Tic-Related Versus Tic-Free Obsessive-Compulsive Disorder: Clinical Picture and 2-Year Natural Course

Long-term remission rates and trajectory predictors in obsessive-compulsive disorder: Findings from a six-year naturalistic longitudinal cohort study

BACKGROUND

This naturalistic study, utilizing data from the Netherlands Obsessive-Compulsive Disorder Association (NOCDA) cohort, investigated the long-term remission rates and predictors of different trajectories of obsessive-compulsive disorder (OCD) within a clinical population.

METHODS

A sample of 213 participants was classified into three illness trajectories: "Chronic," "Episodic, "and "Remitted-OCD." Long-term remission rates were calculated based on three follow-up measurements over a 6-year period. A multinomial logistic regression model, incorporating five selected predictors with high explanatory power and one covariate, was employed to analyze OCD trajectory outcomes.

RESULTS

The long-term full remission rates, calculated from all the measurements combined (14%), were significantly lower than what was observed in earlier studies and when compared to assessments at each individual follow-up (∼30%). Moreover, high baseline symptom severity and early age of onset were identified as significant risk factors for a chronic course of OCD, while male sex and younger age predicted a more favorable trajectory. Notably, the likelihood of an episodic course remained high even without identified risk factors.

LIMITATIONS

The bi-annual data collection process is unable to capture participants' clinical conditions between assessments. Additionally, no data was collected regarding the specific type and duration of psychological treatment received. Regarding the type of treatment participants received.

CONCLUSIONS

Results suggest that long-term remission rates may be lower than previously reported. Consequently, employing multiple assessment points in longitudinal studies is necessary for valid estimation of long-term full remission rates. The results emphasize the importance of personalized clinical care and ongoing monitoring and maintenance for most OCD cases.

Co-Occurring Anxiety in Youth with Tic Disorders: A Review

Objective: To review the current state of the literature regarding anxiety symptoms and anxiety disorders in chronic tic disorder (CTD). Results: We conducted a literature search on anxiety and tic disorders. Anxiety symptoms and anxiety disorders are common in youth with CTD, with ∼30%-50% of youth with CTD having at least one co-occurring anxiety disorder. Tics often improve by young adulthood but anxiety symptoms tend to persist, or worsen, over time. Anxiety and tics are closely related, but the exact nature of their relationship is poorly understood. We discuss some potential ways in which anxiety and tics are linked with an emphasis on the underlying brain circuitry involved. The relationship between anxiety and tics may be related to the premonitory urge. In addition, stress hormones may link anxiety and tics. Individuals with CTD have greater activation of their hypothalamic-pituitary-adrenal system in response to acute stress. We also review the impact of anxiety on youth with CTD and approaches to management of anxiety in youth. Conclusions: Anxiety is common in youth with CTD, is associated with more severe CTD, and can adversely affect a child's function. Thus, it is important to identify anxiety disorders in CTD and manage them appropriately.

Predictors of the 6-year outcome of obsessive-compulsive disorder: Findings from the Netherlands Obsessive-Compulsive Disorder Association study

OBJECTIVE

Obsessive-compulsive disorder is characterized by a chronic course that can vary between patients. The knowledge on the naturalistic long-term outcome of obsessive-compulsive disorder and its predictors is surprisingly limited. The present research was designed to identify clinical and psychosocial predictors of the long-term outcome of obsessive-compulsive disorder.

METHODS

We included 377 individuals with a current diagnosis of obsessive-compulsive disorder, who participated in the Netherlands Obsessive Compulsive Disorder Association study, a multicenter naturalistic cohort study. Predictors were measured at baseline using self-report questionnaires and clinical interviews. Outcome was assessed using the Yale-Brown Obsessive Compulsive Scale at 2-, 4- and 6-year follow-up.

RESULTS

The overall course of obsessive-compulsive disorder was characterized by two prominent trends: the first reflected an improvement in symptom severity, which was mitigated by the second, worsening trend in the long term. Several determinants affected the course variations of obsessive-compulsive disorder, namely, increased baseline symptom severity, late age of onset, history of childhood trauma and autism traits.

