Juvenile-onset OCD: clinical features in children, adolescents and adults

'Excessive and Unreasonable': The Relation Between Clinical Insight and Clinical Correlates and Treatment Outcomes in Obsessive-Compulsive Disorder Across the Life Course

Individuals with mental disorders possess varying levels of clinical insight-the degree to which one understands that they are afflicted with a mental disorder and that their symptoms are manifestations of this psychopathology. Although clinical insight in OCD is thought to play an especially important role in determining various clinical characteristics and treatment outcomes, insight has not been sufficiently addressed developmentally, the importance of which this review will elucidate. Findings from this review suggest that clinical insight is typically associated with more complex cases and worse treatment outcomes across the life course, and also reveal nuances between pediatric and adult OCD cases with low insight. Implications of these findings, future research directions, and recommendations for the field are discussed.

Early-onset obsessive-compulsive disorder: Sociodemographic and clinical characterization of a large outpatient cohort

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a prevalent and disabling condition characterized by a wide variety of phenotypic expressions. Several studies have reinforced the hypothesis of OCD heterogeneity by proposing subtypes based on predominant symptomatology, course, and comorbidities. Early-onset OCD (EO) could be considered a neurodevelopmental subtype of OCD, with evidence of distinct neurocircuits supporting disease progression. To deepen the heterogeneous nature of the disorder, we analyzed sociodemographic and clinical differences between the EO and late-onset (LO) subtypes in a large outpatient cohort.

METHODS

Two hundred and eighty-four patients diagnosed with OCD were consecutively recruited from the OCD Tertiary Clinic at Luigi Sacco University Hospital in Milan. Sociodemographic and clinical variables were analyzed for the entire sample and compared between the two subgroups (EO, age <18 years [n = 117,41.2 %]; LO: late-onset, age ≥18 years [n = 167, 58.8 %]).

RESULTS

The EO group showed a higher frequency of male gender (65 % vs 42.5 %, p < .001), and a higher prevalence of Tic and Tourette disorders (9.4 % vs 0 %, p < .001) compared to the LO group. Additionally, in the EO subgroup, a longer duration of untreated illness was observed (9.01 ± 9.88 vs 4.81 ± 7.12; p < .001), along with a lower presence of insight (13.8 % vs. 7.5 %, p < .05).

CONCLUSIONS

The early-onset OCD subtype highlights a more severe clinical profile compared to the LO group. Exploring distinct manifestations and developmental trajectories of OCD can contribute to a better definition of homogeneous subtypes, useful for defining targeted therapeutic strategies for treatment.

Relationship between insight level and clinical and familial features in pediatric obsessive-compulsive disorder

OBJECTIVE

The aim of this study was to explore the relationship between insight level and clinical and familial psychiatric features of children with obsessive-compulsive disorder (OCD).

METHODS

Children's Yale-Brown Obsessive-Compulsive Scale-Symptom Checklist, 11th item of the Children's Yale-Brown Obsessive-Compulsive Scale, Wechsler Intelligence Scale for Children Revised Form, Affective Disorders and Schizophrenia for School Aged Children Present and Lifetime Version 1.0, and Structured Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders-IV Axis I Disorders were applied to 92 pediatric OCD patients.

RESULTS

In this study, the prevalence of OCD in the first children of the family was high (41.3%), and low insight was significantly related with concomitant intellectual disability (p=0.003). The level of insight was high in patients with comorbid OCD spectrum disorders (p<0.001). Attention deficit and hyperactivity disorder (ADHD) was the most common psychiatric diagnosis accompanying OCD (19.5%). Among the obsession-compulsion subscales, the symmetry/hoarding was higher in males (p=0.046). OCD patients with a family history of major depressive disorder (MDD) had high ADHD comorbidity rates (p=0.038). In OCD patients, whose family had psychiatric disorders besides MDD and anxiety disorders, the diagnosis rate of intellectual disability was higher than other diagnoses (p<0.001).

CONCLUSION

The sociodemographic, clinical, and familial features of pediatric OCD patients cannot be adequately clarified if the patient has limited insight. Therefore, the insight of children with OCD should be considered a range or continuity.

Economic Analyses of Obsessive-Compulsive Disorder Interventions: A Systematic Review

BACKGROUND

Obsessive-compulsive disorder (OCD) is a neuropsychiatric condition featuring patterns of obsessions, compulsions, and avoidant behaviors that are often time consuming and distressing to affected individuals. Cognitive-behavioral therapy (CBT) with exposure and response prevention and/or serotonin reuptake inhibitors are first-line treatments for OCD, though other therapeutic interventions may serve as economically practical modalities under various circumstances. Exploring and understanding the cost effectiveness of all indicated OCD interventions are important to inform therapeutic decisions and provide quality patient-centered care at a cost that is not burdensome to the patient and/or healthcare system.

METHODS

A systematic literature review was performed and studies were extracted from PubMed, Embase, Ovid MEDLINE, and Cochrane. All cost-effectiveness studies that included economic analyses with respect to OCD treatment modalities and were written in English and published between January 2010 and July 2022 were eligible for inclusion in the present study. We report a narrative synthesis of the findings and quality appraisal of the selected references.

RESULTS

Of the 707 references returned in the literature search, a total of 18 cost-effectiveness studies were included for review. Compared with treatment as usual, several studies reported clinical superiority and cost effectiveness of Internet-based CBT programs for adults and children with OCD at various willingness-to-pay thresholds and economic reference indicators, though cost effectiveness relative to in-person CBT with exposure and response prevention is unclear and estimates of efficacy are likely lower for Internet-based CBT. One study favored the cost utility of serotonin reuptake inhibitor monotherapy over CBT with exposure and response prevention although efficacy estimates of the former tend to be lower, and relative cost differences were low. Five studies evaluated the cost effectiveness of high-intensity neuroaugmentation, including deep brain stimulation and stereotactic radiosurgical capsulotomy, in the context of treatment-refractory OCD.

CONCLUSIONS

Despite the relatively high prevalence of OCD worldwide, cost-effectiveness data for therapeutic modalities remain sparse. Because of the chronic nature of OCD, the cost of treatment accumulates and may lead to a significant financial burden over time, particularly when non-evidence-based interventions are used. However, several alternative therapeutic modalities hold promise for economic practicality without significant sacrifice in clinical efficacy. Future studies are necessary to directly compare the cost effectiveness of such therapeutic alternatives with the current standard of care, CBT with exposure and response prevention.

Childhood Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) frequently affects children and adolescents, with most cases beginning during this time. Symptoms of OCD in youth may present as exaggerated developmental concerns and excessive ritualistic behavior beyond what is part of normal development, yet low levels of insight may prevent recognition. Affected youth commonly have comorbid neurodevelopmental diagnoses, especially males. Early detection and intervention are critical to recovery and remission, as well as family involvement in treatment. Cognitive behavioral therapy and serotonin reuptake inhibitors are first-line treatments.

