Symptom dimensions in obsessive-compulsive disorder: implications for the DSM-V

Psychologists' Diagnostic Accuracy and Treatment Recommendations for Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a debilitating condition prevalent in up to 2.3% of the population, yet obsessive-compulsive symptoms are commonly misidentified by mental health professionals, adversely impacting treatment recommendations. This study examined OCD misidentification rates across two different types of obsessions, the influence of misidentification on treatment recommendation, and attitudes associated with clinicians' decisions surrounding the diagnosis of OCD and treatment recommendations in a sample of 110 licensed psychologists. Results showed that over one-third (35.0%) of participants incorrectly diagnosed two vignettes, representing symptoms of sexual orientation OCD (SO-OCD) and symmetry. Of those who correctly diagnosed the vignettes, about half of participants (symmetry = 55.4%; SO-OCD = 47.1%) recommended exposure and response prevention (ERP) as the primary treatment choice. Participants who endorsed greater client empowerment were more likely to misdiagnose the SO-OCD vignette (t(108) = 2.97, p = 0.004). Less experience with evidence-based practice and negative attitudes toward evidence-based practice were associated with the choice of treatment other than ERP (t(71) = -2.98, p = 0.004 and t(72) = 3.40, p < 0.001, respectively). Elevated OCD misdiagnosis and its adverse impact on treatment recommendations, as well as knowledge of factors contributing to misdiagnosis and mistreatment, imply the need for greater education and training.

Individual differences in probabilistic learning and updating predictive representations in individuals with obsessive-compulsive tendencies

BACKGROUND

Obsessive-compulsive (OC) tendencies involve intrusive thoughts and rigid, repetitive behaviours that also manifest at the subclinical level in the general population. The neurocognitive factors driving the development and persistence of the excessive presence of these tendencies remain highly elusive, though emerging theories emphasize the role of implicit information processing. Despite various empirical studies on distinct neurocognitive processes, the incidental retrieval of environmental structures in dynamic and noisy environments, such as probabilistic learning, has received relatively little attention.

METHODS

In this study, we aimed to unravel potential individual differences in implicit probabilistic learning and the updating of predictive representations related to OC tendencies in a non-clinical population. We conducted two independent online experiments (NStudy1 = 164, NStudy2 = 256) with university students. Probabilistic learning was assessed using an implicit visuomotor probabilistic learning task, involving sequences with second-order non-adjacent dependencies.

RESULTS

Our findings revealed that implicit probabilistic learning remained remarkably robust among OC tendencies within a non-clinical population. Furthermore, the results highlighted effective updating capabilities of predictive representations, which were not influenced by OC tendencies.

CONCLUSIONS

These results offer new insights into individual differences in probabilistic learning and updating in relation to OC tendencies, contributing to theoretical, methodological, and practical approaches for understanding the maladaptive behavioural manifestations of OC disorder and subclinical tendencies.

Investigating the Association Between Obsessive-Compulsive Disorder Symptom Subtypes and Health Anxiety as Impacted by the COVID-19 Pandemic: A Cross-Sectional Study

Background

Since the COVID-19 outbreak was declared a global pandemic, public health messages have emphasised the importance of frequent handwashing in limiting the transmission of the virus. Whilst crucial in controlling transmission, such messaging may have an adverse effect on individuals with OCD.

Methods

A cross-sectional study was conducted, with a total of 332 participants recruited. Participants who scored above the optimal cut-off score on the Obsessive-Compulsive Inventory Revised edition (OCI-R) were included in the analysis (n = 254). Scores on the six subscales of the OCI-R were correlated with responses to a COVID-19 Impact measure.

Results

Factor analysis of the COVID-19 Impact measure revealed that items loaded on two components of the measure (handwashing and distress-avoidance). Canonical correlation analyses revealed significant associations between the OCI-R subscales and COVID-19 Impact measure, F (12, 490) = 8.14, p = 0.001, and the SHAI subscales with the COVID-19 Impact Measure, F (4, 498) = 8.18, p = 0.001). Specifically, washing and checking OCI-R subscales correlated with both components of the COVID-19 Impact measure, as did the health anxiety and beliefs SHAI subscales. Content analysis revealed disruption to treatment delivery and worsening symptom severity in participants with contamination-related OCD.

Discussion

Contamination and checking OCD subtypes have been associated with increased hand-washing behaviour and avoidance of distress-inducing cues. Consideration should be given to targeted support tailored to patients with these subtypes of OCD.

What is at the core of OCD? A network analysis of selected obsessive-compulsive symptoms and beliefs

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous condition that consists of distinct subtypes, and identification of its core symptoms may inform how to best conceptualize the heterogeneity. Accordingly, we used network analysis to evaluate which symptoms (and associations between symptoms) are most central to OCD symptoms and beliefs.

METHODS

Participants consisted of a combined sample of adults with a primary diagnosis of OCD (N = 150), those with other primary diagnoses (N = 114), and an unselected nonclinical sample (N = 310). Network analysis was used to identify the most central symptoms (nodes) and associations between symptoms (edges) assessed by the Obsessive-Compulsive Inventory-Revised and the Obsessional Beliefs Questionnaire-44.

RESULTS

The most central symptoms in the network were negative appraisals of intrusive thoughts (i.e., Having intrusive thoughts means I'm out of control). Some of the strongest associations between symptoms were also observed for those pertaining to intrusive thoughts and their negative appraisal. Furthermore, central symptoms in the network predicted depression and anxiety (over and above peripheral symptoms) among those with a primary diagnosis of OCD, but not the severity of OCD symptoms.

LIMITATIONS

The approach was exploratory rather than experimental and relied solely on self-report measures of OCD symptoms and beliefs.

CONCLUSIONS

Negative appraisals of intrusive thoughts were the most central symptoms in the OCD network, and they uniquely predict co-occurring symptoms of anxiety and depression, suggesting that these symptoms should be prioritized in theoretical and treatment models of OCD.

BDNF gene and obsessive compulsive disorder risk, symptom dimensions and treatment response

AIM

Genetic etiology of Obsessive Compulsive Disorder (OCD) has been investigated extensively, with mixed results across candidate gene studies. The dimensional subtypes of OCD are shown to better correlate with brain imaging endophenotypes and thus could potentially enhance the power of genetic association. In this study, we perform a case control analysis of association of a single nucleotide polymorphism rs6265(Val66Met) in Brain Derived Neurotrophic Factor gene, that has been previously implicated in a variety of psychiatric syndromes, and examine its association with symptom dimensions of OCD.

METHODS

Individuals diagnosed to have OCD (n=377) and controls (n=449) of South Indian origin were genotyped for polymorphism rs6265 (196G/A, Val66Met). Detailed phenotypic assessment of the cases were carried out in the cases using structured instruments. The genotypic association was tested for clinical variables such as age of onset, gender, family history, co-morbidity, treatment response, and factor analyzed OCD symptom dimensions.

RESULTS

The allele 'A' frequency was found to be significantly higher in the controls, as compared to cases suggesting a protective effect. The contamination/washing symptom dimension score was significantly lower in carriers of 'A' allele which remained significant even after testing for confounding effects on linear regression.

CONCLUSIONS

Our results support findings from previous studies on a possible protective effect of the 'Met' allele at the Val66Met locus in OCD. Its association with lower scores on the contamination/washing dimension is a novel finding of this study.