CONCLUSION

The long-term outcome of obsessive-compulsive disorder in naturalistic settings was characterized by an overall improvement in symptom severity, which was gradually halted to the point of increased worsening. However, after 6 years, the severity of symptoms remained below the baseline level. While certain determinants predicted a more favorable course, their effect diminished over time in correspondence to the general worsening trend. The results highlight the importance of a regular and continuous monitoring for symptom exacerbations as part of the management of the obsessive-compulsive disorder, regardless of the presence of putative predictors.

Moderating Role of Depression on the Association of Tic Severity With Functional Impairment in Children

BACKGROUND

Chronic tic disorders (CTDs) commonly co-occur with other psychiatric disorders. CTDs have been linked to functional impairment and reduction in quality of life. Insufficient research is available on depressive symptoms in patients with CTD, especially children and adolescents, yielding conflicting findings. To investigate the presence of depressive symptoms in a cohort of children and young adolescents with CTD and to test whether they moderate the link between tic severity and functional impairment.

METHODS

The sample consisted of 85 children and adolescents (six to 18 years) with a CTD who were treated in a large referral center. Participants were evaluated using gold-standard self- and clinician-reporting instruments to measure tic symptom severity and tic-related functional impairment (Yale Global Tic Severity Scale), depression (Child Depression Inventory), and obsessive-compulsive symptoms (Children Yale Brown Obsessive Compulsive Scale).

RESULTS

Depressive symptoms (mild to severe) were exhibited by 21% of our sample. Study participants with CTD and comorbid obsessive-compulsive disorder (OCD) and/or attention-deficit/hyperactivity disorder had higher rates of depressive symptoms compared with those without comorbidities. Significant correlations were found within and among all tic-related and OCD-related measures, yet depressive symptoms only correlated to tic-related functional impairment. Depression significantly and positively moderated the correlation between tic severity and tic-related functional impairment.

CONCLUSIONS

Findings suggest that depression plays an important part as a moderator in the link between tic severity and functional impairment in children and adolescents. Our study highlights the importance of screening for and treating depression in patients with CTD.

The Tourette OCD Alberta Network: Development of a Continuing Professional Development Program for Community Based Mental Health Therapists

The Tourette OCD Alberta Network (TOAN) supports mental health therapists to improve the delivery of care to patients with Tourette syndrome (TS) and OCD in Alberta. We evaluated the professional development needs of health care workers to develop a continuing professional development (CPD) webinar series. Health care workers demonstrated an urgent need to access a CPD program grounded in evidenced based knowledge about TS and OCD. While 80% of health care workers treated children with TS and OCD, 50% had no formal training. A curriculum consisting of a series of twelve live, online webinars was developed and delivered between September 2020 and June 2021, covering a range of clinical topics. The webinars were attended on average by 63 attendees, with the outcome of a positive knowledge gain. In future, the educational program will need to reflect the ongoing developing clinical understanding of TS and OCD.

Treatment-resistant OCD: Pharmacotherapies in adults

Serotonin reuptake inhibitor (SRI) medications are well established as first-line pharmacotherapeutic treatment for Obsessive-Compulsive Disorder (OCD). However, despite the excellent safety profile and demonstrated efficacy of these medications, a substantial proportion of individuals with OCD fail to attain sufficient benefit from SRIs. In this narrative review, we discuss clinical features of OCD that have been associated with poorer response to SRIs, and we present pharmacotherapeutic interventions that have been explored as augmenting or alternative treatments for treatment-resistant OCD. We additionally highlight non-SRI interventions for OCD that are currently under investigation. Pharmacotherapeutic interventions were identified via expert consensus. To assess the evidence base for individual pharmacotherapies, targeted searches for relevant English-language publications were performed on standard biomedical research databases, including MEDLINE. Information relevant to ongoing registered clinical trials in OCD was obtained by search of ClinicalTrials.gov. Pharmacotherapies are grouped for review in accordance with the general principles of Neuroscience-based Nomenclature (NbN). Clinical features of OCD that may suggest poorer response to SRI treatment include early age of onset, severity of illness, duration of untreated illness, and the presence of symmetry/ordering or hoarding-related symptoms. Based on evolving pathophysiologic models of OCD, diverse agents engaging serotonin, dopamine, norepinephrine, glutamate, and anti-inflammatory pathways have been explored as alternative or adjunctive therapies for treatment-resistant OCD and have at least preliminary evidence of efficacy. Medications with dopamine antagonist activity remain the most robustly evidence-based of augmenting interventions, yet dopamine antagonists benefit only a minority of those who try them and carry elevated risks of adverse effects. Interventions targeting glutamatergic and anti-inflammatory pathways are less well evidenced, but may offer more favorable benefit to risk profiles. Ongoing research should explore whether specific interventions may benefit individuals with particular features of treatment-resistant OCD.

