCD). Furthermore, some studies are trying to demonstrate alterations of immune parameters in OCD patients, with few positive results. In this narrative review, our objective was to describe the immunologic findings in OCD, PANDAS, and their association with SC.

What every psychiatrist should know about PANDAS: a review

The term Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus infections (PANDAS) was coined by Swedo et al. in 1998 to describe a subset of childhood obsessive-compulsive disorders (OCD) and tic disorders triggered by group-A beta-hemolytic Streptococcus pyogenes infection. Like adult OCD, PANDAS is associated with basal ganglia dysfunction. Other putative pathogenetic mechanisms of PANDAS include molecular mimicry and autoimmune-mediated altered neuronal signaling, involving calcium-calmodulin dependent protein (CaM) kinase II activity. Nonetheless the contrasting results from numerous studies provide no consensus on whether PANDAS should be considered as a specific nosological entity or simply a useful research framework. Herein we discuss available data that could provide insight into pathophysiology of adult OCD, or might explain cases of treatment-resistance. We also review the latest research findings on diagnostic and treatment.

Autoimmune neuropsychiatric disorders associated with streptococcal infection: Sydenham chorea, PANDAS, and PANDAS variants

Streptococcal infection in children is usually benign and self-limited. In a small percentage of children, prominent neurologic and/or psychiatric sequelae can occur. Sydenham chorea is the best defined and best recognized. PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection) is a well-defined syndrome in which tics (motor and/or vocal) and/or obsessive-compulsive disorder consistently exacerbate in temporal correlation to a group A beta-hemolytic streptococcal infection. PANDAS constitutes a subset of children with tics, Tourette syndrome, and obsessive-compulsive disorder. In addition to strictly defined PANDAS, we and others have recognized several PANDAS variants, including adult-onset variant, a dystonic variant, a myoclonic variant, and a "chronic" PANDAS variant. The nosology and classification of these entities are rapidly evolving. The recognition that some pediatric neurobehavioral syndromes have infectious and/or immunologic triggers points to important new avenues of disease treatment. In this review, we summarize this complex and rapidly evolving area of clinical research.

Immunology of obsessive-compulsive disorder

Childhood OCD often develops into a chronic illness that lasts decades. Proof that some type of immunotherapy (such as antibiotic prophylaxis) could significantly reduce recurrence or exacerbation of symptoms of OC or tics would suggest a supportive role for immune triggers in the onset or worsening of these conditions and provide additional tools for improving outcome. The validity of PANDAS will continue to be questioned, however,because demonstrating a clear causation will be difficult on a background ofa common childhood illness. Along with the previously mentioned immuno-therapy study, validation of the PANDAS phenotype (broadly interpreted)would be advanced from new and continued research in the following areas: (1) prospective studies to identify infectious triggers in the onset and exacerbations of OCD spectrum disorders, (2) biological measures for immune and genetic susceptibility, and (3) large scale epidemiological studies demonstrating the relationship between infection and OCD spectrum disorders. The assimilation of these study results should allow for elucidation of the immune system's role in the onset and maintenance of OCD.

Subtyping obsessive-compulsive disorder: clinical and immunological findings in child and adult onset

It has been suggested that certain kinds of childhood OCD with specific clinical, biological and immunological characteristics may form a subgroup of OCD. We study the presence of these characteristics in child onset OCD and propose that the disorder be considered as a subtype of adult OCD. Forty adult patients with OCD were divided in two groups according to time of disease onset: 18 early onset and 21 late. Both sets were compared with a control group of 14 psychiatric patients. Child onset OCD was associated with higher mean ASLO titers, higher frequencies of history of tic disorders and tonsillitis in childhood and compulsive symptoms. No differences were found in D8/17 antibody titers or in other autoimmune parameters. The findings suggest that child onset OCD can be considered as a subgroup of adult OCD, although more specific biological markers are needed to identify it.

Síndromes neuropsiquiátricas pós-estreptocócicas

Nesta revisão narrativa, o nosso objetivo foi descrever as síndromes neuropsiquiátricas pós-estreptocócicas e discuti-las à luz das evidências científicas atuais sobre os possíveis mecanismos patogenéticos envolvidos. Nos últimos anos, uma série de distúrbios do movimento, como tiques, distonia, parkinsonismo, e transtornos psiquiátricos, como o transtorno obsessivo-compulsivo (TOC) e o transtorno de hiperatividade com déficit de atenção (THDA), vem sendo considerada parte do espectro das manifestações pós-estreptocócicas. O termo PANDAS (acrônimo do inglês: pediatric autoimmune neuropsychiatric disorder associated with streptococcus) foi inclusive cunhado para descrever um subgrupo de pacientes com TOC e tiques que exibe flutuação clínica dos sintomas associada a infecção estreptocócica. Entretanto a análise crítica das evidências clinicolaboratoriais não apóia esse espectro ampliado das manifestações pós-estreptocócicas. Apenas na coréia de Sydenham há evidências consistentes de patogênese mediada por processo auto-imune pós-estreptocócico.