A review of the role of serotonin system genes in obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a debilitating neuropsychiatric disorder that causes the patient to experience intrusive thoughts and/or to carry out repetitive, ritualized behaviors that are time consuming and impairing. OCD is familial and heritable. The genetic factors responsible for pathogenesis, however, remain largely unknown despite the numerous candidate gene studies conducted. Based on efficacy of serotonin reuptake inhibitors (SRIs) in treating OCD, serotonin system genes have been a dominant focus in OCD candidate gene studies. We review the most commonly studied candidate serotonin system gene variants (specifically in SLC6A4, HTR2A, HTR1B, and HTR2C) and their association with OCD. Although findings to date are mixed, serotonin transporter polymorphism 5-HTTLPR and HTR2A polymorphism rs6311 (or rs6313) are most consistently associated with OCD. Mixed findings may be the result of genetic complexity and phenotypic heterogeneity that future studies should account for. Homogenous patient subgroups reflecting OCD symptom dimensions, OCD subtypes, and sex should be used for gene discovery.

Examination of a Bifactor Model of Obsessive-Compulsive Symptom Dimensions

Although obsessive-compulsive (OC) symptoms are observed along four dimensions (contamination, responsibility for harm, order/symmetry, and unacceptable thoughts), the structure of the dimensions remains unclear. The current study evaluated a bifactor model of OC symptoms among those with and without obsessive-compulsive disorder (OCD). The goals were (a) to evaluate if OC symptoms should be conceptualized as unidimensional or whether distinct dimensions should be interpreted and (b) to use structural equation modeling to examine the convergence of the OC dimensions above and beyond a general dimension with related criteria. Results revealed that a bifactor model fit the data well and that OC symptoms were influenced by a general dimension and by four dimensions. Measurement invariance of the bifactor model was also supported among those with and without OCD. However, the general OC dimension accounted for only half of the variability in OC symptoms, with the remaining variability accounted for by distinct dimensions. Despite evidence of multidimensionality, the dimensions were unreliable after covarying for the general OC dimension. However, the four dimensions did significantly converge with a latent OC spectrum factor above and beyond the general OC dimension. The implications of these findings for conceptualizing the structure of OCD are discussed.

Development and validation of the Youth Obsessive-Compulsive Symptoms Scale (YOCSS)

From the existing self-report measures for youth Obsessive-Compulsive (OC) symptoms, several challenges can be delineated to further improve the assessment of youth OC-related pathology. The current manuscript incorporates these challenges and reports on the development and validation of a new self-report OC scale for younger age groups, that was labeled the Youth Obsessive-Compulsive Symptoms Scale (YOCSS), assessing OC symptoms and impairment in adolescents (three independent samples: N = 336; N = 289; and N = 209). Study 1 reports on the construction of the items and facets, and their higher-order structure, whereas Study 2 focuses on the confirmation of this structure, measurement invariance across age, and on the convergent and incremental predictive validity. These psychometric analyses resulted in ten symptom facets (structured in three domains) and one impairment facet, and further suggest that the YOCSS is a promising tool for describing early OC symptoms along a dimensional perspective.

Emerging drugs to treat obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a chronic and disabling neuropsychiatric disorder with a lifetime prevalence of approximately 1 - 2% and a rate of treatment resistance of 40%. Other disorders have been related to OCD and have been grouped together in a separate DSM-5 chapter, hypothesizing the existence of an 'OC spectrum', showing a paradigm shift in the conceptualization of the disorder.

AREAS COVERED

A review of the most important and recent neurobiological findings that sustain the hypothesis of a more sophisticated model of the disorder is provided, together with a brief overview of the most relevant pharmacological animal models of OCD and its first-line treatments. Current research goals, new compounds tested and the rationale behind the development of these new pharmacologic agents are then explained and reviewed.

EXPERT OPINION

In the past years, no effective novel compounds have emerged for the treatment of OCD, even if many efforts has been made in the study of its neurobiological underpinnings. Relevant changes in the conceptualization of the disorder, suggested by interesting new neurobiological evidences, may result helpful in the development of new treatments.

Bipolar disorder in children: assessment in general pediatric practice

PURPOSE OF REVIEW

Pediatricians are increasingly confronted with the mental health needs of children. Given the unanticipated role, well-described diagnostic guidelines and treatment protocols are essential: but often lacking. Identification of bipolar disorder in children, a condition which lacks diagnostic criteria consensus, presents a particular challenge. Despite this, it is generally regarded as a condition associated with considerable morbidity and mortality. Extended delays to treatment, typical for the condition, contribute to significantly reduced adult functionality.

RECENT FINDINGS

Most children with bipolar disorder exhibit a subsyndromal course of illness. This has prompted many investigative groups to explore whether such a presentation is developmental or unique. Despite the ongoing debate, there has been a rapid increase in the rate of diagnoses. Concurrently, breakthroughs in neurology, neuroimaging, and genetics have called into question the existing conceptually based psychiatric constructs altogether. New research approaches which reflect these advances are more likely to lead to evidence-based diagnosis and treatment. Such an example is a novel phenotype called Fear of Harm (FOH). A new research perspective resulted in the unification of a broad range of symptoms from bipolar disorder as well as many of the co-occurring disorders. When considered as a whole, the syndrome maps on to a known neural pathway and has led investigators to a putative biomarker.

SUMMARY

If given the right information and tools, pediatricians are uniquely positioned to interrupt the decline caused by mental illnesses. Importantly, the newly defined FOH syndrome includes clinical symptoms which are frequently first brought to the attention of pediatricians. Although these symptoms are not exclusive to the mood disorder, they could alert pediatricians to the need for further evaluation.

Five-year course of obsessive-compulsive disorder: predictors of remission and relapse

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous and disabling condition; however, no studies have examined symptom categories or subtypes as predictors of long-term clinical course in adults with primary OCD.

METHOD

A total of 213 adults with DSM-IV OCD were recruited from several mental health treatment sites between July 2001 and February 2006 as part of the Brown Longitudinal Obsessive Compulsive Study, a prospective, naturalistic study of treatment-seeking adults with primary OCD. OCD symptoms were assessed annually over the 5-year follow-up period using the Longitudinal Interval Follow-Up Evaluation.

RESULTS

Thirty-nine percent of participants experienced either a partial (22.1%) or a full (16.9%) remission. Two OCD symptom dimensions impacted remission. Participants with primary obsessions regarding overresponsibility for harm were nearly twice as likely to experience a remission (P < .05), whereas only 2 of 21 participants (9.5%) with primary hoarding achieved remission. Other predictors of increased remission were lower OCD severity (P < .0001) and shorter duration of illness (P < .0001). Fifty-nine percent of participants who remitted subsequently relapsed. Participants with obsessive-compulsive personality disorder were more than twice as likely to relapse (P < .005). Participants were also particularly vulnerable to relapse if they experienced partial remission versus full remission (70% vs 45%; P < .05).

CONCLUSIONS

The contributions of OCD symptom categories and comorbid obsessive-compulsive personality disorder are critically important to advancing our understanding of the prognosis and ultimately the successful treatment of OCD. Longer duration of illness was also found to be a significant predictor of course, highlighting the critical importance of early detection and treatment of OCD. Furthermore, having full remission as a treatment target is an important consideration for the prevention of relapse in this disorder.

Obsessive-compulsive symptom dimensions correlate to specific gray matter volumes in treatment-naïve patients

BACKGROUND

Clinical and sociodemographic findings have supported that OCD is heterogeneous and composed of multiple potentially overlapping and stable symptom dimensions. Previous neuroimaging investigations have correlated different patterns of OCD dimension scores and gray matter (GM) volumes. Despite their relevant contribution, some methodological limitations, such as patient's previous medication intake, may have contributed to inconsistent findings.