Addressing co-occurring conditions in behavioural therapy for tic disorders: a review and guideline

Co-occurring psychiatric conditions are very common in tic disorders and Tourette syndrome. These additional symptoms are often detrimental to quality of life and may impact upon the implementation and efficacy of evidence-based behavioural therapies (BT) for tics. Combining a review of the available literature, relevant theory, and expert clinical practice, we present a guideline for implementing behavioural and psychosocial interventions when common comorbidities are present. These include attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, disruptive behaviour, autism spectrum disorder (ASD) and depression. Practical recommendations are provided for assessment, formulation and management of specific and multiple comorbidities in BT for both children and adults. Despite comorbidities being common in tic disorders, few studies have comprehensively addressed how they may influence the efficacy or implementation of existing therapies or how such treatments may need to be modified or sequenced. We outline recommendations for future research, including randomised control trials of BT for those with specific or multiple comorbidities, as well as adequately powered sub-group analyses within larger scale trials or naturalistic study designs. Transdiagnostic models of psychiatric disorders and treatment, including modular cross-diagnostic therapies, which recognise the dimensionality of psychiatric disorders are also highlighted as an important focus in treatment development in tic disorders.

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.

Specialty knowledge and competency standards for pharmacotherapy for adult obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) affects approximately one person in 40 and causes substantial suffering. Evidence-based treatments can benefit many; however, optimal treatment can be difficult to access. Diagnosis is frequently delayed, and pharmacological and psychotherapeutic interventions often fail to follow evidence-based guidelines. To ameliorate this distressing situation, the International OCD Accreditation Task Force of the Canadian Institute for Obsessive-Compulsive Disorders has developed knowledge and competency standards for specialized treatments for OCD through the lifespan. These are foundational to evidence-based practice and will form the basis for upcoming ATF development of certification/accreditation programs. Here, we present specialty standards for the pharmacological treatment of adult OCD. We emphasize the importance of integrating pharmacotherapy with clear diagnosis, appreciation of complicating factors, and evidence-based cognitive behavioral therapy. Clear evidence exists to inform first- and second-line pharmacological treatments. In disease refractory to these initial efforts, multiple strategies have been investigated, but the evidence is more equivocal. These standards summarize this limited evidence to give the specialist practitioner a solid basis on which to make difficult decisions in complex cases. It is hoped that further research will lead to development of a clear, multi-step treatment algorithm to support each step in clinical decision-making.

Specialty knowledge and competency standards for pharmacotherapy for pediatric obsessive-compulsive disorder

Evidence based treatments for pediatric Obsessive-Compulsive Disorder (OCD) are delivered with varying levels of expertise. This paper is part of the phase two series by the International OCD Accreditation Task Force (ATF) to advance a standardized high level of care globally. This paper presents specific knowledge and competencies recommended for specialized practice for pediatric psychopharmacologists working with OCD, developed by an international group of clinicians with extensive expertise in assessment and treatment of OCD. Tabulated knowledge and competency standards are operationalized as clinician abilities with specification of evidence for each standard. The distinction between current practice guidelines and ATF standards is discussed. Drug treatment has a solid evidence base. However, it should not be applied isolated, but informed by broad competence in general child and adolescent psychiatry and pediatrics. Other treatment relevant areas such as specialty CBT, family functioning, developmental issues, and neurobiology require consideration. Drug treatment includes several phases with varying degrees of evidence: Starting up medication, titration to maximum tolerated dose, maintenance, termination, and relapse prevention. In complex cases, pharmacotherapy with weak evidence may be needed to target symptoms and/or co-morbidity. The ATF knowledge and competency standards presented will be reviewed and updated commensurate with research.

