Clinical features of obsessive-compulsive disorder

The effects of psychological flexibility and resilience on psychopharmacological treatment response in patients with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a challenging psychiatric condition to treat. Previous research has explored various aspects of treatment response, but limited attention has been given to the significance of psychological flexibility and resilience. This study aimed to investigate the correlation between psychological flexibility, resilience, and different dimensions of OCD, as well as their role in treatment response specifically concerning OCD symptom sub-dimensions. The study involved 50 OCD patients and 42 healthy individuals as controls. Participants completed the Dimensional Obsessive-Compulsive Scale (DOCS), Acceptance and Action Questionnaire (AAQ-2), and Resilience Scale for Adults (RS). Initial scale scores were compared to post-treatment scores obtained after a 3-month follow-up using pharmacotherapy. The patient group exhibited significantly higher AAQ-2 scores and lower RS scores compared to the control group. During the post-treatment follow-up, a reduction in DOCS and AAQ-2 scores was observed, along with an increase in RS scores. The impact of differences in AAQ-2 and RS scores on the change in DOCS total scores was analyzed using mixed model linear regression analysis. The results showed a statistically significant effect of changes in AAQ-2 and RS sub-dimension scores on the change in DOCS total scores. The findings highlight the importance of flexibility and resilience in influencing treatment response among patients with OCD. When conventional pharmacotherapy and psychotherapy approaches prove insufficient, interventions focused on enhancing flexibility and resilience may contribute to improved treatment outcomes.

Comparison of accidental findings of brain magnetic resonance imaging of patients with obsessive-compulsive disorder and healthy controls

BACKGROUND

Abnormalities in brain magnetic resonance imaging (MRI) have been reported in drug-naive and chronic patients with obsessive-compulsive disorder (OCD). The Fazekas scale is a method used to categorize and grade the severity of white matter hyperintensities (WMH) in brain MRI. These lesions can be indicative of various neurological conditions, particularly small vessel disease or cerebrovascular pathology.

METHODS

Brain MRIs of patients followed up with the diagnosis of OCD were retrospectively analyzed. 58 OCD (36 females, 22 males) and 58 healthy controls (HC) (30 females, 28 males) were included in the study. Age, gender, and brain MRI findings of the participants were recorded.

RESULTS

The mean ages of the OCD and HC groups were 33.4 ± 10.6 and 35.9 ± 9.3. There was no difference between the groups in terms of mean ages and gender distribution (p = 0.180 and p = 0.260, accordingly). Generalized cerebral atrophy was more common in patients with OCD than in HC (p = 0.008). Fazekas grade 1 was detected in 17.2% of the patients with OCD and 1.7% of HC. Accordingly, it was significantly more common in Fazekas grade 1 OCD patients (p = 0.002). Fazekas grade 2 was detected in only 2 patient with OCD. CVI was present in 20.7% of the patients with OCD and 1.7% of HC. There was a significant difference between the groups regarding CVI (p = 0.001). Ethmoidal thickening was more common in patients with OCD than in HC (p = 0.004). The YBOCS scores and ages of OCD patients with Fazekas grade 1 and 2 were significantly higher than those of patients with Fazekas grade 0. Likewise, the YBOCS scores and ages of OCD patients with generalized cerebral atrophy were significantly higher than those of patients without atrophy.

CONCLUSION

It is understood from the present study's findings that CVI, a neurodevelopmental malformation, is more common in patients with OCD. Due to the potential relationship of this anomaly with neuronal migration, it would be appropriate to pay attention to OCD symptoms in individuals with CVI and to perform white matter examination on brain imaging. In future studies, Fazekas grade can be evaluated in drug-naive OCD patients, and data on the pre-disease period can be obtained.

Long-term stability in obsessive thoughts and compulsive behavior in the general population: a longitudinal study in Sweden

OBJECTIVE

Obsessive thoughts and compulsive behavior and their related disorder Obsessive-Compulsive Disorder (OCD) commonly occur in the general population. Clinical populations indicate a high level of stability, although there are few longitudinal studies in the general population. The recommended drug treatments are SSRIs/TCAs. However, there are few long-term follow up studies. The goal of this study was to 1) examine the occurrence and stability of obsessions, compulsions, and OCD in a longitudinal population-based survey, 2) investigate the use of SSRI and TCA and the potential effect on symptoms.

METHODS

A ten-year longitudinal general population in Stockholm was used (2000 and 2010, n = 5650) Obsessional washing, checking, intrusive unpleasant thoughts and the level of suffering due to these symptoms were measured by self-report. Information on use of SSRIs and TCAs by these individuals was obtained from registers. Stability was examined using contingency tables and multinomial logistic regression.

RESULTS

At baseline, 2.1, 11.7 and 11.9% reported obsessional washing, checking and intrusive thoughts. A total of 5% reported considerable suffering from these (i.e. OCD). Based on psychiatric interview only 0.4% had OCD. Ten years later a quarter of OCD cases were still classified as having OCD, one quarter reported any obsessive or compulsive symptom and half were classified as symptom-free. Treatment receipt was low and controlling for medication did not change the stability.

CONCLUSION

Obsessive thoughts and compulsive behavior are common and stable. While this group is potentially undertreated, there is no indication that those treated display a different pattern of recovery.

The prevalence and severity of misophonia in the Turkish population and validation of the Amsterdam Misophonia Scale-Revised

The Amsterdam Misophonia Scale-Revised (AMISOS-R) is a self-report scale that measures the presence and severity of symptoms experienced in response to specific auditory stimuli. This cross-sectional, descriptive study aims to evaluate psychometric properties of the AMISOS-R in the Turkish language and to examine psychosocial factors associated with misophonia. A total of 374 individuals (female/male: 154/220) between 15 and 45 years of age were included in the study. Confirmatory factor analysis showed that the fit indices were at a good level, and they supported the single-factor structure. Test-retest results and Cronbach's alpha coefficient showed that the scale had high reliability. Misophonia scores were also found to be moderately correlated with obsessive-compulsive disorder and neuroticism. The AMISOS-R was found to be a valid and reliable tool to evaluate misophonia in the Turkish language.