Early Identification and Intervention in Pediatric Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by persistent thoughts with subsequent repetitive behaviors. Interventions that are effective for adult OCD cannot simply be generalized to pediatric OCD, since OCD in children and adolescents usually has a different clinical presentation, etiology and course from adult OCD. Delayed and inadequate treatment is associated with a worse prognosis, making the need for early identification and intervention in pediatric OCD very urgent. In this paper, we reflected on the current constraints that make early interventions for pediatric OCD unpromoted and reviewed the approaches with potential application for early identification and early intervention in pediatric OCD, categorized by three-level prevention stages corresponding to a clinical staging model. Since the etiology of pediatric OCD is still unclear, primary prevention is most lacking, and early interventions for pediatric OCD are currently focused on the secondary prevention stage, which aims to prevent the conversion of obsessive-compulsive symptoms into full-blown OCD; tertiary prevention mostly focuses on the alleviation of mild to moderate OCD, while interventions for co-morbidities are still in their infancy. We closed by considering the important research questions on this topic.

The global assessment of OCD

Obsessive Compulsive Disorder (OCD) is a common mental disorder that often causes great sufferance, with substantial impairment in social functioning and quality of life and affects family and significant relationships. Notwithstanding its severity, OCD is often not adequately diagnosed, or it is diagnosed with delay, leading often to a long latency between onset of the OCD symptoms and the start of adequate treatments. Several factors contribute to the complexity of OCD's clinical picture: early age of onset, chronic course, heterogeneity of symptoms, high rate of comorbidity with other psychiatric disorders, slow or partial response to therapy. Therefore, it is of primary importance for clinicians involved in diagnosing OCD, to assess all aspects of the disorder. This narrative review focuses on the global assessment of OCD, highlighting crucial areas to explore, pointing out the clinical features which are relevant for the treatment of the disorder, and giving an overview of the psychometric tools that can be useful during the screening procedure.

The role of gender in a large international OCD sample: A Report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) Network

INTRODUCTION

Obsessive-compulsive disorder (OCD) is characterized by a range of phenotypic expressions. Gender may be a relevant factor in mediating the disorder's heterogeneity. The aim of the present report was to explore a large multisite clinical sample of OCD patients, hypothesizing existing demographic, geographical and clinical differences between male and female patients with OCD.

METHODS

Socio-demographic and clinical variables of 491 adult OCD outpatients recruited in the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) network were investigated with a retrospective analysis on a previously gathered set of data from eleven countries worldwide. Patients were assessed through structured clinical interviews, the Yale- Brown Obsessive-Compulsive Scale (Y-BOCS), the Montgomery-Asberg Depression Rating Scale (MADRS) and the Self-rating Depression Scale (SDS).

RESULTS

Among females, adult onset (>18 years old) was significantly over-represented (67% vs. 33%, p < 0.005), and females showed a significantly older age at illness onset compared with males (20.85 ± 10.76 vs. 17.71 ± 8.96 years, p < 0.005). Females also had a significantly lower education level than males (13.09 ± 4.02 vs. 13.98 ± 3.85 years; p < 0.05), a significantly higher rate of being married (50.8% vs. 33.5%; p < 0.001) and a higher rate of living with a partner (47.5% vs. 37.6%; p < 0.001) than males. Nonetheless, no significant gender differences emerged in terms of the severity of OCD symptoms nor in the severity of comorbid depressive symptoms. No predictive effect of gender was found for Y-BOCS, MADRS and SDS severity.

DISCUSSION/CONCLUSIONS

Our findings showed significant differences between genders in OCD. A sexually dimorphic pattern of genetic susceptibility may have a crucial role to OCD clinical heterogeneity, potentially requiring different specific therapeutic strategies. Further research is warranted to validate gender as an important determinant of the heterogeneity in OCD.

Brain-derived neurotrophic factor as a biomarker for obsessive-compulsive disorder: A meta-analysis

BACKGROUND

Brain-derived neurotrophic factor (BDNF) is a growth factor that plays many critical functions in the central nervous system (CNS) and may be involved in the development of a range of psychopathologies, including depression, dementia, and neurodegenerative disorders.

METHODS

In the present study, we performed the first systematic review with a meta-analysis to quantitatively compare the peripheral blood BDNF levels between patients with obsessive-compulsive disorder (OCD) and healthy controls (HCs). A systematic search was conducted using PubMed and Web of Science databases to identify the relevant articles.

RESULTS

Nine studies encompassing 474 adults with OCD and 436 HCs were included in this meta-analysis. A random-effects meta-analysis showed that patients with OCD had significantly decreased peripheral blood levels of Brain-derived neurotrophic factor (BDNF) when compared with the HCs (Hedges' g = -0.722, 95% confidence interval [CI] = -1.152 to -0.292, P = 0.001). Subgroup analyses revealed decreased BDNF levels in plasma of patients (Hedges' g = -1.137, 95% CI = -1.463 to -0.810, P = 0.000) and drug-free patients (Hedges' g = -1.269, 95% CI = -1.974 to -0.564, P = 0.000) as compared to patients on active drug therapy and HCs. Meta-regression analyses showed that age, sex, sample size, Y-BOS total score, and publication year had no moderating effects on the outcome.

CONCLUSION

Although the relationship between our findings and the pathophysiology of OCD and the role BDNF plays in the development of the disease remains to be determined, the outcomes suggest that BDNF may serve as a potential biomarker of OCD.

Thalamic Subregions and Obsessive-Compulsive Symptoms in 2,500 Children From the General Population

OBJECTIVE

Pediatric obsessive-compulsive disorder (OCD) and clinically relevant obsessive-compulsive symptoms in the general population are associated with increased thalamic volume. It is unknown whether this enlargement is explained by specific thalamic subregions. The relation between obsessive-compulsive symptoms and volume of thalamic subregions was investigated in a population-based sample of children.

METHOD

Obsessive-compulsive symptoms were measured in children (9-12 years of age) from the Generation R Study using the Short Obsessive-Compulsive Disorder Screener (SOCS). Thalamic nuclei volumes were extracted from structural 3T magnetic resonance imaging scans using the ThalamicNuclei pipeline and regrouped into anterior, ventral, intralaminar/medial, lateral, and pulvinar subregions. Volumes were compared between children with symptoms above clinical cutoff (probable OCD cases, SOCS ≥ 6, n = 156) and matched children without symptoms (n = 156). Linear regression models were fitted to investigate the association between continuous SOCS score and subregional volume in the whole sample (N = 2500).

RESULTS

Children with probable OCD had larger ventral nuclei compared with children without symptoms (d = 0.25, p = .025, false discovery rate adjusted p = .126). SOCS score showed a negative association with pulvinar volume when accounting for overall thalamic volume (β = -0.057, p = .009, false discovery rate adjusted p = .09). However, these associations did not survive multiple testing correction.

CONCLUSION

The results suggest that individual nuclei groups contribute in varying degrees to overall thalamic volume in children with probable OCD, although this did not survive multiple comparisons correction. Understanding the role of thalamic nuclei and their associated circuits in pediatric OCD could lead toward treatment strategies targeting these circuits.

Phenomenology of obsessive-compulsive disorder in children and adolescents: Sample from a tertiary care center in Istanbul, Turkey

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous disease in many respects and exhibits this diversity in terms of phenomenology. It also displays several different characteristics in children compared to adults.

AIM

To describe the socio-demographic and phenomenological features of children with OCD and to investigate the impact of these features on response to pharmacotherapy.

METHODS

This retrospective study was carried out with 150 children and adolescents who had been diagnosed with OCD between 2014 and 2018. Data was collected by examining the files of the patients with diagnosis of OCD and similar disorders from the hospital database. Yale-Brown Obsessive-Compulsive Scale for Children was used for the assessment of obsession-compulsion subtypes. The Clinical Global Impression (CGI) scale was used to evaluate the severity of the disease (CGI-S) and global improvement (CGI-I). The predictors of treatment response were evaluated using linear regression analysis. The level of significance for all statistic tests was set as P < 0.05.