Anxiety Symptoms Differ in Youth With and Without Tic Disorders

We compared anxiety symptoms in youth with and without tic disorders by comparing scores on the Multidimensional Anxiety Scale for Children (MASC) in youth with tic disorders to those in a concurrent community control group and in a group of treatment-seeking anxious youth from the Child/Adolescent Anxiety Multimodal Study (CAMS). Data from 176 youth with tic disorders, 93 control subjects, and 488 CAMS participants were included. Compared to youth with tic disorders, controls had lower total MASC scores (p < 0.0001) and CAMS participants had similar total MASC scores (p = 0.13). Separation Anxiety (p = 0.0003) and Physical Symptom (p < 0.0001) subscale scores were higher in youth with tic disorders than in CAMS participants. We conclude that the anxiety symptom profile differs in youth with and without tic disorders, which may have important implications for targeting treatment of anxiety in youth with tic disorders.

Early onset obsessive-compulsive disorder: the biological and clinical phenotype

Moving from a behavioral-based to a biological-based classification of mental disorders is a crucial step toward a precision-medicine approach in psychiatry. In the last decade, a big effort has been made in order to stratify genetic, immunological, neurobiological, cognitive, and clinical profiles of patients. Making the case of obsessive-compulsive disorder (OCD), a lot have been made in this direction. Indeed, while the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of OCD aimed to delineate a homogeneous group of patients, it is now clear that OCD is instead an heterogeneous disorders both in terms of neural networks, immunological, genetic, and clinical profiles. In this view, a convergent amount of literature, in the last years, indicated that OCD patients with an early age at onset seem to have a specific clinical and biological profile, suggesting it as a neurodevelopmental disorder. Also, these patients tend to have a worse outcome respect to adult-onset patients and there is growing evidence that early-interventions could potentially improve their prognosis. Therefore, the aim of the present paper is to review the current available genetic, immunological, neurobiological, cognitive, and clinical data in favor of a more biologically precise subtype of OCD: the early-onset subtype. We also briefly resume current available recommendations for the clinical management of this specific population.

A population-based family clustering study of tic-related obsessive-compulsive disorder

In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), obsessive-compulsive disorder (OCD) included a new "tic-related" specifier. However, strong evidence supporting tic-related OCD as a distinct subtype of OCD is lacking. This study investigated whether, at the population level, tic-related OCD has a stronger familial load than non-tic-related OCD. From a cohort of individuals born in Sweden between 1967 and 2007 (n = 4,085,367; 1257 with tic-related OCD and 20,975 with non-tic-related OCD), we identified all twins, full siblings, maternal and paternal half siblings, and cousins. Sex- and birth year-adjusted hazard ratios (aHR) were calculated to estimate the risk of OCD in relatives of individuals with OCD with and without comorbid tics, compared with relatives of unaffected individuals. We found that OCD is a familial disorder, regardless of comorbid tic disorder status. However, the risk of OCD in relatives of individuals with tic-related OCD was considerably greater than the risk of OCD in relatives of individuals with non-tic-related OCD (e.g., risk for full siblings: aHR = 10.63 [95% CI, 7.92-14.27] and aHR = 4.52 [95% CI, 4.06-5.02], respectively; p value for the difference < 0.0001). These differences remained when the groups were matched by age at first OCD diagnosis and after various sensitivity analyses. The observed familial patterns of OCD in relation to tics were not seen in relation to other neuropsychiatric comorbidities. Tic-related OCD is a particularly familial subtype of OCD. The results have important implications for ongoing gene-searching efforts.