Impact of sertraline daily treatment regimen on adherence, persistence and healthcare resource utilisation in patients with major depressive disorder or obsessive-compulsive disorder: A real-world evidence analysis from the United States

OBJECTIVE

To generate real-world evidence (RWE) from the United States to assess the impact of pill burden and the importance of achieving a stable daily dose of sertraline (time taken, number of dose adjustments needed) on adherence/persistence and healthcare resource utilisation (HCRU).

METHODS

Retrospective analysis of the PharMetrics^® Plus database (1 October 2012 to 31 March 2020) in the United States. Eligible patients had major depressive disorder (MDD) or obsessive-compulsive disorder (OCD) and ≥1 claim for sertraline during index period (1 April 2013 to 31 March 2019, allowing 6-months prior, 1-year post-index follow-up). Patients who achieved stable daily dose of sertraline (>90 days on same dose) were categorised into five cohorts, depending on pill burden/daily dose: Cohort (1): 1 × 50 mg/d; Cohort (2): 1 × 100 mg/d; Cohort (3): 2 × 50 mg/d; Cohort (4): 1.5 × 100 mg/d; Cohort (5): 3 × 50 mg/d. Impact of pill burden on adherence/persistence and HCRU was assessed among cohorts using logistic regression analysis, and between patients who did vs did not stabilise on therapy. P < .05 was considered significant for all analyses.

RESULTS

Of 224 412 eligible patients, 108 729 stabilised on sertraline (50, 100 or 150 mg/d) and formed Cohorts 1-5. Stabilised patients on lower pill burden had statistically higher adherence and were more likely to remain persistent throughout 1-year post-index period vs patients on higher pill burden but same overall dose (100 mg/d [Cohort 2 vs 3] and 150 mg/d [Cohort 4 vs 5], respectively). Patients who did not stabilise had significantly lower adherence/persistence vs patients who achieved stable daily dose (Cohorts 1-5 combined). Persistence improved when stable daily dose was achieved quickly (within 1-4 months) and efficiently (within 1-3 dose adjustments). Probability of HCRU increased for patients who did not stabilise on their initial prescription.

CONCLUSION

Simplifying treatment regimen and decreasing pill burden improved adherence and/or persistence with sertraline therapy (100 or 150 mg/d). Patients achieving stable daily dose of sertraline in an efficient and timely manner were more likely to remain persistent throughout 1-year follow-up.

Defining functional brain networks underlying obsessive-compulsive disorder (OCD) using treatment-induced neuroimaging changes: a systematic review of the literature

Approximately 2%-3% of the population suffers from obsessive-compulsive disorder (OCD). Several brain regions have been implicated in the pathophysiology of OCD, but their various contributions remain unclear. We examined changes in structural and functional neuroimaging before and after a variety of therapeutic interventions as an index into identifying the underlying networks involved. We identified 64 studies from 1990 to 2020 comparing pretreatment and post-treatment imaging of patients with OCD, including metabolic and perfusion, neurochemical, structural, functional and connectivity-based modalities. Treatment class included pharmacotherapy, cognitive-behavioural therapy/exposure and response prevention, stereotactic lesions, deep brain stimulation and transcranial magnetic stimulation. Changes in several brain regions are consistent and correspond with treatment response despite the heterogeneity in treatments and neuroimaging modalities. Most notable are decreases in metabolism and perfusion of the caudate, anterior cingulate cortex, thalamus and regions of prefrontal cortex (PFC) including the orbitofrontal cortex (OFC), dorsolateral PFC (DLPFC), ventromedial PFC (VMPFC) and ventrolateral PFC (VLPFC). Modulating activity within regions of the cortico-striato-thalamo-cortical system may be a common therapeutic mechanism across treatments. We identify future needs and current knowledge gaps that can be mitigated by implementing integrative methods. Future studies should incorporate a systematic, analytical approach to testing objective correlates of treatment response to better understand neurophysiological mechanisms of dysfunction.

A pilot study examining the use of Goal Management Training in individuals with obsessive-compulsive disorder

BACKGROUND

Recent meta-analyses point towards cognitive impairments in obsessive-compulsive disorder (OCD), particularly in such executive function subdomains as planning and organization. Scant attention has focused on cognitive remediation strategies that may reduce cognitive dysfunction, with a possible corresponding decrease in symptoms of OCD.

OBJECTIVE

The aim of this study was to assess the implementation of a standardized cognitive remediation program, Goal Management Training (GMT), in a pilot sample of individuals with OCD.

METHOD

Nineteen individuals with a primary DSM-5 diagnosis of OCD were randomized to receive either the 9-week GMT program (active group; n = 10) or to complete a 9-week waiting period (waitlist control; n = 9). Groups were assessed at baseline, post-treatment, and 3-month follow-up. The assessment comprised neuropsychological tasks assessing a variety of cognitive domains, and subjective measures of functioning and of symptom severity.

RESULTS

The active condition showed significant improvements from baseline to post-treatment on measures of inattention, impulsivity, problem-solving, and organization compared to controls. Moreover, whereas the active group reported a significant improvement in subjective cognition over the course of treatment, no such improvement emerged in the waitlist group over this same period. Neither group showed improvement on indices of depressive, anxiety, or OCD-related symptom severity.

DISCUSSION

The results of this small pilot investigation indicate that, although promising, this protocol requires several modifications to be best suited for this population. Replication of these findings is awaited, with current results potentially limited by sample characteristics including motivation to seek and complete treatment, and high attrition at 3-month follow-up (n = 6 completers).

TRIAL REGISTRATION

NCT02502604. (December 7, 2018).

Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder

OBJECTIVE

Trichotillomania (TTM) is characterized by the pulling out of one's hair. TTM was classified as an impulse control disorder in DSM-IV, but is now classified in the obsessive-compulsive related disorders section of DSM-5. Classification for TTM remains an open question, especially considering its impact on treatment of the disorder. In this review, we questioned the relation of TTM to tic disorder and obsessive-compulsive disorder (OCD).

METHOD

We reviewed relevant MEDLINE-indexed articles on clinical, neuropsychological, neurobiological, and therapeutic aspects of trichotillomania, OCD, and tic disorders.

RESULTS

Our review found a closer relationship between TTM and tic disorder from neurobiological (especially imaging) and therapeutic standpoints.

CONCLUSION

We sought to challenge the DSM-5 classification of TTM and to compare TTM with both OCD and tic disorder. Some discrepancies between TTM and tic disorders notwithstanding, several arguments are in favor of a closer relationship between these two disorders than between TTM and OCD, especially when considering implications for therapy. This consideration is essential for patients.

Specificity of Childhood Trauma Type and Attenuated Positive Symptoms in a Non-Clinical Sample

BACKGROUND

Childhood traumatic experiences have been consistently associated with psychosis risk; however, the specificity of childhood trauma type to interview-based attenuated positive psychotic symptoms has not been adequately explored. Further, previous studies examining specificity of trauma to specific positive symptoms have not accounted for co-occurring trauma types, despite evidence of multiple victimization.

METHODS

We examined the relationship between childhood trauma (Childhood Trauma Questionnaire) with type of attenuated positive symptom, as measured by the Structured Interview for Psychosis-risk Syndromes (SIPS) among a non-clinical, young adult sample (n = 130). Linear regressions were conducted to predict each attenuated positive symptom, with all trauma types entered into the model to control for co-occurring traumas.

RESULTS

Results indicated that childhood sexual abuse was significantly associated with disorganized communication and childhood emotional neglect was significantly associated with increased suspiciousness/persecutory ideas, above and beyond the effect of other co-occurring traumas. These relationships were significant even after removing individuals at clinical high-risk (CHR) for psychosis (n = 14).

CONCLUSIONS

Our results suggest that there are differential influences of trauma type on specific positive symptom domains, even in a non-clinical sample. Our results also confirm the importance of controlling for co-occurring trauma types, as results differ when not controlling for multiple traumas.

Attenuation of Compulsive-Like Behavior Through Positive Allosteric Modulation of α4β2 Nicotinic Acetylcholine Receptors in Non-Induced Compulsive-Like Mice

Nicotinic α4β2 receptors are the most abundant subtypes of nicotinic acetylcholine receptors (nAChRs) expressed in brain regions implicated in obsessive compulsive disorder (OCD). These receptors are known to modify normal and addictive behaviors by modulating neuronal excitability. Desformylflustrabromine (dFBr) is a novel, positive allosteric modulator (PAM) of high acetylcholine sensitivity (HS) and low acetylcholine sensitivity (LS) α4β2 nAChRs. The present study tested the hypothesis that positive allosteric modulation of α4β2 receptors by dFBr will attenuate compulsive-like behavior in a non-induced compulsive-like mouse model. Male mice (Mus musculus) selected for compulsive-like nesting behavior (NB; 48 animals; 12 per group) received acute (once) and chronic (every day for 32 days) subcutaneous injection of dFBr at 2, 4 and 6 mg/kg doses. Saline was used as a control (0 mg/kg). Compulsive-like NB was assessed after 1, 2, 3, 4, 5 and 24 h, while compulsive-like marble burying (MB) and anxiety-like open field (OF) behaviors were performed 2 h after dFBr administration. In the acute administration protocol, dFBr dose dependently attenuated NB and MB. Rapid effects (1–2 h after drug administration) of dFBr on MB and NB were observed for the chronic administration which was in congruence with the acute study. Chronic administration also revealed sustained suppression of NB by dFBr following 5 weeks of treatment. In both the acute and chronic regimen dFBr did not modulate OF behaviors. This research demonstrates the novel role of positive allosteric modulation of α4β2 nicotinic receptors by dFBr as a translational potential for OCD.

Investigation of the Phenomenological and Psychopathological Features of Trichotillomania in an Italian Sample

Trichotillomania (TTM) is still a scarcely known and often inadequately treated disorder in Italian clinical settings, despite growing evidence about its severe and disabling consequences. The current study investigated the phenomenology of TTM in Italian individuals; in addition, we sought to examine patterns of self-esteem, anxiety, depression, and OCD-related symptoms in individuals with TTM compared to healthy participants. The current study represents the first attempt to investigate the phenomenological and psychopathological features of TTM in Italian hair pullers. One hundred and twenty-two individuals with TTM were enrolled: 24 were assessed face-to-face (face-to-face group) and 98 were recruited online (online group). An additional group of 22 face-to-face assessed healthy controls (HC group) was included in the study. The overall female to male ratio was 14:1, which is slightly higher favoring female than findings reported in literature. Main results revealed that a higher percentage of individuals in the online group reported pulling from the pubic region than did face-to-face participants; furthermore, the former engaged in examining the bulb and running the hair across the lips and reported pulling while lying in bed at higher frequencies than the latter. Interestingly, the online TTM group showed greater functional and psychological impairment, as well as more severe psychopathological characteristics (self-esteem, physiological and social anxiety, perfectionism, overestimation of threat, and control of thoughts), than the face-to-face one. Differences between the two TTM groups may be explained by the anonymity nature of the online group, which may have led to successful recruitment of more serious TTM cases, or fostered more open answers to questions. Overall, results revealed that many of the phenomenological features of Italian TTM participants matched those found in U.S. clinical settings, even though some notable differences were observed; therefore, cross-cultural invariance might represent a characteristic of OCD-related disorders.