RESULTS

The sample was divided into prepubertal (44%) and adolescent (56%) age groups. The most prevalent obsessions were contamination and aggression obsessions, and the most frequent compulsions were washing and checking. While contamination was observed more commonly in the prepubertal age group, the religious obsession was seen more frequently in adolescents. Patients with aggression obsession presented a higher frequency of comorbid anxiety (P = 0.022) and mood (P = 0.047) disorder. CGI-I scores did not differ according to phenomenological subgroups (P > 0.05). A lower CGI-I score was linked to a lower CGI-S score (95% confidence interval 0.21-0.39, P < 0.001) and the prepubertal age of admission (95% confidence interval 0.03-0.87, P = 0.020).

CONCLUSION

The phenomenology of OCD shows differences depending on the age group and the comorbid psychiatric disorders. Earlier identification and treatment of OCD may help to prevent the impairment of the mental health of children and adolescents.

Preschool-onset OCD: A review of literature and clinical experience

Obsessive-compulsive disorder (OCD) has been described in preschool children as young as 2-3 years old. A preschool age onset of OCD has unique diagnostic and therapeutic challenges. In this article, the authors review published literature on preschool onset OCD and present data on preschool-onset OCD (age of onset ≤ 5 years) from clinical records at a tertiary care child and adolescent psychiatry center in India. Literature suggests that OCD that starts this early is phenomenologically similar to OCD in older individuals; however, it has very high rates of comorbidity and a family history of OCD. There is a paucity of data on course, treatment, and long-term outcome in this group. At their center, the authors found a 3% prevalence of preschool-onset OCD, with a male predominance (69%) and fairly high comorbidity rates (62%). Qualitative review highlighted delay in treatment seeking, poor follow-up rates, frequent use of pharmacological treatment, and a high remission rate in those treated adequately.

Clinical characteristics and comorbidity associated with female gender in obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a heterogeneous condition characterized by largely variable phenotypic expressions. Previous findings suggested that gender may be a relevant factor in mediating this heterogeneity. The present study aimed at exploring gender differences in a large clinical sample of Italian OCD patients.

METHODS

Socio-demographic and clinical variables of a sample of 229 consecutive OCD outpatients were included in a common database. Patients were assessed through structured clinical interviews, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Clinical Global Impression (CGI) scale.

RESULTS

Female OCD patients were more likely than males to have lifetime psychiatric comorbidities (72.6% vs 56.9%; p < 0.05), poly-comorbidities being twice as high compared to males. The female group also showed a significant later onset of symptoms (63.7% vs 44.8%; p < 0.005) and a higher age at first treatment (30.98 ± 13.1 years vs 27.81 ± 11.3; p < 0.005). Moreover, the female subgroup presented higher rates of cleaning and washing compulsions, compared to the male subgroup (28.7% vs 12.6% in the male group; p < 0.005).

CONCLUSIONS

The current study supports the notion that OCD in female gender is frequently a comorbid condition with other specific clinical characteristics compared to male patients. These findings should be considered in epidemiologic and therapeutic perspectives.

Perceived Stress in Relation to Obsessions and Compulsions in South Asian Adults: Moderating Role of Socio-demographic Characteristics

This study examines perceived stress associated with obsessions and compulsions (OC) in a normative sample of adults. The aim was to discover whether socio-demographic characteristics (i.e., gender, marital status, employment status, age and education) had a moderating effect on perceived stress and OC symptoms. The participants were 362 Pakistani adults (M age = 26.82 years, SD = 4.75; males = 188, females = 174) and the findings were based on a demographic questionnaire, the perceived stress scale (Cohen et al., in Applied multiple correlation/regression analysis for the behavioral sciences, Taylor & Francis, London, 1983), and the Padua inventory of obsessive compulsion disorder symptoms (Burns et al., in Behav Res Ther, 34(2), 163-173, 1996). A series of stepwise regression analyses showed that socio-demographic characteristics (employment status, age, and education) significantly moderated the relationship between perceived stress and OC symptoms. The current findings have implications for clinicians and researchers in generating effective stress management programs and learning mechanism for managing OC symptoms, particularly in the context of socio-demographic characteristics.

The Features of Comorbidity of Childhood ADHD in Patients With Obsessive Compulsive Disorder

Objective: Our aim is to investigate the impact of childhood ADHD comorbidity on the clinical features of obsessive compulsive disorder (OCD). Method: Ninety-five adult outpatients with a diagnosis of OCD were assessed by using the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version, ADHD module, and the Yale-Brown Obsessive Compulsive Scale. Patients with or without childhood ADHD were compared in terms of the sociodemographic and clinical features, psychiatric comorbidities, and rating scales. Results: The rate of episodic course of OCD (p < .001), religious and sexual obsessions (p = .009, p = .020, respectively), lifetime comorbidity of bipolar disorder (BD), social anxiety disorder (SAD; p = .001, p = .009, respectively), and tic disorder (TD) comorbidity (p < .001) were higher in the OCD + ADHD group than in the OCD without ADHD group. Conclusion: Childhood ADHD may be associated with higher rates of BD, SAD, and TD comorbidity and episodic course of OCD as well as higher frequency of certain types of obsessions.

Prevalence and correlates of attention deficit hyperactivity disorder in obsessive-compulsive disorder patients

Background

High rates of history of childhood attention deficit hyperactivity disorder (ADHD) symptoms have been found in obsessive-compulsive disorder (OCD) adults. Both, when comorbid, cause the clinical course to be unfavorable, more susceptibility to substance use, and a bad response to treatment. We planned to assess the impact of childhood ADHD symptoms on OCD adults and the effect of this on clinical characteristics and comorbidities of the disorder.

Results

Our cross-sectional investigation uncovered that 44% of the OCD patients had childhood ADHD symptoms. Patients with childhood ADHD manifestations with at present grown-up ADHD had more elevated amounts of depression, anxiety, and impulsiveness. OCD patients with child ADHD symptoms but not continued symptoms till adulthood versus those without child ADHD symptoms had higher levels of depression, anxiety, and impulsiveness and more severe OCD symptoms.

Conclusion

ADHD in adults with OCD is associated with some features impairing the clinical picture including higher levels of anxiety, depression, and impulsiveness reflecting more chronic illness. A childhood history of ADHD symptoms, even if not continued till adulthood, caused more impulsiveness, more severe OCD symptoms, and more anxiety and depression comorbidity.

Are candidate neurocognitive endophenotypes of OCD present in paediatric patients? A systematic review

To-date it has been difficult to ascertain the exact cognitive profile of childhood OCD as studies report variable results. Adult OCD research lately utilises the endophenotype approach; studying cognitive traits that are present in both patients and their unaffected first-degree relatives, and are thought to lie closer to the genotype than the full-blown disorder. By observing whether candidate endopenotypes of adult OCD are present in child patients, we can determine whether the two subtypes show cognitive overlap. We conducted a systematic review of the paediatric OCD literature focussing on proposed neurocognitive endophenotypes of OCD: cognitive flexibility, response inhibition, memory, planning, decision-making, action monitoring, and reversal learning. We found that paediatric patients present robust increases in brain error related negativity associated with abnormal action monitoring, impaired decision-making under uncertainty, planning, and visual working memory, but there is less evidence for deficits in other cognitive domains. This implies that children with OCD show some cognitive similarities with adult patients, but other dysfunctions may only manifest later in the disorder trajectory.