METHOD

Voxel-based morphometry was used to investigate correlations between regional GM volumes and symptom dimensions severity scores in a sample of 38 treatment-naïve OCD patients. Several standardized instruments were applied, including an interview exclusively developed for assessing symptom dimensions severity (DY-BOCS).

RESULTS

Scores on the "aggression" dimension were positively correlated with GM volumes in lateral parietal cortex in both hemispheres and negatively correlated with bilateral insula, left putamen and left inferior OFC. Scores on the "sexual/religious" dimension were positively correlated with GM volumes within the right middle lateral OFC and right DLPFC and negatively correlated with bilateral ACC. Scores on the "hoarding" dimension were positively correlated with GM volumes in the left superior lateral OFC and negatively correlated in the right parahippocampal gyrus. No significant correlations between GM volumes and the "contamination" or "symmetry" dimensions were found.

CONCLUSIONS

Building upon preexisting findings, our data with treatment-naïve OCD patients have demonstrated distinct GM substrates implicated in both cognitive and emotion processing across different OCS dimensions.

The Netherlands Obsessive Compulsive Disorder Association (NOCDA) study: design and rationale of a longitudinal naturalistic study of the course of OCD and clinical characteristics of the sample at baseline

In half of Obsessive Compulsive Disorder (OCD) patients the disorder runs a chronic course despite treatment. The factors determining this unfavourable outcome remain unknown. The Netherlands Obsessive Compulsive Disorder Association (NOCDA) study is a multicentre naturalistic cohort study of the biological, psychological and social determinants of chronicity in a clinical sample. Recruitment of OCD patients took place in mental health organizations. Its design is a six-year longitudinal cohort study among a representative clinical sample of 419 OCD patients. All five measurements within this six-year period involved validated semi-structured interviews and self-report questionnaires which gathered information on the severity of OCD and its co-morbidity as well as information on general wellbeing, quality of life, daily activities, medical consumption and key psychological and social factors. The baseline measurements also include DNA and blood sampling and data on demographic and personality variables. The current paper presents the design and rationale of the study, as well as data on baseline sample characteristics. Demographic characteristics and co-morbidity ratings in the NOCDA sample closely resemble other OCD study samples. Lifetime co-morbid Axis I disorders are present in the majority of OCD patients, with high current and lifetime co-morbidity ratings for affective disorders (23.4% and 63.7%, respectively) and anxiety disorders other than OCD (36% current and 46.5% lifetime).

Skin picking and trichotillomania in adults with obsessive-compulsive disorder

The objective of this study was to compare patients with obsessive-compulsive disorder (OCD) associated with pathologic skin picking (PSP) and/or trichotillomania, and patients with OCD without such comorbidities, for demographic and clinical characteristics. We assessed 901 individuals with a primary diagnosis of OCD, using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I disorders. Diagnoses of PSP and trichotillomania were made in 16.3% and 4.9% of the sample, respectively. After the logistic regression analysis, the following factors retained an association with OCD-PSP/trichotillomania: younger (odds ratio [OR] = 0.979; P = .047), younger at the onset of compulsive symptoms (OR = 0.941; P = .007), woman (OR = 2.538; P < .001), with a higher level of education (OR = 1.055; P = .025), and with comorbid body dysmorphic disorder (OR = 2.363; P = .004). These findings support the idea that OCD accompanied by PSP/trichotillomania characterizes a specific subgroup.

Risk factors prospectively associated with adult obsessive-compulsive symptom dimensions and obsessive-compulsive disorder

BACKGROUND

Very few longitudinal studies have evaluated prospective neurodevelopmental and psychosocial risk factors for obsessive-compulsive disorder (OCD). Furthermore, despite the heterogeneous nature of OCD, no research has examined risk factors for its primary symptom dimensions, such as contamination/washing.

METHOD

Potential risk factors for symptoms or diagnosis of OCD in adulthood and for specific adult obsessive-compulsive (OC) symptom dimensions were examined in the Dunedin Study birth cohort. The presence of obsessions and compulsions and psychological disorders was assessed using the Diagnostic Interview Schedule (DIS) at ages 26 and 32 years. Individuals with a diagnosis of OCD at either age (n=36) were compared to both a healthy control group (n=613) and an anxious control group (n=310) to determine whether associations between a risk factor and an OCD diagnosis were specific.

RESULTS

Childhood neurodevelopmental, behavioral, personality and environmental risk factors were associated with a diagnosis of OCD and with OC symptoms at ages 26 and 32. Social isolation, retrospectively reported physical abuse and negative emotionality were specific predictors of an adult OCD diagnosis. Of note, most risk factors were associated with OC symptoms in adulthood and several risk factors predicted specific OCD dimensions. Perinatal insults were linked to increased risk for symmetry/ordering and shameful thoughts dimensions, whereas poor childhood motor skills predicted the harm/checking dimension. Difficult temperament, internalizing symptoms and conduct problems in childhood also predicted specific symptom dimensions and lower IQ non-specifically predicted increased risk for most dimensions.

CONCLUSIONS

The current findings underscore the need for a dimensional approach in evaluating childhood risk factors for obsessions and compulsions.

Obsessive-compulsive disorder in children and adolescents: symptom dimensions in a naturalistic setting

BACKGROUND

Obsessive-compulsive disorder (OCD) is a frequent and clinically heterogeneous disorder. The complex clinical presentation can be summarized using a few consistent and temporally stable symptom dimensions. Only few studies in children and adolescents have examined the importance of symptom dimensions.

AIMS

This retrospective study was undertaken to describe the relation between symptom dimensions, pattern of comorbidity and family disposition, in a sample of Danish children and adolescents with OCD assessed in a naturalistic setting.

METHODS

A retrospective study of children and adolescents (n=83) diagnosed with OCD in the period 1998-2004, at the Psychiatric Hospital for Children and Adolescents, Risskov, Denmark. Information from clinical records was systematically collected and Children's Yale-Brown Obsessive-compulsive Scale (CY-BOCS) scores and symptom checklists were obtained.

RESULTS

High scores on the symmetry/ordering dimension were related to OCD in first-degree relatives and high scores on the aggressive/checking dimension were associated to comorbidity with tic disorders. We showed a correlation between limited insight and younger age.

CONCLUSION

This is one of the first studies to examine symptom dimensions in children and adolescents in naturalistic settings. The results were comparable with those in adult studies, showing an association between the occurrence of the symmetry/ordering dimension and family OCD and the occurrence of the aggressive/checking dimension and comorbid tic disorders. In small children, insight into symptoms may be limited.

The involvement of distinct neural systems in patients with obsessive-compulsive disorder with autogenous and reactive obsessions

OBJECTIVE

To investigate the regional metabolite abnormalities and changes after treatment in patients with OCD with autogenous and reactive obsessions.

METHOD

We assessed right anterior cingulate cortex (ACC) and amygdala-hippocampal region (Am + Hpp) N-acetyl-aspartate (NAA), choline (Cho) and creatine (Cr) concentrations and NAA/Cr and Cho/Cr ratios using single-voxel proton magnetic resonance spectroscopy in 15 patients with autogenous obsessions (OCD-A), 15 patients with reactive obsessions (OCD-R) and 15 healthy controls (HC). Measurements were repeated after 16 weeks of fluoxetine treatment.

