Level of insight and clinical features of obsessive-compulsive disorder with and without body dysmorphic disorder

Obsessive-compulsive symptoms and dissociative experiences: Suggested underlying mechanisms and implications for science and practice

A strong and specific link between obsessive-compulsive disorder or symptoms (OCD/S) and a tendency for dissociative experiences (e.g., depersonalization-derealization, absorption and imaginative involvement) cannot be explained by trauma and is poorly understood. The present theoretical formulation proposes five different models conceptualizing the relationship. According to Model 1, dissociative experiences result from OCD/S through inward-focused attention and repetition. According to Model 2, dissociative absorption causally brings about both OCD/S and associated cognitive risk factors, such as thought-action fusion, partly through impoverished sense of agency. The remaining models highlight common underlying causal mechanisms: temporo-parietal abnormalities impairing embodiment and sensory integration (Model 3); sleep alterations causing sleepiness and dreamlike thought or mixed sleep-wake states (Model 4); and a hyperactive, intrusive imagery system with a tendency for pictorial thinking (Model 5). The latter model relates to Maladaptive Daydreaming, a suggested dissociative syndrome with strong ties to the obsessive-compulsive spectrum. These five models point to potential directions for future research, as these theoretical accounts may aid the two fields in interacting with each other, to the benefit of both. Finally, several dissociation-informed paths for further developing clinical intervention in OCD are identified.

Greater history of traumatic event exposure and PTSD associated with comorbid body dysmorphic disorder in a large OCD cohort

The present study examined whether or not there are differential rates of traumatic event exposure and presumed Post-Traumatic Stress Disorder (PTSD) between individuals with OCD without comorbid presumed BDD (OCD-Non-BDD) and individuals with OCD with comorbid presumed BDD (OCD+BDD) within a large cohort of OCD participants (N = 605). Individuals in the OCD+BDD group had significantly higher rates of endorsing at least one lifetime traumatic event and presumed PTSD than individuals with OCD-Non-BDD. Additionally, individuals in the OCD+BDD group with comorbid presumed PTSD had significantly higher rates of major depressive disorder (MDD) and presumed panic disorder (PD). A logistic regression analysis revealed that presumed PTSD significantly predicted the presence of BDD symptoms among individuals who experienced at least one lifetime traumatic event in our sample. These findings suggest that individuals in the OCD+BDD group were more likely to have experienced a traumatic event in their lives, to experience presumed PTSD, and to have MDD and presumed PD than individuals in the OCD-Non-BDD group. Clinical implications and possible mechanistic pathways from trauma exposure to OCD and BDD symptomatology are discussed.

Insight in body dysmorphic disorder (BDD) relative to obsessive-compulsive disorder (OCD) and psychotic disorders: Revisiting this issue in light of DSM-5

INTRODUCTION

In DSM-5, body dysmorphic disorder (BDD) was reclassified under the obsessive-compulsive and related disorders (OCRDs), but little is known about the nature of BDD beliefs. This study aimed to compare level of insight in BDD and consider related implications for DSM-5 classification.

METHOD

Participants were 27 BDD, 19 obsessive-compulsive disorder (OCD), and 20 psychosis (SZ) participants as well as 42 non-clinical controls (NC), who completed the Brown Assessment of Beliefs Scale (BABS) and Peters Delusions Inventory (PDI).

RESULTS

For total (and most individual) BABS items, BDD and SZ participants scored significantly higher than OCD and NC participants. On the PDI, there were significant group differences in number of questions endorsed, with clinical groups scoring significantly higher than the NC group on dimensions of distress and preoccupation, but not conviction.

CONCLUSION

These findings suggest appearance-related concerns in BDD somewhat resemble delusions seen in psychosis (and not OCD), and convey important nosological and therapeutic implications.

Comorbidity between obsessive-compulsive disorder and body dysmorphic disorder: prevalence, explanatory theories, and clinical characterization

BACKGROUND

With the advent of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, body dysmorphic disorder (BDD) has been subsumed into the obsessive-compulsive disorders and related disorders (OCDRD) category.

OBJECTIVE

We aimed to determine the empirical evidence regarding the potential relationship between BDD and obsessive-compulsive disorder (OCD) based on the prevalence data, etiopathogenic pathways, and clinical characterization of patients with both disorders.

METHOD

A comprehensive search of databases (PubMed and PsycINFO) was performed. Published manuscripts between 1985 and May 2015 were identified. Overall, 53 studies fulfilled inclusion criteria.

RESULTS

Lifetime comorbidity rates of BDD-OCD are almost three times higher in samples with a primary diagnosis of BDD than those with primary OCD (27.5% vs 10.4%). However, other mental disorders, such as social phobia or major mood depression, are more likely among both types of psychiatric samples. Empirical evidence regarding the etiopathogenic pathways for BDD-OCD comorbidity is still inconclusive, whether concerning common shared features or one disorder as a risk factor for the other. Specifically, current findings concerning third variables show more divergences than similarities when comparing both disorders. Preliminary data on the clinical characterization of the patients with BDD and OCD indicate that the deleterious clinical impact of BDD in OCD patients is greater than vice versa.