Does Family Accommodation Predict Outcome of Concentrated Exposure and Response Prevention for Adolescents?

Findings suggest that increased levels of family accommodation are associated with a poorer treatment outcome in obsessive-compulsive disorder (OCD). A concentrated treatment format, the Bergen 4-day treatment (B4DT), has previously demonstrated promising results in the treatment of adolescents with OCD. The present paper examined changes in family accommodation and investigated whether family accommodation predicted outcome, in a sample of 63 adolescents (age range 11-18) participating in the B4DT. There were significant reductions on CY-BOCS and FAS from pre- to post-treatment and from pre-treatment to follow-up (p < 0.001), with large within-group effect sizes on both measures. Pre-treatment levels of symptom severity or family accommodation was not found to predict outcome at post-treatment or at follow-up. Less OCD-related functional impairment at pre-treatment predicted a better outcome at both post-treatment and follow-up. The findings suggest that the B4DT significantly reduces OCD-symptoms regardless of pre-treatment levels of family accommodation or OCD severity.

Clinical profile of obsessive-compulsive disorder in children and adolescents: A multicentric study from India

CONTEXT

Data from the Western countries suggest that obsessive-compulsive disorder (OCD) in children and adolescents is associated with male preponderance, comorbid neurodevelopmental disorders, and high family loading. However, data are limited from the developing countries with respect to the demographic and clinical characteristics of OCD in children and adolescents.

AIMS

To study the demographic and clinical characteristics of children and adolescents (age ≤18 years) with OCD.

SETTING AND DESIGN

This was a cross-sectional study, conducted in outpatient treatment setting, across six centers in India.

MATERIALS AND METHODS

Participants were assessed using a semi-structured pro forma for sociodemographic information, clinical characteristics, the Children's Yale Brown Obsessive Compulsive Scale (CYBOCS), Structured Clinical Interview for Diagnostic and Statistical Manual, 5^th Edition Research Version, Children's Depression Rating Scale, and Family Interview for Genetic Studies.

RESULTS

The sample was largely male with a moderate illness severity. Nearly 75% of the sample had illness onset before the age of 14 years. Aggressive, contamination-related obsessions and washing, checking, and repeating compulsions were the most common symptoms. CYBOCS assessment revealed that >2/3^rd of children and adolescents endorsed avoidance, pathological doubting, overvalued sense of responsibility, pervasive slowness, and indecisiveness. Family history and comorbidity rates were low. OC-related disorders were present in about 10% of the sample.

CONCLUSIONS

This study suggests that the clinical characteristics of OCD in children and adolescents in developing countries differ on certain aspects as reported from developed countries.

The role of sex in the genomics of human complex traits

Nearly all human complex traits and disease phenotypes exhibit some degree of sex differences, including differences in prevalence, age of onset, severity or disease progression. Until recently, the underlying genetic mechanisms of such sex differences have been largely unexplored. Advances in genomic technologies and analytical approaches are now enabling a deeper investigation into the effect of sex on human health traits. In this Review, we discuss recent insights into the genetic models and mechanisms that lead to sex differences in complex traits. This knowledge is critical for developing deeper insight into the fundamental biology of sex differences and disease processes, thus facilitating precision medicine.

The impact of attention deficit hyperactivity disorder in obsessive-compulsive disorder subjects

BACKGROUND

Recent findings suggest an association between attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). Thus, we evaluated the clinical associated features of ADHD in a large sample of adult OCD patients.

METHODS

A cross-sectional study including 955 adult patients with OCD from the Brazilian Research Consortium of Obsessive-Compulsive Spectrum Disorders (C-TOC). Clinical characteristics in adult OCD patients with and without comorbid ADHD were compared using Fisher's exact test, t-tests or Mann-Whitney tests. Bivariate analyses were followed by logistic regression analysis to identify clinical characteristics independently associated with ADHD comorbidity.

RESULTS

The lifetime prevalence of ADHD in adult OCD patients was 13.7%. The current results indicate that OCD + ADHD patients were more severe, had an earlier onset of the obsessive-compulsive symptoms, a higher history of rheumatic fever, with higher frequencies of sensory phenomena and comorbidity with Tourette syndrome. They also had an increased risk for academic impairment and suicide attempts.

CONCLUSION

Adult OCD patients with ADHD present some specific clinical features and may represent a special subgroup of adult OCD. Future studies should focus on the development of interventions more tailored to the phenotype of this subgroup of patients.

Co-occurrence of Sensory Overresponsivity with Obsessive-Compulsive Symptoms in Childhood and Early Adolescence

OBJECTIVE

Sensory overresponsivity (SOR) is characterized by challenges in integrating and responding to everyday sensory experiences. Obsessive-compulsive disorder (OCD) is characterized by intrusive thoughts, ritualistic behaviors, and sensory phenomena. There is some evidence that individuals with co-occurring symptoms of SOR and OCD experience more severe anxiety than those with symptoms of OCD alone, but most studies employed small numbers of participants (typically with an OCD diagnosis) assessed at a single time point. Our 2-fold objective was to replicate previous research showing an association between OCD symptoms and SOR symptoms concurrently and to extend these analyses longitudinally in a large, birth-register-based sample.

METHOD

Twins (N = 1613) and their primary caregivers participated in a multimodal, multimethod, longitudinal study. Primary caregivers completed the SOR inventory for their offspring at the age of 8 years, and twins completed the adult sensory profile at the age of 13 years. Parents completed the OCD module of the Diagnostic Interview Schedule for Children-IV when twins were 8 years; twins completed the same module at 13 years. Linear regression models tested for the concurrent and longitudinal associations between SOR and OCD controlling for socioeconomic status.

RESULTS

Concurrently, participants' likelihood of exhibiting OCD symptoms increased with each symptom of tactile or auditory overresponsivity at 8 years and 13 years (odds ratio = 1.1-2.7). However, SOR measured at age 8 years was unrelated to adolescent OCD symptoms at 13 years and vice versa.

CONCLUSION

SOR symptoms, although significantly related to concurrent OCD symptoms, do not appear to precede OCD symptoms, suggesting that SOR symptoms may reflect another type of OCD sensory phenomenon rather than a comorbid condition.