RESULTS

Baseline ACC NAA/Cr ratios of both OCD groups were significantly lower than HC. OCD-A group had significantly lower baseline NAA/Cr ratios in the Am + Hpp than other groups. These differences were more likely to be explained by higher Cr levels in ACC. We found no significant differences and changes for Cho levels and Cho/Cr ratios between groups and within groups. Significant increase in NAA/Cr ratios of OCD-A group found in the Am + Hpp was more likely to be explained by increased NAA levels. No significant changes were found in ACC NAA/Cr ratios.

CONCLUSION

While disturbed energy metabolism in ACC might reflect a common pathology in patients with OCD regardless of symptom dimension, alterations in mesiotemporal lobe are more likely for autogenous obsessions.

Annual Research Review: Transgenic mouse models of childhood-onset psychiatric disorders

Childhood-onset psychiatric disorders, such as attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), mood disorders, obsessive compulsive spectrum disorders (OCSD), and schizophrenia (SZ), affect many school-age children, leading to a lower quality of life, including difficulties in school and personal relationships that persist into adulthood. Currently, the causes of these psychiatric disorders are poorly understood, resulting in difficulty diagnosing affected children, and insufficient treatment options. Family and twin studies implicate a genetic contribution for ADHD, ASD, mood disorders, OCSD, and SZ. Identification of candidate genes and chromosomal regions associated with a particular disorder provide targets for directed research, and understanding how these genes influence the disease state will provide valuable insights for improving the diagnosis and treatment of children with psychiatric disorders. Transgenic mouse models are one important approach in the study of human diseases, allowing for the use of a variety of experimental approaches to dissect the contribution of a specific chromosomal or genetic abnormality in human disorders. While it is impossible to model an entire psychiatric disorder in a single mouse model, these models can be extremely valuable in dissecting out the specific role of a gene, pathway, neuron subtype, or brain region in a particular abnormal behavior. In this review we discuss existing transgenic mouse models for childhood-onset psychiatric disorders. We compare the strength and weakness of various transgenic mouse models proposed for each of the common childhood-onset psychiatric disorders, and discuss future directions for the study of these disorders using cutting-edge genetic tools.

General and maladaptive personality dimensions in pediatric obsessive-compulsive symptoms

Obsessive-compulsive disorder (OCD) is a chronic and impairing clinical disorder in childhood, often characterized by a heterogeneous symptomatic profile and high co-occurrence with other disorders. The present study introduces a new perspective on the description of OCD symptoms in youth, and empirically examines the value of a personality framework (e.g. Five Factor of Personality; FFM) for understanding early OCD symptomatology in a referred sample of 274 children and adolescents, relying on age-specific measures of general and maladaptive personality. Differences in general and maladaptive personality traits for high versus low-scoring children and adolescents on the Obsessive-Compulsive Scale of the Child Behavior Checklist (CBCL-OCS) were explored. The discriminant validity of both higher-and lower-order personality traits was supported, showing that high CBCL-OCS scorers are characterized by specific personality features ranging from adaptive to pathological, especially in terms of Conscientiousness. In addition, personality traits contributed to the accurate classification of high- versus low-scorers on the CBCL-OCS. Implications for clinical practice and recommendations for future research are discussed.

Adding motivational interviewing and thought mapping to cognitive-behavioral group therapy: results from a randomized clinical trial

OBJECTIVE

Recent factor-analytic studies of obsessive-compulsive disorder identified consistent symptom dimensions. This study was designed in order to observe which obsessive compulsive symptom dimensions could be changed by adding two individual sessions of motivational interviewing and thought mapping of cognitive-behavioral group therapy using a randomized clinical trial.

METHOD

Forty outpatients with a primary diagnosis of obsessive-compulsive disorder were randomly assigned to receive cognitive-behavioral group therapy (control group) or motivational interviewing+thought mapping plus cognitive-behavioral group therapy. To evaluate changes in symptom dimensions, the Dimensional Yale-Brown Obsessive-Compulsive Scale was administered at baseline and after treatment.

RESULTS

At post-treatment, there were statistically significant differences between cognitive-behavioral group therapy and motivational interviewing+thought mapping+cognitive behavioral group therapy groups in the mean total Dimensional Yale-Brown Obsessive-Compulsive Scale score, and in the contamination and aggression dimension score. Hoarding showed a statistical trend towards improvement.

CONCLUSION

These findings suggest that adding motivational interviewing+thought mapping to cognitive-behavioral group therapy can facilitate changes and bring about a decrease in the scores in different obsessive-compulsive disorder symptom dimensions, as measured by the Dimensional Yale-Brown Obsessive-Compulsive Scale. Nonetheless, additional trials are needed to confirm these results.

The clinical utility of symptom dimensions in obsessive-compulsive disorder

Factor analyses in obsessive-compulsive disorder (OCD) have consistently identified several different symptom dimensions. Nevertheless the clinical utility of identifying such symptom dimensions remains somewhat unclear. On the basis of their principal symptoms, 343 OCD patients were divided into four symptom dimension subgroups; 1) contamination/washing, 2) hoarding, 3) symmetry/repeating and ordering, and 4) forbidden thoughts/checking. Clinical variables including 1-year treatment outcome were compared across these patient subgroups. Most patients (74%) could distinctively be categorized as falling into a particular symptom subgroup. The groups were differentially characterized by some demographic and clinical features. For instance, both the symmetry and hoarding groups were significantly associated with decreased global functioning and greater OCD severity. Moreover the hoarding group was significantly more likely than the others to show longer duration of illness, lower rate of marriage, poor insight, and poorer outcome. However, about a quarter of the participants could not be classified definitively into a particular group. Our findings provide partial support for the clinical utility of a simple measure of symptom dimensions in OCD. In clinical settings, however, the limitations of such a simple measure of predominant symptom dimensions should be borne in mind and further work on their validity and utility is needed.

A novel, multiple symptom model of obsessive-compulsive-like behaviors in animals

BACKGROUND

Current animal models of obsessive-compulsive disorder (OCD) typically involve acute, drug-induced symptom provocation or a genetic association with stereotypies or anxiety. None of these current models demonstrate multiple OCD-like behaviors.

METHODS

Neonatal rats were treated with the tricyclic antidepressant clomipramine or vehicle between days 9 and 16 twice daily and behaviorally tested in adulthood.

RESULTS

Clomipramine exposure in immature rats produced significant behavioral and biochemical changes that include enhanced anxiety (elevated plus maze and marble burying), behavioral inflexibility (perseveration in the spontaneous alternation task and impaired reversal learning), working memory impairment (e.g., win-shift paradigm), hoarding, and corticostriatal dysfunction. Dopamine D2 receptors were elevated in the striatum, whereas serotonin 2C, but not serotonin 1A, receptors were elevated in the orbital frontal cortex.

CONCLUSIONS

This is the first demonstration of multiple symptoms consistent with an OCD-like profile in animals. Moreover, these behaviors are accompanied by biochemical changes in brain regions previously identified as relevant to OCD. This novel model of OCD demonstrates that drug exposure during a sensitive period can program disease-like systems permanently, which could have implications for current and future therapeutic strategies for this and other psychiatric disorders.