A review of the treatment for refractory obsessive-compulsive disorder: from medicine to deep brain stimulation

This article provides an overview of the etiology, epidemiology, and first-line treatment options for obsessive-compulsive disorder (OCD). The subject of treatment-resistant and treatment-refractory OCD is then discussed, including a definition of these often-debated terms, and the latest treatment options delineated. This includes a review of the latest research concerning the pharmacological agents that have been studied as monotherapy or augmenting agents for the treatment of OCD, the use of experimental medications and procedures, treatment with reversible, minimally invasive procedures, such as vagal nerve stimulation and transcranial magnetic stimulation, invasive but the potentially reversible deep brain stimulation, and irreversible lesioning with ablative psychosurgery. A discussion of the role of psychotherapy in the treatment of OCD is also included.

Distinguishing PANDAS from Sydenham's chorea: case report and review of the literature

Children with Sydenham's chorea and PANDAS (Pediatric autoimmune neuropsychiatric disorders associated with streptococcal throat infections) share an array of neuropsychiatric symptoms and distinguishing one from the other, especially at onset can prove challenging. It is, however, important to distinguish between these two post-streptococcal disorders since their response to therapy differs. Children with Sydenham's chorea require long-term benzathine penicillin prophylaxis to reduce the risk of rheumatic heart disease. In contrast, the efficacy of penicillin prophylaxis in preventing tic or obsessive-compulsive symptom exacerbations in children with PANDAS remains doubtful. Immunomodulatory therapies such as plasma exchange and intravenous immunoglobulin have shown to reduce neuropsychiatric symptom severity in children with PANDAS. Tonsillectomy may also represent an effective treatment option in children severely affected by PANDAS. We present this case to demonstrate the pitfalls in differentiating between these two closely associated conditions in a developing country where the prevalence of rheumatic fever is high.

An immunological marker (D8/17) associated with rheumatic fever as a predictor of childhood psychiatric disorders in a community sample

BACKGROUND

Previous studies have documented that various behavioral disturbances accompany Sydenham's chorea, a neurologic variant of rheumatic fever. Further, an immunological marker associated with rheumatic fever (monoclonal antibody D8/17) has been reported to be elevated in several neuropsychiatric disorders, most frequently tics and obsessive-compulsive disorder. We examined this association in a community sample of children previously identified as being D8/17 positive or negative. It was hypothesized that D8/17 positivity would predict increased rates of tics and obsessive-compulsive disorder, even in the absence of Sydenham's chorea. Possible associations with other disorders accompanying Sydenham's chorea--hyperactivity, anxiety, and depression, also were explored.

METHOD

From 1991 to 1995, 2631 children (mean age = 9.6 +/- 1.6 years) from a low socioeconomic area of Mexico City were screened for the D8/17 marker. In a 2- to 5-year follow-up of 240 of these children (108 positive and 132 negative), structured psychiatric interviews and rating scales were administered to the child and main caretaker. Assessments were conducted and scored blind to the child's D8/17 status.

RESULTS

No association was seen between D8/17 positivity and tics or OCD.

CONCLUSION

This study failed to provide support for the generalized use of D8/17 as a marker of susceptibility to tics and OCD in a community sample.

Cerebrospinal fluid interleukin-6 in obsessive-compulsive disorder and trichotillomania

Recent studies have suggested that neuroimmune abnormalities may play an important role in the pathogenesis of obsessive-compulsive disorder (OCD) and related disorders. This study was undertaken to determine whether cerebrospinal fluid (CSF) concentrations of the proinflammatory cytokine interleukin (IL)-6 differ between OCD and trichotillomania patients and healthy control subjects. Lumbar puncture with a standardized procedure was performed on 26 patients with OCD and 9 with trichotillomania. All patients were drug-free and met DSM-IV criteria. Twenty-six age- and sex-matched healthy volunteers underwent the same procedure. CSF was assayed for IL-6 using a quantitative 'sandwich' enzyme immunoassay technique. Mean+/-S.D. CSF IL-6 levels did not differ between OCD patients (n=26) (2.4+/-1.1 pg/ml) and controls (n=26) (2.4+/-1.9 pg/ml) or between trichotillomania patients (n=9) (2.3+/-0.8 pg/ml) and their matched controls (n=14) (1.9+/-0.5 pg/ml). These findings fail to support speculation that ongoing immune activation may be causally involved in the pathogenesis of OCD or trichotillomania.

Obsessive-compulsive disorder

Obsessive-compulsive disorder is a frequent, chronic, costly, and disabling disorder that presents in several medical settings, but is under-recognised and undertreated. For many years, obsessive-compulsive neurosis was seen as a disorder that provided an important window on the workings of the unconscious mind. Today, obsessive-compulsive disorder is viewed as a good example of a neuropsychiatric disorder, mediated by pathology in specific neuronal circuits, and responsive to specific pharmacotherapeutic and psychotherapeutic interventions. In the future we can expect more precise delineation of the origins of this disorder, with integration of data from neuroanatomical, neurochemical, neuroethological, neurogenetic, and neuroimmunological research.