Immunoglobulin A Dysgammaglobulinemia Is Associated with Pediatric-Onset Obsessive-Compulsive Disorder

Background: Inflammation and immune dysregulation have been implicated in the pathogenesis of pediatric-onset obsessive-compulsive disorder (OCD) and tic disorders such as Tourette syndrome (TS). Though few replicated studies have identified markers of immune dysfunction in this population, preliminary studies suggest that serum immunoglobulin A (IgA) concentrations may be abnormal in these children with these disorders. Methods: This observational retrospective cohort study, conducted using electronic health records (EHRs), identified 206 children with pediatric-onset OCD and 1024 adults diagnosed with OCD who also had testing for serum levels of IgA. IgA deficiency and serum IgA levels in pediatric OCD were compared with IgA levels from children diagnosed with autism spectrum disorders (ASD; n = 524), tic disorders (n = 157), attention-deficit/hyperactivity disorder (ADHD; n = 534), anxiety disorders (n = 1206), and celiac disease, a condition associated with IgA deficiency (n = 624). Results: Compared with ASD and anxiety disorder cohorts, the pediatric OCD cohort displayed a significantly higher likelihood of IgA deficiency (OR = 1.93; 95% CI = 1.18-3.16, and OR = 1.98; 95% CI = 1.28-3.06, respectively), though no difference was observed between pediatric OCD and TS cohorts. Furthermore, the pediatric OCD cohort displayed similar rates of IgA deficiency and serum IgA levels when compared with the celiac disease cohort. The pediatric OCD cohort also displayed the highest percentage of IgA deficiency (15%,) when compared with TS (14%), celiac disease (14%), ADHD (13%), ASD (8%), and anxiety disorder (8%) cohorts. When segregated by sex, boys with OCD displayed a significantly higher likelihood of IgA deficiency when compared with all comparison cohorts except for celiac disease and tic disorders; no significant difference in IgA deficiency was observed between female cohorts. Pediatric OCD subjects also displayed significantly lower adjusted serum IgA levels than the ASD and anxiety disorder cohorts. Adults with OCD were also significantly less likely than children with OCD to display IgA deficiency (OR = 2.71; 95% CI = 1.71-4.28). When compared with children with celiac disease, no significant difference in IgA levels or rates of IgA deficiency were observed in the pediatric OCD cohort. Conclusions: We provide further evidence of IgA abnormalities in pediatric-onset OCD. These results require further investigation to determine if these abnormalities impact the clinical course of OCD in children.

Epidemiological and Clinical Gender Differences in OCD

PURPOSE OF REVIEW

This review highlights recent research regarding gender differences in OCD, with a focus on prevalence, course of illness, symptom presentation, comorbidity, and treatment response.

RECENT FINDINGS

Overall, findings remain mixed. OCD may be more common among males in childhood, but is more common among females in adolescence and adulthood. Males tend to report an earlier age of onset and present with symptoms related to blasphemous thoughts. Females often describe symptom onset as occurring during or after puberty or pregnancy and present with symptoms related to contamination and/or aggressive obsessions. Females also tend to report significantly higher depression and anxiety. There are no reported gender differences in treatment outcome. Gender may play a role in the onset, presentation, and impact of OCD symptoms. However, more work is needed to account for differences across studies, with one promising future direction being the study of reproductive hormones.

Obsessive-Compulsive Disorder: Puzzles and Prospects

Obsessive-compulsive disorder is a severe and disabling psychiatric disorder that presents several challenges for neuroscience. Recent advances in its genetic and developmental causation, as well as its neuropsychological basis, are reviewed. Hypotheses concerning an imbalance between goal-directed and habitual behavior together with neural correlates in cortico-striatal circuitry are evaluated and contrasted with metacognitive theories. Treatments for obsessive-compulsive disorder (OCD) tend to be of mixed efficacy but include psychological, pharmacological, and surgical approaches, the underlying mechanisms of which are still under debate. Overall, the prospects for new animal models and an integrated understanding of the pathophysiology of OCD are considered in the context of dimensional psychiatry.

Neurocognitive deficits in obsessive-compulsive disorder: A selective review

Obsessive-compulsive disorder (OCD) is a debilitating mental illness characterized by an early onset and chronic course. Evidence from several lines of research suggests significant neuropsychological deficits in patients with OCD; executive dysfunction and nonverbal memory deficits have been reported consistently in OCD. These deficits persist despite controlling potential confounders such as comorbidity, severity of illness, and medications. Neuropsychological impairments are independent of illness severity, thus suggesting that the neuropsychological deficits are trait markers of the disease. In addition, these deficits are seen in first-degree relatives of individuals with OCD. These reports suggest that neuropsychological deficits are potential endophenotype markers in OCD. Neuropsychological studies in pediatric OCD are limited; they show impairments of small effect size across multiple domains but with doubtful clinical significance. Preliminary evidence shows that different symptom dimensions of OCD may have unique neuropsychological deficits suggestive of discrete but overlapping neuroanatomical regions for individual symptom dimensions. Overall, neuropsychological deficits further support the role of frontostriatal circuits in the neurobiology of OCD. In addition, emerging literature also suggests the important role of other areas, in particular parietal cortex. Preliminary evidence suggests the possible role of neuropsychological deficits to be markers of treatment response but needs to be examined in future. Longitudinal studies with examination of patients at different time points and examination of their potential utility as predictors of treatment response are needed in future.

Systematic review of co-occurring OCD and TD: Evidence for a tic-related OCD subtype?

OBJECTIVE

The aim of this review is to summarize the current knowledge of associated features of co-occurring obsessive-compulsive disorder (OCD) and tic disorders (TD) and to critically evaluate hypotheses regarding the nature of their comorbidity.

METHOD

We conducted a systematic review following PRISMA guidelines. To this aim, the PubMed, PsychInfo and ISI Web of Knowledge databases were searched up to August 30, 2018. For gender and age-of-onset we additionally conducted meta-analyses.

RESULTS

One hundred eighty-nine studies met inclusion criteria. We substantiate some acknowledged features and report evidence for differential biological mechanisms and treatment response. In general, studies were of limited methodological quality.

CONCLUSIONS

Several specific features are reliable associated with co-occurring OCD + TD. The field lacks methodological sound studies. The review found evidence against and in favor for different hypotheses regarding the nature of comorbidity of OCD and TD. This could indicate the existence of a stepwise model of co-morbidity, or could be an artefact of the low methodological quality of studies.

Distinguishing Fear Versus Distress Symptomatology in Pediatric OCD

Prior research has identified OCD subtypes or "clusters" of symptoms that differentially relate to clinical features of the disorder. Given the high comorbidity between OCD and anxiety, OCD symptom clusters may more broadly associate with fear and/or distress internalizing constructs. This study examines fear and distress dimensions, including physical concerns (fear), separation anxiety (fear), perfectionism (distress), and anxious coping (distress), as predictors of previously empirically-derived OCD symptom clusters in a sample of 215 youth diagnosed with primary OCD (ages 7-17, mean age = 12.25). Self-reported separation fears predicted membership in Cluster 1 (aggressive, sexual, religious, somatic obsessions, and checking compulsions) while somatic/autonomic fears predicted membership in Cluster 2 (symmetry obsessions and ordering, counting, repeating compulsions). Results highlight the diversity of pediatric OCD symptoms and their differential association with fear, suggesting the need to carefully assess both OCD and global fear constructs that might be directly targeted in treatment.

Quality of life in children and adolescents with obsessive-compulsive disorder: a systematic review and meta-analysis

Obsessive-compulsive disorder (OCD) is a seriously impairing psychiatric condition that affects 1%-3% of youth. Investigating the quality of life (QOL) is an important issue for treatment planning of this disorder, as targeting symptoms without taking it into account may bias assessment and prognosis when the patient presents with reduced symptoms that do not correspond to improved QOL. However, QOL in young individuals with OCD has been understudied. This meta-analysis summarized current evidence that assessed differences in global, social and school QOL dimensions, between children/adolescents with OCD and screened controls. Age, sex and OCD severity were examined as moderators. Case-control studies were included if children/adolescents with primary OCD were compared with screened controls on validated self-reported QOL outcomes. Online databases (January 1966-January 2016) were searched. Five case-control studies were included (n=543, 17 effect sizes overall). On global QOL, a large effect size emerged (d=-1.16, P<0.001), suggesting that individuals with OCD had lower global QOL than controls. Moderate effect sizes emerged for school (d=-0.61, P<0.01) and social QOL (d=-0.54, P<0.01), respectively, indicating worse QOL on these domains for individuals with OCD. For samples with higher OCD severity, global QOL of individuals with OCD was lower than that for controls (β=-0.02, P<0.05). For samples with lower percentages of females, global QOL of individuals with OCD was more impaired (β=0.02, P<0.001). Age was not correlated with effect sizes. Assessment and treatment should target QOL for young males suffering from more severe OCD. The small number of included studies highlighted that QOL is under-recognized. Future research should focus on additional QOL domains and compare which ones are impaired among individuals with OCD compared with other psychiatric conditions. Overall, the results pointed out the importance of addressing QOL in both practice and research on assessment and treatment of children/adolescents with this condition.