Multidimensional assessment of OCD: integration and revision of the Vancouver Obsessional-Compulsive Inventory and the Symmetry Ordering and Arranging Questionnaire

This article reports on the integration and revision of two self-report measures of obsessive-compulsive symptoms based on data from an obsessive-compulsive disorder (OCD) sample (n=228): the Vancouver Obsessional-Compulsive Inventory (VOCI) and the Symmetry Ordering and Arranging Questionnaire (SOAQ). The revised measure provides scores on five symptom subscales (Contamination, Checking, Hoarding, Symmetry and Ordering, Obsessions). It shows improvement upon current versions in several ways: it has a good model fit, eliminates redundancy, reduces overlap across subscales, is much shorter, and covers those OCD dimensions most frequently identified in factor-analytic studies. Strengths of the revision compared with other measures are high distinctiveness of subscales, discriminant validity with depression and anxiety, and a more fine-grained and comprehensive assessment of obsessional contents.

Psychometric analysis of the Yale-Brown Obsessive-Compulsive Scale Second Edition Symptom Checklist

The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was recently revised to address several clinical and conceptual issues. The resultant measure, named the Yale-Brown Obsessive-Compulsive Scale-Second Edition, consists of two primary scales: the Severity Scale and the Symptom Checklist. Although the Severity Scale has been the subject of a comprehensive psychometric analysis, no data have been reported on the psychometric properties of the Y-BOCS-II Symptom Checklist (Y-BOCS-II-SC). Accordingly, in the present study, clinician ratings on the Y-BOCS-II-SC for 130 patients with obsessive-compulsive disorder (OCD) were examined on a number of validity and reliability indices. Partially consistent with past factor analytic studies of the Y-BOCS Symptom Checklist, the Y-BOCS-II-SC yielded four factors representing symmetry/ordering, contamination/washing, hoarding, and sexual/religious/aggression dimensions; checking rituals cross-loaded with other dimensions. Generally, the Y-BOCS-II-SC dimensions were internally consistent and rated stably across raters and over a short interval. The Y-BOCS-II-SC symptom dimensions showed good convergence with self-reported obsessive-compulsive symptoms, and were at best moderately associated with divergent measures (e.g., OCD symptom severity, depressive symptoms, and symptoms of anxiety). Overall, the Y-BOCS-II-SC shows good psychometric properties; we highlight several domains in which the Y-BOCS-II-SC may have clinical and research utility, as well as several areas for future study.

Executive dysfunctions in obsessive-compulsive patients and unaffected relatives: searching for a new intermediate phenotype

BACKGROUND

Evidence in literature suggests that neurocognitive deficits may represent suitable intermediate-phenotype candidates for the dissection of obsessive-compulsive disorder (OCD) genetic heterogeneity. The aim of this study was to search for possible OCD neurocognitive endophenotypes by assessing decision-making, planning, and mental flexibility profiles in OCD probands, healthy control subjects (HC), and their respective relatives.

METHODS

The sample consisted of 35 pairs of OCD probands without other Axis I comorbidities and unaffected first-degree relatives and 31 pairs of HC subjects without a known family history of OCD and their relatives. Neuropsychological assessment was performed using the Iowa Gambling Task (IGT), the Tower of Hanoi (ToH), and the Wisconsin Card Sorting Test (WCST).

RESULTS

Obsessive-compulsive disorder patients showed impairments in decision making, planning, and mental flexibility, given that OCD probands performed significantly poorer than HC probands at the IGT, the ToH, and the WCST. Obsessive-compulsive disorder relatives performed poorer at these tests than HC probands and relatives. Symptom severity was found to have no influence on neurocognitive performance. Analysis of proband/relative concordance in task performance was performed for each task. A significant overall difference was found when comparing the percentages of the different concordance profiles of our OCD and HC samples with regard to IGT and ToH performance. No significant difference was found in the WCST.

CONCLUSIONS

Executive dysfunctions may qualify as a suitable endophenotype candidate for OCD. Concordance rates in neuropsychological task performance suggest that decision-making and planning deficits aggregate in these families and therefore might be a heritable component of OCD.

Obsessive-compulsive disorder: a review of the diagnostic criteria and possible subtypes and dimensional specifiers for DSM-V

BACKGROUND

Since the publication of the DSM-IV in 1994, research on obsessive-compulsive disorder (OCD) has continued to expand. It is timely to reconsider the nosology of this disorder, assessing whether changes to diagnostic criteria as well as subtypes and specifiers may improve diagnostic validity and clinical utility.

METHODS

The existing criteria were evaluated. Key issues were identified. Electronic databases of PubMed, ScienceDirect, and PsycINFO were searched for relevant studies.

RESULTS

This review presents a number of options and preliminary recommendations to be considered for DSM-V. These include: (1) clarifying and simplifying the definition of obsessions and compulsions (criterion A); (2) possibly deleting the requirement that people recognize that their obsessions or compulsions are excessive or unreasonable (criterion B); (3) rethinking the clinical significance criterion (criterion C) and, in the interim, possibly adjusting what is considered "time-consuming" for OCD; (4) listing additional disorders to help with the differential diagnosis (criterion D); (5) rethinking the medical exclusion criterion (criterion E) and clarifying what is meant by a "general medical condition"; (6) revising the specifiers (i.e., clarifying that OCD can involve a range of insight, in addition to "poor insight," and adding "tic-related OCD"); and (7) highlighting in the DSM-V text important clinical features of OCD that are not currently mentioned in the criteria (e.g., the major symptom dimensions).

CONCLUSIONS

A number of changes to the existing diagnostic criteria for OCD are proposed. These proposed criteria may change as the DSM-V process progresses.

Clinical features and treatment characteristics of compulsive hoarding in Japanese patients with obsessive-compulsive disorder

INTRODUCTION

Compulsive hoarding has been studied primarily in Western countries. Here we sought to examine compulsive hoarding in Japanese patients with obsessive-compulsive disorder (OCD). The heterogeneous nature of hoarding was also investigated.

METHODS

One hundred and sixty-eight OCD outpatients were initially assessed to determine the presence or absence of compulsive hoarding, and whether hoarding was primary or secondary to another symptom dimension for which they had received treatment for 1 year.

RESULTS

Of the participants, 54 patients were found to have compulsive hoarding. Hoarders were significantly more likely than non-hoarding patients to have more severe psychopathology including elevated severity of OCD symptoms, poorer insight, higher prevalence of comorbid schizotypal or obsessive-compulsive personality disorder, closer association with symmetry dimension, and poorer treatment outcome. Comparisons of subjects with primary and secondary hoarding found that the former group had more severe clinical features, while the latter group hoarded a wider variety of items, including apparently bizarre ones.

CONCLUSION

The prevalence and clinical characteristics of compulsive hoarding in OCD subjects was similar to those reported in Western countries, supporting its trans-cultural consistency. The distinction between primary and secondary hoarding in OCD is clinically useful, and may contribute to the debate about whether hoarding should be a separate diagnostic entity.

Volitional disorders: a proposal for DSM-V

In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.

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

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

A single-blinded case-control study of memantine in severe obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a common debilitating psychiatric illness that typically improves but does not remit with first-line medication and behavioral treatments. Serotonergic agents including selective serotonin reuptake inhibitors and clomipramine have provided the mainstay of OCD medication management for decades. Combined dopamine/serotonergic agents such as atypical antipsychotics are presently the only OCD-augmenting strategies proven effective via randomized controlled trials. Despite increasing evidence for a pathogenic role of glutamate in OCD, no controlled trials of glutamatergic augmenting agents have been reported.