CONCLUSION

Despite the recent inclusion of BDD within the OCDRD, data from comparative studies between BDD and OCD need further evidence for supporting this nosological approach. To better define this issue, comparative studies between BDD, OCD, and social phobia should be carried out.

The impact of comorbid body dysmorphic disorder on the response to sequential pharmacological trials for obsessive-compulsive disorder

Our aim was to investigate the impact of comorbid body dysmorphic disorder (BDD) on the response to sequential pharmacological trials in adult obsessive-compulsive disorder (OCD) patients. The sequential trial initially involved fluoxetine monotherapy followed by one of three randomized, add-on strategies: placebo, clomipramine or quetiapine. We included 138 patients in the initial phase of fluoxetine, up to 80 mg or the maximum tolerated dosage, for 12 weeks. We invited 70 non-responders to participate in the add-on trial; as 54 accepted, we allocated 18 to each treatment group and followed them for an additional 12 weeks. To evaluate the combined effects of sex, age, age at onset, initial severity, type of augmentation and BDD on the response to sequential treatments, we constructed a model using generalized estimating equations (GEE). Of the 39 patients who completed the study (OCD-BDD, n = 13; OCD-non-BDD, n = 26), the OCD-BDD patients were less likely to be classified as responders than the OCD-non-BDD patients (Pearson Chi-Square = 4.4; p = 0.036). In the GEE model, BDD was not significantly associated with a worse response to sequential treatments (z-robust = 1.77; p = 0.07). The predictive potential of BDD regarding sequential treatment strategies for OCD did not survive when the analyses were controlled for other clinical characteristics.

Body dysmorphic disorder in patients with obsessive-compulsive disorder: prevalence and clinical correlates

BACKGROUND

The prevalence, sociodemographic aspects, and clinical features of body dysmorphic disorder (BDD) in patients with obsessive-compulsive disorder (OCD) have been previously addressed in primarily relatively small samples.

METHODS

We performed a cross-sectional demographic and clinical assessment of 901 OCD patients participating in the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. We used the Structured Clinical Interview for DSM-IV Axis I Disorders; Yale-Brown Obsessive-Compulsive Scale; Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS); Brown Assessment of Beliefs Scale; Clinical Global Impression Scale; and Beck Depression and Anxiety Inventories.

RESULTS

The lifetime prevalence of BDD was 12.1%. The individuals with comorbid BDD (OCD-BDD; n = 109) were younger than were those without it. In addition, the proportions of single and unemployed patients were greater in the OCD-BDD group. This group of patients also showed higher rates of suicidal behaviors; mood, anxiety, and eating disorders; hypochondriasis; skin picking; Tourette syndrome; and symptoms of the sexual/religious, aggressive, and miscellaneous dimensions. Furthermore, OCD-BDD patients had an earlier onset of OC symptoms; greater severity of OCD, depression, and anxiety symptoms; and poorer insight. After logistic regression, the following features were associated with OCD-BDD: current age; age at OCD onset; severity of the miscellaneous DY-BOCS dimension; severity of depressive symptoms; and comorbid social phobia, dysthymia, anorexia nervosa, bulimia nervosa, and skin picking.

CONCLUSIONS

Because OCD patients might not inform clinicians about concerns regarding their appearance, it is essential to investigate symptoms of BDD, especially in young patients with early onset and comorbid social anxiety, chronic depression, skin picking, or eating disorders.

A comparison of insight in body dysmorphic disorder and obsessive-compulsive disorder

Insight/delusionality of beliefs is an important dimension of psychopathology across psychiatric disorders. This construct is of increasing interest in obsessive-compulsive and related disorders, including obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). Even though OCD and BDD are considered closely related, no prior study has compared these disorders across a range of categories of global insight (excellent, good, fair, poor, absent/delusional), and only one study has compared these disorders on individual components of insight. Using the reliable and valid Brown Assessment of Beliefs Scale (BABS), this study examined insight/delusionality of OCD- or BDD-related beliefs in 211 individuals with primary OCD versus 68 individuals with primary BDD. In both disorders, levels of insight spanned the full range, from excellent to absent (i.e., delusional beliefs). However, the distribution of BABS scores across insight categories differed significantly by disorder, with the majority of OCD subjects showing excellent or good insight, and the majority of BDD subjects showing poor or absent insight. Compared to OCD subjects, BDD subjects had significantly poorer insight both overall (total BABS score) and on all individual BABS items. BABS score was significantly correlated with BDD and OCD severity, but in regressions it accounted for only 21% of the variance in OCD and 28% in BDD. In summary, both global insight and its individual components are poorer in BDD than in OCD, which has implications for research and clinical care, as well as understanding of the relationship between these disorders. Disorder severity is associated with but not equivalent to insight/delusionality.