A study of phenomenology, psychiatric co-morbidities, social and adaptive functioning in children and adolescents with OCD

OBJECTIVE

To study the phenomenology, social, adaptive and global functioning of children and adolescents with OCD.

BACKGROUND

Studies have shown varying prevalence of paediatric OCD ranging from 1% to 4%. Childhood-onset OCD have some important differences in sex distribution, presentation, co-morbidities and insight.

MATERIALS AND METHODS

25 subjects (6 to ≤18 years) with a DSM-IV-TR diagnosis of OCD were included in this study. Subjects were evaluated using K-SADS-PL, Children's Y-BOCS, HoNOSCA, C-GAS and VABS-II.

RESULTS

The mean age of the sample was 14.9±2.2 years. Obsession of contamination was commonest (68%) followed by aggressive obsession (60%); commonest compulsions were washing and cleaning (72%) followed by checking (56%). Most distressing obsessions were obsession of doubt about their decision (28%), having horrible thoughts about their family being hurt (20%) and thought that something terrible is going to happen and it will be their fault (16%). Most subjects rate spending far too much time in washing hands (60%) as most distressing compulsion, followed by rewriting and checking compulsions (both 12%). 76% subjects have co-morbid psychiatric diagnosis. Anxiety disorders (24%), depression (16%), and dissociative disorder (16%) were common co-morbidities. Mean C-GAS score of the sample was 53.2±9.9. 44% of subjects had below average adaptive functioning.

CONCLUSIONS

The study shows that, most frequent obsessions and compulsions may be different from most distressing ones and this finding might have clinical implication. Most of the children and adolescent with OCD have co-morbidities. Children also had problems in adaptive functioning.

Parental Accommodation Predicts Symptom Severity at Long-term Follow-Up in Children with Obsessive-Compulsive Disorder

Pediatric obsessive-compulsive disorder (OCD) is a chronic condition affecting millions of children. Though well intentioned, accommodation (i.e., a parent's attempt to assuage their child's distress and anxiety) is thought to increase OCD symptom severity and may cause greater OCD-related impairment. The present study sought to examine the relative contribution of parental accommodation in predicting OCD symptom severity. Children between the ages of 6 and 18 (and their parents) participated in a prospective, longitudinal study investigating the course of pediatric OCD utilizing a longitudinal design. Data was collected at intake (n = 30) and two-years (n = 22) post-intake controlling for age, anxiety and depression. Parental accommodation (measured at intake) significantly predicted OCD symptom severity and was the strongest predictor at both intake and two-year follow-up. These preliminary findings highlight the importance of further research seeking to delineate factors relevant to the development and maintenance of accommodation as well as parent-level variables that might mediate the relationship between accommodation and OCD symptom severity.

Obsessive-compulsive adults with and without childhood ADHD symptoms

Obsessive-compulsive disorder (OCD) and attention-deficit and hyperactivity disorder (ADHD) frequently coexist. To understand whether childhood ADHD can increase the risk of OCD in adulthood and whether it influences the phenomenology of OCD, we investigated the symptoms of ADHD during childhood in obsessive-compulsive adults who had never been diagnosed as ADHD. Adults with OCD (n = 83) were given the Wender Utah Rating Scale (WURS), Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Barratt Impulsiveness Scale-11 (BIS-11), Hamilton Depression Rating Scale-17 (HDRS-17) and Beck Anxiety Inventory (BAI). The prevalence of childhood ADHD symptoms was 40.9 % (n = 34) and that of adult ADHD was 16.9 % (n = 14). Patients with childhood ADHD symptoms had an earlier onset of OCD, higher scores of the BAI and BIS-11. The scores of the Y-BOCS and HDRS-17 did not differ between those having and not having childhood ADHD symptoms. Childhood history of ADHD symptoms is common in adult OCD patients who have never been diagnosed as ADHD. Childhood ADHD symptoms are associated with an earlier age of OCD, more severe anxiety and higher impulsiveness. Even remitted ADHD may be a risk factor for OCD in later life.

Characteristics of Young Children with Obsessive-Compulsive Disorder: Baseline Features from the POTS Jr. Sample

Pediatric obsessive-compulsive disorder (OCD) is a chronic and impairing condition that can emerge early in childhood and persist into adulthood. The primary aim of this paper is to examine the characteristics of a large sample of young children with OCD (age range from 5 to 8). The sample will be described with regard to: demographics, OCD symptoms/severity, family history and parental psychopathology, comorbidity, and global and family functioning. The sample includes 127 youth with a primary diagnosis of OCD who participated in a multi-site, randomized control clinical trial of family-based exposure with response prevention. Key findings include moderate to severe OCD symptoms, high rates of impairment, and significant comorbidity, despite the participants' young age. Discussion focuses on how the characteristics of young children compare with older youth and with the few other samples of young children with OCD. Considerations regarding generalizability of the sample and limitations of the study are discussed.

Admixture analysis of age at symptom onset and age at disorder onset in a large sample of patients with obsessive-compulsive disorder

BACKGROUND

A number of studies tested for the presence of different homogeneous subgroups of obsessive-compulsive disorder (OCD) patients depending on the age at onset (AAO). However, none of the various thresholds of AAO have been validated. No study examined whether age at symptoms onset (ASO) and age at disorder onset (ADO) each define specific and diverse OCD subgroups.

METHODS

We used normal distribution mixture analysis in a sample of 483 OCD patients to test whether we could identify subgroups of patients according to the AAO. We tested whether ASO and ADO had different distributions and identified different subgroups of OCD patients, and whether clinical correlates had similar patterns of associations with patients subgroups identified with ASO or ADO.

RESULTS

The mixture analysis showed a trimodal distribution for ASO (mean ASO: 6.9 years for the early onset, 14.99 years for the intermediate onset, and 27.7 years for the late onset component), and confirmed a bimodal distribution for ADO (mean ADO: 18.0 and 29.5 years). Significant differences in the clinical profile of the subgroups emerged, particularly when identified using ASO.

LIMITATIONS

Limitations of our study are the retrospective investigation of AAO, and the fact that our sample may not represent the OCD population, as we enrolled patients referring to a tertiary center specialized in the treatment of OCD. Our findings need to be confirmed in community samples. Another limitation is the lack of information on medication status at enrollment.

CONCLUSIONS

Age at symptom onset and ADO showed distinct patterns of distributions. Similarly, phenotypic delineation was specific for ASO and ADO identified subgroups. Accurate clinical and biological profiling of ADO and ASO subgroups might show distinct genetic liabilities, ultimately leading to better nosological models and possibly to improved treatment decision making of OCD patients.