METHODS

An intent-to-treat sample included 44 subjects receiving standard treatment at the McLean/Massachusetts General Hospital Intensive Residential Treatment (IRT) program, 22 of whom also received memantine augmentation. Admission, monthly and discharge measures of OCD, depression, and psychosocial functioning were collected by raters blinded to augmentation status. Matched controls were selected based on sex, initial OCD severity, psychosocial functioning, and timing of admission. The Clinical Global Improvement Scale captured global clinical change.

RESULTS

Mean (SD) Yale-Brown Obsessive Compulsive Scale score decreases were 7.2 (6.4) among the cases and 4.6 (5.9) among the matched controls, reflecting mean clinical improvement among the cases (27.0% decrease) but not the controls (16.5% decrease). Mean (SD) depression severity score decreases were 5.8 (9.5) among the cases and 4.7 (9.9) among the controls. Initial intrusive obsessions were significantly more severe among marked responders compared with limited response or nonresponse cases (4.4 vs 2.9; t = 2.15; P = 0.048).

CONCLUSIONS

This study provides preliminary supportive evidence for the effectiveness of memantine as a glutamatergic augmenting agent in severe OCD. Future randomized double-blind placebo-controlled trials are warranted.

Are obsessive-compulsive symptom dimensions familial in nonclinical individuals?

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous condition, which can be expressed as various potentially overlapping symptom dimensions. In clinical samples, some of these dimensions are associated with increased familial risk for OCD and appear to be familial (intercorrelated within pairs of affected family members), whereas others are not. The goal of this study was to determine whether obsessive-compulsive (OC) symptom dimensions are familial in a nonclinical sample.

METHODS

OC symptom dimensions and negative affect were assessed in 184 female undergraduate students and their parents using the Obsessive-Compulsive Inventory-Revised (OCI-R) and the Positive and Negative Affect Scales, respectively. Bivariate correlations and multiple regression models controlling for age and negative affect were employed to examine the familiarity of OC symptom dimensions.

RESULTS

The OCI-R total scores were significantly correlated in both mother-daughter and father-daughter dyads but the magnitude of these correlations tended to be greater for the mother-daughter dyads. Multiple regression models showed that the Ordering and Hoarding subscales of the OCI-R breed true in mother-daughter dyads. Ordering scores in mothers were also predictive of other symptoms in the daughters (Washing and Checking).

CONCLUSIONS

These results are broadly consistent with the findings in clinical samples and suggest that Ordering and Hoarding are more strongly familial than other symptom dimensions and that high Ordering scores in mothers are associated with increased levels of symptoms in daughters in a less specific manner.

Fear of harm, a possible phenotype of pediatric bipolar disorder: a dimensional approach to diagnosis for genotyping psychiatric syndromes

BACKGROUND

In a prior concordance study of affected sibling pairs with a community diagnosis of pediatric bipolar disorder (PBD) a behavioral phenotype termed Fear of Harm (FOH) was found to have one of the strongest concordance coefficients (rho) between probands and siblings, and the widest contrasts between the rho-estimates for the proband/sibling vs. proband/comparison pairs [Papolos, D., Hennen, J., Cockerham, M.S, Lachman, H., 2007]. A strategy for identifying phenotypic subtypes: concordance of symptom dimensions between sibling pairs who met screening criteria for a genetic linkage study of childhood-onset bipolar disorder using the Child Bipolar Questionnaire (CBQ) was employed. J. Affect. Disord. 99, 27-36.]. We used the Child Bipolar Questionnaire (OUT) (CBQ) to further elucidate this behavioral phenotype of PBD. We hypothesized that selective factors including parent reported symptoms of mania and depression, would be distinguishing features of impairment between groups defined by 1) the magnitude of their score on a continuous measure of FOH, and 2) the high FOH group would have significantly greater levels of severity on course of illness variables. These measures included earlier age of onset of first psychiatric symptoms, first hospitalization, and frequency of psychiatric hospitalizations, as well as, degree of social impairment as determined by exposure to the juvenile justice system and school performance problems.

METHODS

The sample was comprised of children with community diagnoses of bipolar disorder or at risk for the illness based on enriched family history with multiple first degree relatives diagnosed with BPD (N=5335). Included were all subjects who had >40 positively endorsed CBQ symptom items at frequencies of very often, almost always, and always. This group was divided randomly into two groups, the exploratory group (N=2668) and the hypothesis testing (study) group (N=2666). The exploratory group was used for the development of hypotheses and the study group was used to test these hypotheses on a new set of data. All results reported here derive from the latter group. In subsequent analyses, we classified each child as having a high degree of FOH, low FOH, or no FOH. We examined a subset of the sample for differences in age of onset of first psychiatric symptoms, course of illness and measures of symptom severity. These groups were compared using the chi-square procedure for categorical data and the Analysis of Variance (ANOVA) with Scheffe pair wise tests for continuous variables. The Child Bipolar Questionnaire V.2.0, the Yale-Brown Obsessive Compulsive Scale (YBOCS) and the Overt Aggression Scale (OAS) were the principal instruments used to obtain diagnostic information for this study.

RESULTS

We found that children representative of the FOH phenotype when compared to children with PBD who lack this trait had higher indices of severity of mania and depression, as well as other indices that reflect severity and course of illness. Trait factors were derived from a factor analysis of CBQ in a large population of children diagnosed with or at risk for PBD, and used to further elucidate trait features of children with FOH. Children with the FOH traits were also more likely to be defined by six CBQ factors; Sleep/Arousal, Harm to Self and Others, Territorial Aggression, Anxiety, Self-esteem, Psychosis/Parasomnias/Sweet Cravings/Obsessions (PPSO).

LIMITATIONS

This data is derived from samples enriched with bipolar disorder cases. Further validation is needed with samples in which childhood-onset BD is rarer and diagnoses more diverse. Clinician diagnosis was not validated via research interview.

CONCLUSIONS

The FOH phenotype, as defined by a metric derived from combining items from the YBOCS/OAS, is a clinically homogeneous behavioral phenotype of PBD with early age of onset, severe manic and depressive symptoms, and significant social impairment that is strongly associated with 6 CBQ factors and can be easily identified using the CBQ. Through the examination of dimensional features of PBD in an enriched sample of large size, we were able to further refine a phenotype and identify clinical dimensions potentially linked to endophenotypic markers that may prove fruitful in differential diagnosis, treatment and etiological studies of PBD. The nature of the sets of specific symptoms that comprise the FOH factors enabled us to propose a biological model for the phenotype (OUT) that involves a complex orexigenic circuit which links hypothalamic, limbic, and other brain nuclei primarily responsible for the regulation of behavioral and proposed physiological features of the FOH phenotype.

Temperament and character in subjects with obsessive-compulsive disorder

BACKGROUND

The aims of this study were to evaluate the differences between personality traits of patients with obsessive-compulsive disorder (OCD) and normal controls using the Temperament and Character Inventory (TCI) and to examine the relationship of personality traits and the severity of obsessive-compulsive (OC) symptoms. We also aimed to examine the influence a particular personality trait might have on the 5 factor-analyzed symptom dimension scores of OCD.

METHOD

We recruited 130 patients with OCD and 185 age- and sex-matched normal controls. All subjects completed the TCI. Patients with OCD were assessed with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Hamilton Depression Rating Scale, and the factor-analyzed symptom dimension scores from the Y-BOCS checklist.

RESULTS

Patients with OCD had higher harm avoidance scores and lower self-directedness (SD), reward dependence (RD), and cooperativeness (C) scores than the controls. Lower SD scores and lower C scores were associated with OC symptom severity measured by the Y-BOCS after adjusting for age and depression severity. Hoarding dimension of OC symptoms was associated with lower SD scores and higher persistence (P) scores after adjusting for age, OC symptom severity, and depression severity.