Obsessive Compulsive Disorder Presenting as Neurological Emergency

Chronic epilepsy is leading to behavioral changes including obsessive-compulsive symptoms has been well-studied and shown to be about 22%, but the converse has not been reported. Here, we present a case discussion of a 45-year-old female, who presented with recurrent seizures with hyponatremia, which latter was ascribed to her undiagnosed obsessive compulsive disorder (OCD). This patient later did well on anti-obsessional treatment without any antiepileptic. This embarks the need for detailed psychiatric evaluation for patients in emergency care settings and gives a rare presentation of OCD.

Prevalence, incidence, and comorbidity of clinically diagnosed obsessive-compulsive disorder in Taiwan: a national population-based study

Obsessive-compulsive disorder (OCD) is a chronic debilitating anxiety disorder significant in intrusive thoughts and compensation repetitive behaviors. Few studies have reported on this condition Asia. This study estimated the prevalence, incidence and psychiatric comorbidities of OCD in Taiwan. We identified study subjects for 2000-2008 with a principal diagnosis of OCD according to the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic criteria by using National Health Research Institute database. These patients received either outpatient or inpatient care for their condition. Rates were directly age- and sex-adjusted to the 2004 Taiwan population distribution. The estimated mean annual incidence was 27.57 per 10(5) inhabitants and the one year prevalence was 65.05 per 10(5) inhabitants. Incidence and prevalence increased with age, peaking at age 18-24 years in males and at 35-44 years in females. About 53% of adults (≥18 years) and 48% of child and adolescent patients (6-17 years) had one or more comorbid psychiatric conditions. The most common comorbid diagnosis was depressive disorders for both adult and child-adolescent patients. We found a lower prevalence and incidence of clinically diagnosed OCD than that of community studies. Many Asian patients with OCD also had various psychiatric comorbidities, a clinically relevant finding.

The relationship between metacognitions and insight in obsessive-compulsive disorder

This study aimed to determine the relationship between metacognitions and insight in obsessive compulsive disorder. One hundred individuals who had been diagnosed according to "Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision" criteria as having obsessive compulsive disorder and 50 healthy controls are included in the study. A sociodemographic and clinical data form, the Yale-Brown Obsession and Compulsion Scale and the Beck Depression Inventory were given to the participants. Insight is assessed by the 11th item of the Yale-Brown Obsession and Compulsion Scale. The Metacognition Questionnaire-30 was administered to both the obsessive compulsive disorder and the control groups to assess metacognitions. We found that the metacognition scores were statistically different in all groups and that the metacognition scores were higher in the obsessive compulsive disorder with good insight group than in the obsessive compulsive disorder with poor insight and control groups. In the obsessive compulsive disorder with poor insight group, all of the metacognition subscale scores were lower than those in the obsessive compulsive disorder with good insight group. Our findings elucidate the relationship between metacognitions and insight in obsessive compulsive disorder.

A randomized clinical trial to examine enhancing cognitive-behavioral group therapy for obsessive-compulsive disorder with motivational interviewing and thought mapping

BACKGROUND

Obsessive-compulsive disorder (OCD) is characterized by repeated and persistent attempts to control thoughts and actions with rituals. These rituals are used in order to prevent feared or personally distressing outcomes. Cognitive behavioral group therapy (CBGT) has been reported to be effective for treating OCD patients. However, about one-third (30%) of patients do not benefit from CBGT. Some of these patients do not show significant improvement and continue to use rituals following CBGT, partially because they fail to complete the exposure and ritual prevention (ERP) exercises. Consequently, it is important to motivate patients to fully engage in CBGT treatment and complete the ERP exercises.

AIMS

A randomized behavioral trial examined 12 weeks of manual directed CBGT, with the addition of individual sessions of Motivational Interviewing (MI) and Thought Mapping (TM), and compared treatment outcome to the effectiveness of CBGT group alone.

METHOD

Subjects were randomized (n=93) into a CBGT group or a CBGT group with MI+TM.

RESULTS

When the two groups were compared, both groups reduced OCD symptoms. However, symptom reduction and remission were significantly higher in the MI+TM CBGT group. Positive outcomes were also maintained, with additional symptom reduction at the 3-month follow-up for the MI+TM CBGT group.

CONCLUSIONS

Adding two individual sessions of MI and TM before CBGT successfully reduced OCD symptoms and was more effective than using CBGT group alone.

High-dose glycine treatment of refractory obsessive-compulsive disorder and body dysmorphic disorder in a 5-year period

This paper describes an individual who was diagnosed with obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) at age 17 when education was discontinued. By age 19, he was housebound without social contacts except for parents. Adequate trials of three selective serotonin reuptake inhibitors, two with atypical neuroleptics, were ineffective. Major exacerbations following ear infections involving Group A β-hemolytic streptococcus at ages 19 and 20 led to intravenous immune globulin therapy, which was also ineffective. At age 22, another severe exacerbation followed antibiotic treatment for H. pylori. This led to a hypothesis that postulates deficient signal transduction by the N-methyl-D-aspartate receptor (NMDAR). Treatment with glycine, an NMDAR coagonist, over 5 years led to robust reduction of OCD/BDD signs and symptoms except for partial relapses during treatment cessation. Education and social life were resumed and evidence suggests improved cognition. Our findings motivate further study of glycine treatment of OCD and BDD.

Obsessive-compulsive disorder and related disorders: a comprehensive survey

Our aim was to present a comprehensive, updated survey on obsessive-compulsive disorder (OCD) and obsessive-compulsive related disorders (OCRDs) and their clinical management via literature review, critical analysis and synthesis. Information on OCD and OCRD current nosography, clinical phenomenology and etiology, may lead to a better comprehension of their management. Clinicians should become familiar with the broad spectrum of OCD disorders, since it is a pivotal issue in current clinical psychiatry.