Obsessive-compulsive disorder concurrent with Melkersson-Rosenthal Syndrome: a case report

OBJECTIVE

To describe a case of obsessive-compulsive disorder (OCD) comorbid with Melkersson-Rosenthal Syndrome (MRS).

METHODS

We present a case study of comorbid OCD and MRS in a 13-year-old girl.

RESULTS

She admitted to doubt obsessions and a control compulsion. The patient history included frequent facial palsy attacks, and she took prednisolone during each attack. She had her first such attack at 5 years of age, and she had suffered five attacks since then, the last one occurring 2 months before her presentation. Her obsessions began 1 week after the last attack. She was diagnosed MRS and concurrent OCD based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria. She was started on 20 mg/day fluoxetine. The control compulsion subsided during the second month of therapy, and the doubt obsessions improved significantly.

CONCLUSION

Considering that the etiologies of MRS and childhood-onset OCD have been attributed to infectious agents and autoimmune events, we conclude that both causes may play an important role in the etiology of these conditions.

Comorbidity Between Attention Deficit/Hyperactivity Disorder and Obsessive-Compulsive Disorder Across the Lifespan: A Systematic and Critical Review

The concept of comorbidity between attention deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) has been discussed for two decades. No review, however, has examined this question in light of the stark contrast in disorder-specific phenomenology and neurobiology. We review reported prevalence rates and the methodological, phenomenological, and theoretical issues concerning concomitant ADHD-OCD. Reported co-occurrence rates are highly inconsistent in the literature. Studies aimed at examining the potential for comorbidity have suffered from various methodological problems, including the existence of very few community samples, highly variable exclusionary criteria, and possible clinical misinterpretation of symptoms. Despite numerous studies suggesting an ADHD-OCD comorbidity, thus far etiological (i.e., genetic) backing has been provided only for a pediatric comorbidity. Additionally, inflated rates of ADHD-OCD co-occurrence may be mediated by the presence of tic disorders, and evidence of impaired neuronal maturational processes in pediatric OCD may lead to possibly transient phenotypical expressions that resemble ADHD symptomatology. Thus, clinicians are encouraged to consider the possibility that ADHD-like symptoms resulting from OCD-specific symptomatology may be misdiagnosed as ADHD. This suggestion may account for the lower co-occurrence rates reported in adolescents and adults and for the lack of a theoretical account for comorbidity in these age groups. Existing literature is summarized and critically reviewed, and recommendations are made for future research.

Impact of Gender, Age at Onset, and Lifetime Tic Disorders on the Clinical Presentation and Comorbidity Pattern of Obsessive-Compulsive Disorder in Children and Adolescents

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous disorder; therefore, there is a need for identifying more homogeneous subtypes. This study aimed to examine the clinical characteristics and comorbidity pattern of a large sample of pediatric OCD subjects, and to examine the impact of gender, age at onset, and lifetime tic disorders on the clinical presentation and comorbidity pattern.

METHODS

A total of 110 children and adolescents diagnosed with OCD were assessed using the Kiddle Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL) for psychiatric comorbidity, and a clinical data form was filled out. The cutoff for differentiating prepubertal from adolescent onset was 11 years of age.

RESULTS

A total of 83.6% of the subjects had at least one comorbid psychiatric disorder. Oppositional defiant disorder and contamination/somatic obsessions were significantly higher in males (p=0.036 and p=0.03, respectively) than in females. Depressive disorders and religious obsessions were significantly higher in the adolescent-onset group (p=0.02, p=0.05, respectively) whereas disruptive behavior disorders were higher in the prepubertal-onset group (p=0.037). Disruptive behavior disorders were significantly more frequent in the tic (+) group than in tic (-) group (p=0.021).

CONCLUSIONS

There were differences in the comorbidity pattern and clinical expression between genders and between prepubertal and adolescent-onset cases. Findings of this study supported the introduction of tic-related OCD as a specifier in Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), and the necessity of a detailed assessment of other psychiatric disorders in youth with OCD.

Variations in symptom prevalence and clinical correlates in younger versus older youth with obsessive-compulsive disorder

Few studies have examined the phenomenology of obsessive-compulsive disorder (OCD) in younger children. A sample of 292 treatment seeking youth with a primary diagnosis of OCD was divided into the young child (3-9 years old) and older child (10-18 years old) groups. Overall OCD severity did not differ between groups. However, older youth demonstrated stronger intensity of obsessive and compulsive symptoms, while younger children were rated as having less resistance and control of compulsions. Older youth exhibited increased occurrence of comorbid depression, and an increased occurrence of sexual, magical thinking, and somatic obsessions, as well as, checking, counting and magical thinking compulsions. Conversely, the group of younger children exhibited significantly poorer insight, increased incidence of hoarding compulsions, higher rates of comorbid attention deficit/hyperactivity disorder, disruptive behavior, and parent-rated anxiety, and more frequently exhibited hoarding compulsions. These differences suggest domains to consider when screening for OCD among younger/older pediatric cohorts.

Long-term course of pediatric obsessive-compulsive disorder: 3 years of prospective follow-up

OBJECTIVE

This study assesses the long-term course of treatment-seeking youth with a primary diagnosis of DSM-IV OCD.

METHOD

Sixty youth and their parents completed intake interviews and annual follow-up interviews for 3 years using the youth version of the Longitudinal Interval Follow-up Evaluation (Y-LIFE) and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Remission was defined as no longer meeting DSM-IV criteria for OCD for 8 weeks or more, and recurrence was defined as meeting full criteria for OCD for 4 consecutive weeks after having achieved symptom remission. Remission rates for youth were compared to rates of adults participating in the same study.

RESULTS

The probability of achieving partial remission of OCD was 0.53 and the probability of achieving full remission was 0.27. Among the 24 youth participants who achieved remission, 79% stayed in remission throughout the study (mean of 88 weeks of follow-up) and 21% experienced a recurrence of symptoms. Better functioning at intake and a shorter latency to initial OCD treatment were associated with faster onset of remission (P<.001).

CONCLUSIONS

Remission is more likely among youth versus adults with OCD. Treatment early in the course of illness and before substantial impact on functioning predicted a better course.

A prospective study of paediatric obsessive-compulsive symptomatology in a Spanish community sample

The obsessive-compulsive manifestations course was assessed with the Leyton obsessional inventory-child version survey (LOI-CV) in a 3-year prospective study, using a non-clinical sample. From an initial sample of 1,514 school-age children who underwent symptoms screening for obsessive-compulsive, anxiety and depression, 562 subjects (risk group/without risk group) were re-assessed in the 2nd phase and 242 subjects were monitored after 3 years. LOI-CV scores significantly decreased over time independently of age and gender. The prevalence, persistence and incidence for two levels of severity of obsessive–compulsive manifestations ranged between 4.8-30.4%, 9.3-28.4% and 1.1-14.4%, respectively. 34.6-64.5% of obsessive-compulsive symptomatology was predicted by anxiety, depressive and obsessive-compulsive symptoms. For the obsessiveness (less severe form of obsessive-compulsive manifestations), the depressive symptoms were not predictors. Gender and socioeconomic status were not related with obsessive-compulsive manifestations. These data support a substantial continuity of the obsessive-compulsive manifestations and the existence of different levels of severity within the obsessive-compulsive spectrum.