CONCLUSIONS

There were significant differences in TCI subscales between patients with OCD and controls. Particular personality traits may have an influence on the severity and the dimensions of OC symptoms.

The Padua Inventory: do revisions need revision?

The purpose of the present study was to examine the psychometric properties, factorial structure, and validity of the Padua Inventory-Washington State University Revision and of the Padua Inventory-Revised in a large sample of patients with obsessive-compulsive disorder (n = 228) and with anxiety disorders and/or depression (n = 213). The five-factor structures of both revisions were not replicated. A 24-item revision, referred to as the Padua Inventory-Palatine Revision (PI-PR), was developed on the basis of both theoretical and statistical considerations. The PI-PR assesses six subscales: Contamination and Washing, Checking, Numbers, Dressing and Grooming, Rumination, and Harming Obsessions and Impulses. The results demonstrate that the PI-PR is a brief, psychometrically sound, and valid measure for the assessment of a broad range of obsessive-compulsive symptoms, which has important advantages over both previous revisions.

Obsessive-compulsive symptom dimensions in schizophrenia patients with comorbid obsessive-compulsive disorder

A substantial proportion of schizophrenia patients also exhibit obsessive-compulsive symptoms (OCS). We sought to determine whether the revealed symptom dimensions in OCD exist in schizophrenia patients with comorbid OCD. One hundred and ten patients who met DSM-IV criteria for both schizophrenia and OCD were recruited. Exploratory factor analysis of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) checklist was conducted. The inter-relationship between the resulting factors and schizophrenia symptom dimensions, as assessed by the Schedule for the Assessment of Positive (SAPS) and Negative (SANS) Symptoms, was examined. The principal component analysis of 13 Y-BOCS checklist categories yielded a five-factor solution and accounted for 58.7% of the total variance: (1) aggressive, sexual, religious obsessions and counting, (2) symmetry and ordering/hoarding compulsions, (3) contamination and cleaning, (4) somatic obsession and repeating compulsion, (5) hoarding obsession and checking/repeating compulsions. The Y-BOCS symptom dimensions did not correlate with schizophrenia symptom dimensions. The five symptom dimensions are comparable to those revealed in "pure" OCD, and suggest the involvement of universal mechanisms in the pathogenesis of OCD regardless of the presence of schizophrenia.

Artificial neural network model for the prediction of obsessive-compulsive disorder treatment response

Several patients with obsessive-compulsive disorder (OCD) who are refractory to adequate treatment with first-line treatments are considered treatment-resistant. Further surveys were to be implemented to explore the outcome predictors of the antiobsessional response. Such study was aimed at building a model suitable to predict the final outcome of a mixed OCD pharmacologic and nonpharmacologic treatment approaches. We studied 130 subjects with OCD who underwent pharmacologic (with selective serotonin reuptake inhibitors alone or with selective serotonin reuptake inhibitors and risperidone at low dosage) and/or behavioral therapy (using exposure and response prevention techniques). The following variables were used as predictors: symptoms dimension, as resulting from the Yale-Brown Obsessive-Compulsive Scale items factor analysis; neuropsychologic performances; and epidemiologic variables. The treatment response arising from 3 to 6 months of therapy was used as dependent variable. A conventional logistic regression was used to define a previsional model of treatment response and multilayer perceptrons and to supervise an artificial neural network technique. The 46.9% of the sample resulted to be refractory to treatment. Results obtained with the logistic regression model showed that the only predictors of treatment outcome are hoarding symptoms, repeating rituals, and counting compulsions. Furthermore, using all the variables considered in the models, multilayer perceptrons showed highly better predictive performance as compared with the logistic regression models (93.3% vs 61.5%, respectively, of correct classification of cases). Complex interactions between different clinical and neuropsychologic variables are involved in defining OCD treatment response profile, and nonlinear and interactive modeling strategies, that is, supervised artificial neural networks, seem to be more suitable to investigate this complexity than linear techniques.

Symptom dimensions and subtypes of obsessive-compulsive disorder: a developmental perspective

In the absence of definitive etiological markers for obsessive-compulsive disorder (OCD% obsessive-compulsive (OC) symptom dimensions may offer a fruitful point of orientation. These dimensions can be understood as defining potentially overlapping clinical features that may be continuous with "normal" worries first evident in childhood. Although the understanding of the dimensional structure of OC symptoms is still imperfect, a recent large-scale meta-analysis has confirmed the presence of at least four separa ble symptom dimensions in children, as well as adults, with OCD. A dimensional approach does not exclude other methods to parse OCD. Thus far, a pediatric age of onset, the presence of other family members with OCD, and the individual's "tic-related" status appear to be potentially useful categorical distinctions. Although the OC symptom dimensions appear to be valid for all ages, it is unlikely that the underlying genetic vulnerability factors and neurobiological substrates for each of these symptom dimensions are the same across the course of development.

Equifinality, multifinality, and the rediscovery of the importance of early experiences: pathways from early adversity to psychiatric and (functional) somatic disorders

Most current mainstream research, diagnostic assessment, and treatment strategies focus on specific psychiatric disorders--on diagnoses that are based on manifest symptoms within a categorical, atheoretical approach. This disorder-centered approach has been antithetical to psychoanalytic views, which are fundamentally person centered, focusing on the dynamics of individual lives. Growing realization of the high comorbidity among psychiatric disorders has led to the need to include developmental considerations and hierarchical models in the classification and treatment of psychopathology. In addition, this realization has led to a renewed interest in the principles of equifinality and multifinality--that a given end state can be the result of different developmental paths and that similar developmental factors may lead to dissimilar outcomes. In this chapter these developments are illustrated by research on the impact of early adversity, a central domain in psychoanalytic thought. Findings from various strands of research in the neurosciences and genetic research, in particular, suggest that early adversity leads to vulnerability for a wide variety of both psychiatric and (functional) somatic disorders. These findings have contributed to the rediscovery of the importance of early experiences more generally and to the need for a broad developmental perspective. In this context, we also discuss the danger of reductionism associated with the growing influence and popularity of affective neuroscience and genetics as well as the vital role a psychoanalytic perspective might play in countering this reductionism by reestablishing the importance of meaning and meaning making in understanding and treating patients with a history of early adversity. In particular, we focus on the importance of narrative and mental representations in the development of the capacity for mentalization in these patients.

Obsessions and compulsions in the community: prevalence, interference, help-seeking, developmental stability, and co-occurring psychiatric conditions

OBJECTIVE

It is unclear how many people in the community have obsessions and compulsions and associated levels of interference. It is also unknown what variables predict help-seeking for these symptoms, whether they are developmentally stable, and whether they increase the risk of mental disorders.

METHOD

The authors analyzed data from the prospective longitudinal Dunedin study of an unselected birth cohort. The presence of obsessions and compulsions and mental disorders was assessed using the Diagnostic Interview Schedule (DIS) at ages 11, 26, and 32. Data on interference and help-seeking were obtained at ages 26 and 32.

RESULTS

Obsessions and compulsions were frequent in individuals with mental disorders other than obsessive-compulsive disorder (OCD) and among people without mental disorders. Even in the latter group, these symptoms caused significant interference. The presence of anxiety/depression and of obsessions (particularly aggressive and shameful thoughts), but not compulsions, was associated with help-seeking. Harm/checking was the most prevalent symptom dimension. Symptom dimensions were temporally stable and associated with increased comorbidity. Obsessive-compulsive symptoms at age 11 predicted a high risk of an adult OCD diagnosis as well as elevated adult symptom dimensions.