Obsessive-compulsive disorder among African Americans and blacks of Caribbean descent: results from the National Survey of American Life

BACKGROUND

There is limited research regarding the nature and prevalence of obsessive-compulsive disorder (OCD) among various racial and ethnic subpopulations within the United States, including African Americans and blacks of Caribbean descent. Although heterogeneity within the black population in the United States has largely been ignored, notable differences exist between blacks of Caribbean descent and African Americans with respect to ethnicity, national heritage, and living circumstances. This is the first comprehensive examination of OCD among African Americans and blacks of Caribbean descent.

METHODS

Data from the National Survey of American Life, a national household probability sample of African Americans and Caribbean blacks in the United States, were used to examine rates of OCD among these groups.

RESULTS

Lifetime and 12-month OCD prevalence estimates were very similar for African Americans and Caribbean blacks. Persistence of OCD and rates of co-occurring psychiatric disorders were very high and also similar between African American and Caribbean black respondents. Both groups had high levels of overall mental illness severity and functional impairment. Use of services was low for both groups, particularly in specialty mental health settings. Use of anti-obsessional medications was also rare, especially among the Caribbean black OCD population.

CONCLUSIONS

OCD among African Americans and Caribbean blacks is very persistent, often accompanied by other psychiatric disorders, and is associated with high overall mental illness severity and functional impairment. It is also likely that very few blacks in the United States with OCD are receiving evidence-based treatment and thus considerable effort is needed to bring treatment to these groups.

The Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders: recruitment, assessment instruments, methods for the development of multicenter collaborative studies and preliminary results

OBJECTIVE: To describe the recruitment of patients, assessment instruments, implementation, methods and preliminary results of The Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders, which includes seven university sites. METHOD: This cross-sectional study included a comprehensive clinical assessment including semi-structured interviews (sociodemographic data, medical and psychiatric history, disease course and comorbid psychiatric diagnoses), and instruments to assess obsessive-compulsive (Yale-Brown Obsessive-Compulsive Scale and Dimensional Yale-Brown Obsessive-Compulsive Scale), depressive (Beck Depression Inventory) and anxious (Beck Anxiety Inventory) symptoms, sensory phenomena (Universidade de São Paulo Sensory Phenomena Scale), insight (Brown Assessment Beliefs Scale), tics (Yale Global Tics Severity Scale) and quality of life (Medical Outcome Quality of Life Scale Short-form-36 and Social Assessment Scale). The raters' training consisted of watching at least five videotaped interviews and interviewing five patients with an expert researcher before interviewing patients alone. The reliability between all leaders for the most important instruments (Structured Clinical Interview for DSM-IV, Dimensional Yale-Brown Obsessive-Compulsive Scale, Universidade de São Paulo Sensory Phenomena Scale) was measured after six complete interviews. RESULTS: Inter-rater reliability was 96%. By March 2008, 630 obsessive-compulsive disorder patients had been systematically evaluated. Mean age (±SE) was 34.7 (±0.51), 56.3% were female, and 84.6% Caucasian. The most prevalent obsessive compulsive symptom dimensions were symmetry and contamination. The most common comorbidities were major depression, generalized anxiety and social anxiety disorder. The most common DSM-IV impulsive control disorder was skin picking. CONCLUSION: The sample was composed mainly by Caucasian individuals, unmarried, with some kind of occupational activity, mean age of 35 years, onset of obsessive-compulsive symptoms at 13 years of age, mild to moderate severity, mostly of symmetry, contamination/cleaning and comorbidity with depressive disorders. The Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders has established an important network for standardized collaborative clinical research in obsessive-compulsive disorder and may pave the way to similar projects aimed at integrating other research groups in Brazil and throughout the world.

Clinical profile of "schizo-obsessive" disorder: a comparative study

Obsessive-compulsive disorder (OCD) is a common comorbid condition in schizophrenia. The clinical implications of this comorbidity are uncertain. There is some evidence to suggest that schizophrenia with OCD (schizo-obsessive) has a poor prognosis, but the effect of OCD on schizophrenia symptom profile is unclear. Therefore, we studied the clinical profile of schizophrenic patients with and without comorbid OCD. Fifty consecutive patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for both schizophrenia and OCD and an equal number of schizophrenic patients without OCD were recruited over a period of 12 months from the clinical services of the National Institute of Mental Health and Neuro Sciences, Bangalore, India. Their clinical profile was systematically assessed and compared to detect significant differences, if any. Schizo-obsessive patients were more likely to have paranoid symptoms and first-rank symptoms of schizophrenia. They had lower anergia, higher depression scores, more comorbid personality disorders, and somewhat lesser disability. Significant correlations were observed between the Yale-Brown Obsessive-Compulsive Scale scores (including the Yale-Brown Obsessive-Compulsive Scale insight score) and schizophrenia symptom dimension scores. Our findings are concordant with the hypothesis that "schizo-obsessive" schizophrenia may be a distinct subtype with unique clinical characteristics, supporting the need for further research in this area.

Dissociation between MEG alpha modulation and performance accuracy on visual working memory task in obsessive compulsive disorder

Oscillatory brain activity in the alpha band (8-13 Hz) is modulated by cognitive events. Such modulation is reflected in a decrease of alpha (event-related desynchronization; ERD) with high cognitive load, or an increase (event-related synchronization) with low cognitive demand or with active inhibition of distractors. We used magnetoencephalography to investigate the pattern of prefrontal and parieto-occipital alpha modulation related to two variants of visual working memory task (delayed matching-to-sample) with and without a distractor. We tested nonmedicated, nondepressed patients suffering obsessive-compulsive disorder (OCD), and pair-matched healthy controls. The level of event-related alpha as a function of time was estimated using the temporal-spectral evolution technique. The results in OCD patients indicated: (1) a lower level of prestimulus (reference) alpha when compared to controls, (2) a task-phase specific reduction in event-related alpha ERD in particular for delayed matching-to-sample task with distractor, (3) no significant correlations between the pattern of modulation in prefrontal and parietal-occipital alpha oscillatory activity. Despite showing an abnormally low alpha modulation, the OCD patients' performance accuracy was normal. The results suggest a relationship of alpha oscillations and the underlying thalamocortical network to etiology of OCD and an involvement of a compensatory mechanism related to effortful inhibition of extrinsic and intrinsic interference.