Somatização na América Latina: uma revisão sobre a classificação de transtornos somatoformes, síndromes funcionais e sintomas sem explicação médica

OBJETIVO: Os sintomas sem explicação médica são frequentes e estão associados a sofrimento mental em vários contextos. Estudos prévios apontam que as populações latino-americanas são propensas à somatização. Diante da reformulação da Classificação Internacional de Doenças para sua 11ª edição, as particularidades dos nativos desta região do mundo devem ser levadas em consideração. O objetivo deste estudo é prover informações sobre somatização na população latino-americana para a tomada de decisões quanto às categorias diagnósticas ligadas a sintomas sem explicação médica na Classificação Internacional de Doenças-11ª edição. MÉTODO: Revisão extensa da produção de 1995 a 2011 sobre somatização em populações de origem latino-americana. RESULTADOS: A análise dos 106 estudos incluídos nesta revisão foi dividida em 15 categorias: revisões sistemáticas, revisões conceituais, prevalências, atenção primária, depressão e ansiedade, fatores de risco, violência, quadros orgânicos, relacionamento com profissionais e o sistema de saúde, etnia, síndromes ligadas à cultura, síndrome da fadiga crônica, fibromialgia, transtorno dismórfico corporal, e conversão e dissociação. CONCLUSÃO: Os estudos latino-americanos confirmam a dificuldade na definição categorial de quadros com sintomas sem explicação médica. O suposto "traço somatizador" das culturas latinas pode estar associado mais à expressão cultural e linguística do que a um caráter de natureza étnica, e tais particularidades devem estar na agenda na nova classificação destes fenômenos na Classificação Internacional de Doenças-11ª edição.

[The concept of insight in patients with obsessive-compulsive disorder]

OBJECTIVE

To update clinicians regarding the existence of a putative subtype of obsessive-compulsive disorder based on poor insight.

METHOD

Opinionative review based on studies indexed in the PubMed and PsychINFO databases, identified by means of the keywords 'obsessive-compulsive disorder' AND 'insight' OR 'ego-syntonic', and published between 1966 and October 2009. The results were analyzed according to the approach adopted, i.e. a categorical or dimensional view of insight in obsessive-compulsive disorder.

RESULTS

The review of recent studies led us to identify some issues that cast doubts over the existence of a clear-cut poor insight subtype of obsessive-compulsive disorder. These issues include 1) an extremely variable prevalence of poor insight obsessive-compulsive disorder in categorical studies, 2) a significant degree of homogeneity in the phenotypical findings (i.e. greater severity) associated with lower levels of insight in obsessive-compulsive disorder in both categorical and dimensional studies and, 3) a lack of studies investigating zones of rarity between poor and good insight obsessive-compulsive disorder.

CONCLUSION

Although a categorical approach to the insight issue in obsessive-compulsive disorder is still important in clinical settings, where decision-making is often a critical issue, a dimensional approach seems to reflect levels of impairment in these patients more reliably.

[French adaptation and validation of the scale to assess unawareness of mental disorder]

OBJECTIVES

To validate the French version of the Scale to Assess Unawareness of Mental Disorder (SUMD) in patients with schizophrenia.

METHOD

One hundred patients with schizophrenic disorders were included. Our statistical analyses evaluated interrater reliability, theoretical validity, and convergent or divergent validity. Finally, an exploratory factor analysis was conducted.

RESULTS

The results revealed good psychometric properties for the French version of the SUMD. Both interrater reliability (ICC ranged from 0.68 to 1.00) and internal consistency (Cronbach 0.70) were satisfactory. Criterion validity was confirmed by high correlation values between SUMD scores and scores on the Positive and Negative Syndrome Scale G12 item evaluating insight. Moreover, as hypothesized, there were few associations between SUMD scores and clinical variables. Finally, Principal Component Analyses confirmed the hypothesis of 2 distinct insight dimensions (consciousness and attribution) for both present and past aspects.

CONCLUSIONS

This French version of the SUMD is a reliable and valid measure of insight in schizophrenia. The clinical relevance of its measure and the development of psychosocial interventions to improve insight into illness in patients with schizophrenia are discussed.

Eating disorders in patients with obsessive-compulsive disorder: prevalence and clinical correlates

OBJECTIVE

The objective is to evaluate the prevalence and associated clinical characteristics of eating disorders (ED) in patients with obsessive-compulsive disorder (OCD).

METHOD

This is a cross-sectional study comparing 815 patients with OCD. Participants were assessed with structured interviews and scales: SCID-I, Y-BOCS, Dimensional Y-BOCS, BABS, Beck Depression and Anxiety Inventories.

RESULTS

Ninety-two patients (11.3%) presented the following EDs: binge-eating disorders [= 59 (7.2%)], bulimia nervosa [= 16 (2.0%)], or anorexia nervosa [= 17 (2.1%)]. Compared to OCD patients without ED (OCD-Non-ED), OCD-ED patients were more likely to be women with previous psychiatric treatment. Mean total scores in Y-BOCS, Dimensional Y-BOCS, and BABS were similar within groups. However, OCD-ED patients showed higher lifetime prevalence of comorbid conditions, higher anxiety and depression scores, and higher frequency of suicide attempts than did the OCD-Non-ED group. Primarily diagnosed OCD patients with comorbid ED may be associated with higher clinical severity.

DISCUSSION

Future longitudinal studies should investigate dimensional correlations between OCD and ED.

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.