CONCLUSIONS

Obsessions and compulsions are common in the adult population, have their roots in childhood, and are associated with interference, risk for disorders, and help-seeking. Subclinical obsessions and compulsions should be taken into account in research, intervention, and DSM-V.

The major symptom dimensions of obsessive-compulsive disorder are mediated by partially distinct neural systems

Obsessive-compulsive disorder (OCD) is a clinically heterogeneous disorder characterized by multiple, temporally stable symptom dimensions. Preliminary functional neuroimaging studies suggest that these symptom dimensions may have distinct neural substrates. Whole-brain voxel-based morphometry was used to examine the common and distinct neuroanatomical (structural) substrates of the major symptom dimensions of OCD. First, we compared 55 medication-free patients with OCD and 50 age-matched healthy control subjects. Multiple regression analyses were then used to examine the relationship between global and regional grey matter (GM) and white matter (WM) volumes and symptom dimension scores within the patient group. OCD patients showed decreased GM volume in left lateral orbitofrontal (BA47), left inferior frontal (BA44/45), left dorsolateral prefrontal (BA9) and right medial prefrontal (BA10) cortices and decreased bilateral prefrontal WM volume. Scores on the 'symmetry/ordering' dimension were negatively correlated with 'global' GM and WM volumes. Scores on the 'contamination/washing' dimension were negatively correlated with 'regional' GM volume in bilateral caudate nucleus and WM volume in right parietal region. Scores on the 'harm/checking' dimension were negatively correlated with regional GM and WM volume in bilateral temporal lobes. Scores on the 'symmetry/ordering' dimension were negatively correlated with regional GM volume in right motor cortex, left insula and left parietal cortex and positively correlated with bilateral temporal GM and WM volume. The results remained significant after controlling for age, sex, educational level, overall illness severity, global WM and GM volumes and excluding patients with comorbid depression. The reported symptom dimension-specific GM and WM alterations support the hypothesis that OCD is an etiologically heterogeneous disorder, with both overlapping and distinct neural correlates across symptom dimensions. These results have clear implications for the current neuroanatomical model of OCD and call for a substantial revision of such model which takes into account the heterogeneity of the disorder.

Genetic and environmental contributions to self-report obsessive-compulsive symptoms in Dutch adolescents at ages 12, 14, and 16

OBJECTIVE

To determine the contributions of genetic and environmental influences to variation in self-report of obsessive-compulsive (OC) symptoms in a population-based twin sample of adolescent boys and girls.

METHOD

Self-report ratings on the eight-item Youth Self-Report Obsessive-Compulsive Scale were collected in Dutch mono- and dizygotic twin pairs who participated at age 12 (N = 746 twin pairs), 14 (N = 963 pairs), or 16 years (N = 1,070 pairs). Structural equation modeling was used to break down the variation in liability to OC symptoms into genetic and environmental components.

RESULTS

At age 12, no difference in prevalence was found for OC symptoms in boys and girls. At ages 14 and 16, the prevalence was higher in girls. At all ages, genetic factors contributed significantly to variation on OC symptom liability; 27% at the age of 12,57% at the age of 14, and 54% at the age of 16. There were no sex differences in heritability. Only at age 12, environmental factors shared by children from the same family contributed significantly (16%) to individual differences in OC symptom scores.

CONCLUSIONS

During adolescence, OC symptoms are influenced by genetic and nonshared environmental factors. Sex differences in prevalence, but not heritability, emerge in adolescence. At age 12, shared environmental factors are of importance, but their influence disappears at later ages. This is in line with earlier research at age 12 that used parental ratings of OC symptoms. Thus, between-family factors play a significant role in explaining individual differences in OC symptoms at this age.

Four-factor structure of obsessive-compulsive disorder symptoms in children, adolescents, and adults

OBJECTIVE

To determine whether the four-factor category-based obsessive-compulsive disorder (OCD) symptom structure from a previous confirmatory factor analysis (CFA) may be appropriately used in child, adolescent, and adult groups. Symptom dimensions are increasingly used as quantitative traits in genetic, neuroimaging, and treatment studies of OCD across all ages. Identification of a category-based OCD symptom dimension structure that is validated for use across child, adolescent, and adult age groups is necessary to guide ongoing translational research.

METHOD

Four OCD samples comprising 356 individuals were divided into child, adolescent, and adult groups. The fit of the only CFA-defined four-factor model was compared across these independent age group samples. Multiple-group CFA using maximum likelihood estimation assessed adequacy of fit comparing unconstrained and measurement weight-constrained models. The fit of previous exploratory factor analysis-defined three- and five-factor models on adults was also examined using CFA.

RESULTS

A four-factor solution provided adequate but imperfect fit across age groups, with comparable indices to the only previous OCD CFA: factor 1 (aggressive/sexual/religious/somatic/checking); factor 2 (symmetry/ordering/counting/repeating); factor 3 (contamination/cleaning), and factor 4 (hoarding). Models in which factor loadings were constrained and unconstrained across the three age groups yielded comparable model fit. Factors were highly correlated and were not mutually exclusive. The four-factor solution provided an improved fit to both three- and five-factor solutions using CFA across the three age groups.

CONCLUSIONS

A four-factor, CFA-defined, category-based model of OCD symptom dimensions is adequate for use in children, adolescents, and adult age groups. The factor structure of this multiple age group sample has limitations and is imperfect, but current findings support the comparability of the defined latent OCD dimensions across age groups. Further work is needed to optimize a comprehensive symptom dimension model reflecting clinical heterogeneity for use in emergent translational studies.

Structure of obsessive-compulsive symptoms in pediatric OCD

OBJECTIVE

It is unclear whether the structure of obsessive-compulsive disorder (OCD) symptoms seen in adults is preserved in pediatric samples.

METHOD

A total of 238 children and adolescents referred to a specialty pediatric OCD clinic were administered the Children's Yale-Brown Obsessive Compulsive Scale Symptom Checklist, and its 13 major symptom categories were subjected to exploratory principal components analysis. The resulting factors were correlated with relevant clinical variables.

RESULTS

Principal components analysis identified four symptom dimensions explaining 55% of the total variance and broadly corresponding to those seen in adult samples. Boys were more likely to have sexual obsessions (34% vs. 18%, p = .01), whereas girls were more likely to endorse hoarding compulsions (53% vs. 36%, p=.009). High scores on the hoarding dimension were associated with increased levels of pervasive slowness, responsibility, indecisiveness, pathological doubt, depression and a variety of emotional difficulties, both self-rated and parent-rated.

CONCLUSIONS

The structure of OCD symptoms is similar across the lifespan. Hoarding symptoms are prevalent in pediatric OCD, especially among girls, and are associated with greater levels of disability.

Theories of autism

The purpose of the present paper was to review psychological theories of autism, and to integrate these theories with neurobiological findings. Cognitive, theory of mind, language and coherence theories were identified, and briefly reviewed. Psychological theories were found not to account for the rigid/repetitive behaviours universally described in autistic subjects, and underlying neurobiological systems were identified. When the developing brain encounters constrained connectivity, it evolves an abnormal organization, the features of which may be best explained by a developmental failure of neural connectivity, where high local connectivity develops in tandem with low long-range connectivity, resulting in constricted repetitive behaviours.