Autogenous and reactive obsessions: further evidence for a two-factor model of obsessions

Obsessive-compulsive disorder is a highly disabling anxiety disorder, characterized by occurrence of intrusive and unwanted thoughts (obsessions), which lead to performance of repetitive compulsions and/or rituals in order to reduce distress. Recently, it has been proposed that obsessions may be divided into two categories, termed autogenous and reactive obsessions [Lee, H.-J., & Kwon, S.-M. (2003). Two different types of obsessions: autogenous obsessions and reactive obsessions. Behavior Research and Therapy, 41, 11-29]. In this study, we aimed to further validate this subtyping of obsessions, and to investigate the cognitive and emotional correlates of the subtypes. Evidence was found for the division, using a confirmatory factor analysis in an analogue sample (N=372). It was found that frequency of reactive obsessions related more strongly to distress caused by overt OC symptoms (e.g., washing, checking), whereas frequency of autogenous obsessions related to distress from impulses of harm. Compared to autogenous obsessions, frequency of reactive obsessions correlated more strongly with all OC-related beliefs. Few differences were found between autogenous and reactive obsessions with respect to depression, anxiety, and view about self (self-ambivalence, self-esteem). It is suggested that existing OC-belief measures are more relevant to reactive obsessions. Implications for theory and treatment are discussed.

Lower levels of whole blood serotonin in obsessive-compulsive disorder and in schizophrenia with obsessive-compulsive symptoms

It has been reported that some schizophrenic patients suffer from obsessive-compulsive symptoms (OCS), and clozapine treatment is quite often associated with an occurrence/increase of OCS in schizophrenic patients. The aim of the study was to explore whether differences would exist in the clinical symptomatology and the whole blood serotonin (5-HT) concentrations in patients with obsessive-compulsive disorder (OCD), schizophrenic patients with and without OCS (S+OCS, S-OCS), and clozapine-treated schizophrenic patients with and without clozapine-induced OCS (CLZ+OCS, CLZ-OCS). We found that S+OCS patients (n=15) showed significantly lower scores on the Hamilton Anxiety Scale (HAMA), but similar levels of compulsions and obsessions using Yale-Brown Obsessive-Compulsive Scale (YBOCS) as compared to the patients (n=35) with OCD. S+OCS patients scored significantly lower on the Positive and Negative Syndrome Scale (PANSS) but higher on the Hamilton Depression Scale (HAMD) compared with S-OCS patients (n=19). However, CLZ+OCS patients (n=15) suffered from dominant compulsions but fewer obsessions compared with the OCD and S+OCS patients. OCD, S+OCS and CLZ+OCS groups had significantly lower levels of whole blood 5-HT than did the healthy volunteers (n=15), S-OCS and CLZ-OCS groups. It suggests that alterations in serotonin metabolism may be a common biological characteristic of OCS in OCD as well as in schizophrenia.

What is the optimal way to subdivide obsessive-compulsive disorder?

The clinical presentation of obsessive-compulsive disorder (OCD) varies not only across patients but over the course of the disorder. This diversity indicates that OCD is a heterogeneous disorder, which may have an important impact on psychopathological, longitudinal, genetic, and treatment research. To better understand OCD heterogeneity, more homogeneous phenotypic descriptions are necessary to delimiting clinically meaningful subgroups of patients. Besides phenotypic descriptions, another method of delimiting OCD patient subgroups includes the search for endophenotypes (extended phenotypes) based on neurophysiological, immunological, genetic, neuropsychological, or neuroanatomic (neuroimaging) paradigms. This article will describe some strategies that deal with OCD heterogeneity, including the identification of more homogeneous phenotypical categories, an improved understanding of obsessive-compulsive symptom dimensions and how to use them as quantitative traits, and broadening the diagnostic boundaries of OCD to include other related conditions. The relevance and limitations of each approach are also discussed. Since the etiological mechanisms associated with the expressions of OCD are unknown, there is probably not one but several heuristic strategies to search for more homogeneous OCD subgroup, that combined may provide the most fruitful results.

Anxiety disorders and control related beliefs: the exemplar of Obsessive–Compulsive Disorder (OCD)

Beliefs about control have been postulated to be important to anxiety and mood disorders. In particular, the phenomenology of Obsessive-Compulsive Disorder (OCD) suggests that it may be an exemplar of an anxiety disorder where control issues related to the self (behavior and thoughts) and world (the external environment) are particularly important. However, only beliefs concerning the need to control thoughts have been incorporated into contemporary theories of OCD. This article summarizes the theoretical and empirical research relevant to control-related beliefs in OCD. It is suggested that discrepancies between an individual's desired level of control and their perceived level of control could contribute to OCD symptoms, and exacerbate the tendency for individuals with OCD to engage in magical ideation and superstitious rituals. Overall, this review demonstrates how consideration of control cognitions could enhance our understanding of OCD and further improve its treatment.

Prevalence and incidence studies of anxiety disorders: a systematic review of the literature

OBJECTIVE

To present the results of a systematic review of literature published between 1980 and 2004 reporting findings of the prevalence and incidence of anxiety disorders in the general population.

METHOD

A literature search of epidemiologic studies of anxiety disorders was conducted, using Medline and HealthSTAR databases, canvassing English-language publications. Eligible publications were restricted to studies that examined age ranges covering the adult population. A set of predetermined inclusion and exclusion criteria were used to identify relevant studies. Prevalence and incidence data were extracted and analyzed for heterogeneity.