Gender differences in obsessive-compulsive disorder: findings from a large Indian sample

AIM

Gender has been considered as one of the possible factors mediating phenotypic expression of obsessive-compulsive disorder (OCD). We examined gender differences in a large sample of subjects with OCD from India with respect to socio-demographic parameters, symptom characteristics, and comorbidity patterns.

METHODS

Consecutive patients (n=545) who consulted a specialty OCD clinic over 5 years at a large psychiatric hospital in India were evaluated.

RESULTS

Men (n=332) compared to women (n=213) with OCD had an earlier onset (p<0.001), higher frequency of sexual (p<0.001) and religious obsessions (p=0.001) pathological doubts (p<0.001) and checking (p<0.001) and repeating compulsions (p<0.001), and a greater tendency to have comorbid social phobia (p=0.006). Women compared to men were more likely to be married, had a higher frequency of fear of contamination (p=0.017), comorbid depression (p=0.014) and greater suicidal risk (p=0.003).

CONCLUSIONS

Our study provides further evidence for gender related differences in clinical features of obsessive-compulsive disorder. Our findings are only partly comparable with results from studies across the world possibly due to various biological and cultural factors mediating the phenotypic expression of OCD across the genders. There is a need to examine the biological basis for these gender differences.

Bilateral stereotactic anterior capsulotomy for obsessive-compulsive disorder: long-term follow-up

BACKGROUND AND PURPOSE

Psychosurgery, such as anterior capsulotomy, is a therapeutic option for treatment-resistant obsessive-compulsive disorder (OCD). In this paper, we present a prospective, long-term follow-up study aimed at evaluating both the efficacy and the safety of anterior capsulotomy for the treatment of severe, refractory OCD.

METHODS

Twenty-four patients were surgically treated in our centre between 1997 and 2009, 19 of whom were included in this study. Patients were assessed at 3, 6, 12, and 24 months and last follow-up (mean of 7 years) was carried out by phone. OCD symptom severity was evaluated using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). A patient with an improvement rate of over 35% in the Y-BOCS score was considered a responder, while a patient with a 25% improvement was considered a partial responder.

RESULTS

With a mean improvement of 31% in the Y-BOCS score at long-term follow-up, 36.8% of the patients responded fully to the procedure and 10.5% were considered partial responders, for an overall response rate of 47.3% of patients. At the end of the study, 3/19 patients had recovered (Y-BOCS score <8) and 3/19 were in remission (Y-BOCS score <16). No cases of mortality were reported and the overall adverse event rate was 57.9%. Only 2 patients had permanent surgical complications.

CONCLUSIONS

Anterior capsulotomy is an effective and safe technique for the treatment of severe refractory OCD in patients who have no other alternative to improve their symptoms.

Clinical features of pure obsessive-compulsive disorder

OBJECTIVE

Psychiatric comorbidity is the rule in obsessive-compulsive disorder (OCD); however, very few studies have evaluated the clinical characteristics of patients with no co-occurring disorders (non-comorbid or "pure" OCD). The aim of this study was to estimate the prevalence of pure cases in a large multicenter sample of OCD patients and compare the sociodemographic and clinical characteristics of individuals with and without any lifetime axis I comorbidity.

METHOD

A cross-sectional study with 955 adult patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (C-TOC). Assessment instruments included the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, The USP-Sensory Phenomena Scale and the Brown Assessment of Beliefs Scale. Comorbidities were evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders. Bivariate analyses were followed by logistic regression.

RESULTS

Only 74 patients (7.7%) presented pure OCD. Compared with those presenting at least one lifetime comorbidity (881, 92.3%), non-comorbid patients were more likely to be female and to be working, reported less traumatic experiences and presented lower scores in the Y-BOCS obsession subscale and in total DY-BOCS scores. All symptom dimensions except contamination-cleaning and hoarding were less severe in non-comorbid patients. They also presented less severe depression and anxiety, lower suicidality and less previous treatments. In the logistic regression, the following variables predicted pure OCD: sex, severity of depressive and anxious symptoms, previous suicidal thoughts and psychotherapy.

CONCLUSIONS

Pure OCD patients were the minority in this large sample and were characterized by female sex, less severe depressive and anxious symptoms, less suicidal thoughts and less use of psychotherapy as a treatment modality. The implications of these findings for clinical practice are discussed.

Impact of age of onset of illness on clinical phenotype in OCD

BACKGROUND

This study aims to examine the demographic, clinical and comorbid patterns in a large sample of adult OCD subjects at a specialty OCD clinic in India.

METHODS

Consecutive patients (n=545) who consulted a specialty OCD Clinic over 5 years at a large psychiatric hospital in India were evaluated with the Mini International Neuropsychiatric Interview, the Yale-Brown Obsessive-Compulsive Scale, and the Clinical Global Impression scale.

RESULTS

Earlier age onset of OCD (years) was characterized by male preponderance (19.61±7.98 vs. 25.19±10.39, U=23453.5, p=<0.001), positive family history of OCD (19.60±10.02 vs. 22.27±9.20, U=16590.5, p<0.001) and presence of tic disorder (16.28±8.21 vs. 22.01±9.38, OR=0.86, p=0.001). In addition, early age of onset was associated with presence of sexual obsessions (18.92±7.49 vs. 22.88±9.82, OR=0.96, p=0.02), hoarding (19.61±9.32 vs. 22.21±9.36, OR=0.95, p=0.009), repeating rituals (19.76±8.37 vs. 23.29±9.84, OR=0.95, p=0.006) and need to touch compulsions (16.40±7.19 vs. 22.36±9.43, OR=0.89, p<0.001).

CONCLUSIONS

Our findings from a large sample not only confirm that early onset OCD could be a valid and distinct subtype of OCD but also support the cross-cultural similarity of early onset phenotype.

Phenomenology, psychiatric comorbidity and family history in referred preschool children with obsessive-compulsive disorder

OBJECTIVE

The study aimed to investigate phenomenology, psychiatric comorbidity, and family history of obsessive-compulsive disorder (OCD) in a clinical sample of normally developing preschool children with OCD.

METHOD

Subjects in this study were recruited from a clinical sample of preschool children (under 72 months of age) who were referred to a university clinic. Subjects with a normal developmental history and significant impairment related to OCD symptoms were included in the study. Children's Yale-Brown Obsessive-Compulsive Scale was used to assess OCD symptoms. Each subject was assessed for comorbid DSM-IV psychiatric disorders using a semi-structured interview. Parents were evaluated for lifetime history of OCD in individual sessions.

RESULTS

Fifteen boys and ten girls (age range: 28 to 69 months; 54.12±9.08 months) were included. Mean age of onset of OCD was 35.64±13.42 months. All subjects received at least one comorbid diagnosis. The most frequent comorbid disorders were non-OCD anxiety disorders (n=17; 68.0%), attention-deficit hyperactivity disorder (ADHD) (n=15; 60.0%), oppositional defiant disorder (ODD) (n=12; 48.0%), and tic disorders (n=6; 24.0%). Mean number of comorbid disorders was 3.65 and 2.35 for boys and girls, respectively. At least one parent received lifetime OCD diagnosis in 68 percent of the subjects.

CONCLUSIONS

The results indicated that OCD in referred preschool children is more common in males, highly comorbid with other psychiatric disorders, and associated with high rates of family history of OCD. Given the high rates of comorbidity and family history, OCD should be considered in referred preschool children with disruptive behavior disorders and/or with family history of OCD.