RESULTS

A total of 41 prevalence and 5 incidence studies met eligibility criteria. We found heterogeneity across 1-year and lifetime prevalence rates of all anxiety disorder categories. Pooled 1-year and lifetime prevalence rates for total anxiety disorders were 10.6% and 16.6%. Pooled rates for individual disorders varied widely. Women had generally higher prevalence rates across all anxiety disorder categories, compared with men, but the magnitude of this difference varied.

CONCLUSION

The international prevalence of anxiety disorders varies greatly between published epidemiologic reports. The variability associated with all anxiety disorders is considerably smaller than the variability associated with individual disorders. Women report higher rates of anxiety disorders than men. Several factors were found to be associated with heterogeneity among rates, including diagnostic criteria, diagnostic instrument, sample size, country studied, and response rate.

Yale-Brown Obsessive Compulsive Scale: the dimensional structure revisited

The factor structure of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) has been examined in a number of prior investigations; however, findings have not consistently yielded a stable factor solution. The present study therefore tested the fit of each previously reported factor structure. One hundred thirty-one adults with obsessive-compulsive disorder (OCD) were administered the Y-BOCS; a portion of these participants completed self-report measures of depression and obsessive-compulsive symptoms and were rated on a global impairment index. Consistent with the originally proposed structure, confirmatory factor analyses supported a factor structure comprised of obsession and compulsion factors. Reliability and convergent validity of these factors were generally satisfactory, although divergent validity was not entirely supported. Implications of these findings on scoring the Y-BOCS are discussed.

Epidemiologia do transtorno obsessivo-compulsivo: uma revisão

Os inquéritos populacionais são importantes, pois amostras clínicas tendem a apresentar vieses de seleção. Aspectos sociodemográficos e relacionados à própria condição mórbida podem interferir na procura por tratamento. Pela natureza egodistônica do transtorno obsessivo-compulsivo, seus portadores tendem a ocultar o problema, podendo não procurar ou demorar a procurar tratamento. Porém, a maior parte do conhecimento atual sobre o transtorno obsessivo-compulsivo advém de amostras clínicas, que não representam a totalidade dos casos. Foi feita uma revisão convencional da literatura através do Medline, PsicoInfo e Lilacs de inquéritos populacionais sobre o transtorno obsessivo-compulsivo, cobrindo o período de 1980 a 2004, utilizando-se como palavras-chave "epidemiologia", "transtorno obsessivo-compulsivo", "inquéritos populacionais" e "prevalência". Estudos realizados em diferentes países indicam para o transtorno obsessivo-compulsivo uma prevalência atual em torno de 1,0% e ao longo da vida de 2,0 a 2,5%. Diferentemente de amostras clínicas, em quase todas as amostras populacionais há predomínio de mulheres e portadores que têm apenas obsessões. A freqüente comorbidade com outros transtornos mentais, particularmente depressão e outros transtornos ansiosos, repete-se em casos da população geral, que apresentam ainda uma associação com abuso de substâncias. Muitos portadores não estão em tratamento, particularmente os casos "puros". Indicadores de incapacitação funcional demonstram um considerável impacto negativo do transtorno obsessivo-compulsivo. É preciso melhorar o conhecimento da população e dos profissionais de saúde sobre os sintomas do transtorno obsessivo-compulsivo para aumentar a procura de atendimento, assim como a correta identificação e abordagem terapêutica deste grave problema de saúde.

Antipsychotic treatment in obsessive-compulsive disorder: a literature review

OBJECTIVE

To review the role of antipsychotic medications in the treatment of obsessive-compulsive disorder (OCD); to explore current hypothesized conceptualizations of their mechanism of action; to highlight evolving interest in the validation of meaningful OCD subtypes within a heterogeneous spectrum of OCD, based on treatment response and other psychobiological variables.

METHOD

A computerized literature search (MEDLINE: 1966 to December 2003, EMBASE: 1982 to December 2003) was used to locate relevant literature, using the terms obsessive-compulsive, antipsychotic and subtypes, with no restrictions imposed on searches.

RESULTS

Earlier studies of augmentation of serotonergic antidepressants (SRIs) with typical antipsychotics including haloperidol and pimozide in OCD demonstrated favourable responses, also highlighting patient subgroups with robust treatment response. Studies examining augmentation with atypical agents are emerging. SRI-resistant OCD patients are likely to benefit from augmentation with atypical antipsychotics in around 50% of cases.

CONCLUSIONS

While there is little role for antipsychotic monotherapy in OCD, there is growing evidence in support of adjunctive antipsychotics in OCD refractory to serotonin-reuptake inhibitors (SRIs). Further controlled trials are warranted. Particular subgroups of OCD patients, notably those with comorbid tic disorder and those with schizotypal personality disorder, have been shown to respond more robustly to augmentation strategies in some trials of both typical and atypical antipsychotics. Dopaminergic mediation with or without a moderating effect on serotonergic systems is likely to be important in the pharmacodynamic mechanisms of action of antipsychotic-SRI combinations in OCD.

Diagnostic interview assessed neuropsychiatric disorder comorbidity in 334 individuals with obsessive-compulsive disorder

Is obsessive-compulsive disorder (OCD) a discrete disorder? Three hundred thirty-four individuals with OCD were interviewed using the Structured Clinical Interview for DSM (SCID). Results demonstrate that OCD is highly comorbid with other neuropsychiatric disorders, with 92% of OCD study participants receiving one or more additional Axis I DSM diagnoses. Among these additional diagnoses, lifetime mood disorders (81%) and anxiety disorders (53%) were the most prevalent. With the exception of substance-related disorders and specific phobias, all disorders assessed were found in considerably higher frequency than in the general population, indicating that OCD is associated with highly complex comorbidity. These data have implications for genetic studies of OCD and disorders related to OCD, as well as for specific psychotherapeutic and psychopharmacologic interventions.

Phenomenological and comorbid features associated in obsessive-compulsive disorder: influence of age of onset

BACKGROUND

To explore clinical features of symptoms and comorbidity according to the age of onset of patients suffering from obsessive-compulsive disorder (OCD).

METHODS

The survey involved collecting data from both patient members of an OCD association, and a sample of 175 OCD patients seen in OCD specialty practice. All the patients (n=617) responded to a questionnaire on family and personal psychiatric OCD history, phenomenological features of OCD and comorbidity. They were classified according to OCD age at onset [group early age of onset (EO): under 15, group late age of onset (LO): older than 15].

RESULTS

A higher percentage of patients from Group LO complained of OCD triggering by factors such as professional difficulties and childbirth (P<0.05); also they more often had (P=0.05) a sudden onset of symptoms. On the other hand, clinical features, such as superstition and magic thoughts, parasite obsessions and repeating, counting, hoarding, tapping/rubbing and collecting compulsions were significantly more frequent (P<0.05) in EO; likewise, history of tics was more frequent in this group. The existence of comorbid depression (at least one episode) did not show any significant difference between groups. However, depression preceding OCD was more frequent in LO. There was no significant difference in treatment response according to age of onset OCD.

CONCLUSIONS

The results showed a clear association of EO with obsessions of superstition and parasites, repetitive compulsions and motor and vocal tics, whereas a sudden onset, triggering factors and a more frequent depression preceding OCD characterized LO.

Lack of association of catechol-O-methyltransferase gene polymorphism in obsessive-compulsive disorder

The COMT gene has been implicated to be involved in the pathogenesis of obsessive-compulsive disorder (OCD) and various other psychiatric disorders. COMT enzyme activity is governed by a common genetic polymorphism at codon 158 that results in substantial 3- to 4-fold variation in enzymatic activity [a high-activity COMT variant (H) and a low activity variant (L)]. This study evaluates the association between OCD and the COMT gene polymorphism. Fifty-nine OCD patients that were diagnosed according to DSM-IV criteria and 114 healthy control subjects were included in the study. PCR technique was used for molecular analysis. The genotypic pattern of distribution of the COMT gene (H/H, H/L, and L/L genotypes) was not different between the OCD patients and controls. There were no significant differences among the patients with positive family history for OCD, those with negative family history for OCD, and the controls with respect to allele frequencies of the COMT gene polymorphisms. Patients that were homozygous or heterozygous for the L allele had significantly higher insight scores (i.e., poorer insight) on Y-BOCS compared to those homozygous for the H allele. We did not find an association between OCD, family history for OCD, and the COMT gene polymorphism. This study suggests that the COMT gene polymorphism is not directly associated with OCD in our patient group.

PANDAS: pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections--an uncommon, but important indication for tonsillectomy

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, also know as "PANDAS," is well described in the neurologic and psychiatric literature. PANDAS is associated with obsessive compulsive disorders (OCD) and tic disorders. The streptococcal infections may trigger an autoimmune reaction that exacerbates these conditions. Recurrent streptococcal tonsillitis is one of the recurrent infections associated with PANDAS. This paper reviews the case reports of two brothers, one with OCD and the other with a tic disorder, both of whom improved significantly after undergoing adenotonsillectomy for treatment of their recurrent tonsillitis. A review of the pathophysiology and current understanding of PANDAS is presented.

Single photon emission computed tomography imaging in obsessive-compulsive disorder and for stereotactic bilateral anterior cingulotomy

In conclusion, the present study suggests that SPECT, using a sophisticated SPM analysis method, may be useful as a potential diagnostic tool for OCD and a possible predictor of treatment outcome for OCD patients undergoing bilateral anterior cingulotomy. The anterior cingulate gyrus seems to be an important structure in the pathogenesis of OCD symptoms. Furthermore, our operative technique of anterior cingulotomy, featuring a larger lesion, seems to be effective in ameliorating the symptoms of OCD without causing any serious complications.

Axis I comorbidity in body dysmorphic disorder

Although research on body dysmorphic disorder (BDD) has increased in recent years, this disorder's comorbidity has received little empirical attention. Further work in this area is needed, as it appears that most patients with BDD have at least one comorbid disorder. This study examined axis I comorbidity and clinical correlates of comorbidity in 293 patients with DSM-IV BDD, 175 of whom participated in a phenomenology study and 118 of whom participated in treatment studies of BDD. Subjects were evaluated with the Structured Clinical Interview for DSM-III-R (SCID-P) and a semistructured instrument to obtain information on clinical correlates. Comorbidity was common, with a mean of more than two lifetime comorbid axis I disorders in both the phenomenology and treatment groups. In both groups, the most common lifetime comorbid axis I disorders were major depression, social phobia, obsessive compulsive disorder (OCD), and substance use disorders. Social phobia usually began before onset of BDD, whereas depression and substance use disorders typically developed after onset of BDD. A greater number of comorbid disorders was associated with greater functional impairment and morbidity in a number of domains. Thus, axis I comorbidity is common in BDD patients and associated with significant functional impairment.

Johanson-Blizzard syndrome--a case study, behavioral manifestations, and successful treatment strategies

Mental retardation has multiple causes, including genetic, and is often accompanied by severe behavioral difficulties. These behavioral problems frequently disrupt care, reduce quality of life, and represent risk of injury. In treating special populations where biologic interventions are most important, the psychiatrist must often combine appropriate pharmacologic interventions with behavioral strategies, employing staff support and using a multidisciplined team approach. This article reviews a case in which a person with Johanson-Blizzard syndrome, a rare genetic disorder whose physical manifestations have been described in the literature, is successfully treated using a combination of psychotropic medication and behavioral programming. Target behaviors of severe obsessive compulsive disorder and aggression were ameliorated using these strategies.Currently, specific pharmacologic interventions in combination with structured behavioral programming represents the most successful method of dealing with various forms of behavioral problems linked to mental retardation.