Animal Models for OCD Research

OCD has lagged behind other psychiatric illnesses in the identification of molecular treatment targets, due in part to a lack of significant findings in genome-wide association studies. However, while progress in this area is being made, OCD's symptoms of obsessions, compulsions, and anxiety can be deconstructed into distinct neural functions that can be dissected in animal models. Studies in rodents and non-human primates have highlighted the importance of cortico-basal ganglia-thalamic circuits in OCD pathophysiology, and emerging studies in human post-mortem brain tissue point to glutamatergic synapse abnormalities as a potential cellular substrate for observed dysfunctional behaviors. In addition, accumulated evidence points to a potential role for neuromodulators including serotonin and dopamine in both OCD pathology and treatment. Here, we review current efforts to use animal models for the identification of molecules, cell types, and circuits relevant to OCD pathophysiology. We start by describing features of OCD that can be modeled in animals, including circuit abnormalities and genetic findings. We then review different strategies that have been used to study OCD using animal model systems, including transgenic models, circuit manipulations, and dissection of OCD-relevant neural constructs. Finally, we discuss how these findings may ultimately help to develop new treatment strategies for OCD and other related disorders.

Stressful Life Events and the Clinical Expression of Obsessive-Compulsive Disorder (OCD): An Exploratory Study

BACKGROUND

In obsessive-compulsive disorder (OCD), symptom content and severity appear to fluctuate over the course of the life cycle in accordance with stressful life events. The objective of this paper was to compare OCD patients with and without reported stressful life events (SLEs) in terms of the sociodemographics of patients and the clinical characteristics of OCD.

METHODS

This was a cross-sectional study involving 1001 patients with OCD. Data concerning SLEs were collected via the Yale OCD Natural History Questionnaire, while for OCD symptoms, the Dimensional Yale-Brown Obsessive-Compulsive Scale was used.

RESULTS

Of the 1001 OCD patients, 605 (60.5%) reported experiencing at least one SLE in their lifetime. Self-declared nonwhite skin color (odds ratio (OR) = 1.51), the presence of a sensory phenomenon (OR = 1.47), and comorbidity with post-traumatic stress disorder (PTSD) (OR = 2.38) were some of the logistic regression variables related to the reported SLEs with relevant statistical significance and risk (i.e., OR) values.

CONCLUSIONS

Our results indicate that SLEs may make Brazilian OCD patients vulnerable to the onset or exacerbation of obsessive-compulsive symptoms. The positive association of the occurrence of SLEs and sensory phenomena in this population could corroborate that environmental influences impact the neurobiology associated with OCD, and likely with other psychiatric disorders as well.

Childhood trauma and attachment style predict the four-year course of obsessive compulsive disorder: Findings from the Netherlands obsessive compulsive disorder study

INTRODUCTION

Obsessive compulsive disorder (OCD) is a chronic psychiatric disorder where most patients do not reach full symptomatic remission. Identifying predictors of course can improve patients' care by informing clinicians on prognosis and enhancing treatment strategies. Several predictors associated with improved outcome of OCD were identified. However, research focused mainly on clinical, illness-related predictors of the course of OCD. This study examined the contribution of environmental and interpersonal predictors on the long-term outcome of OCD, in addition to the previously identified clinical indicators.

METHODS

We used the baseline, two and four-year data of 382 adult OCD patients participating in the naturalistic cohort study of the Netherlands Obsessive Compulsive Disorder Association (NOCDA). Remission was assessed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Predictors of outcome were assessed at baseline, via clinician-rated and self-report instruments.

RESULTS

Remission at two and at four-year follow-up ranged from 11% to 26%. Early age of onset and the presence of childhood trauma predicted a worse four-year course. Secure attachment style emerged as a protective predictor of improved outcome.

LIMITATIONS

The naturalistic design of our study did not enable a systematic estimation the effect of treatments received during the follow-up period. Furthermore, age of onset and childhood trauma were assessed retrospectively, which may contribute to recall bias.

CONCLUSION

Results coincide with previous prediction research and stress the importance of adaptive interpersonal functioning in the course of OCD. Clinical implications and future research directions are discussed.

Examining the functional activity of different obsessive-compulsive symptom dimensions in Tourette syndrome

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Patients with Tourette Syndrome completed an obsessive–compulsive provocation task.

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Patients reported higher anxiety for the provocation conditions than did controls.

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Group differences found in the insula, sensorimotor cortex and supramarginal gyri.

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Obsessive–compulsive severity associated with frontal and parietal lobe activity.

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Tic severity associated with anterior cingulate activity for the symmetry condition.

Objectives

Tourette syndrome (TS) is commonly comorbid with obsessive–compulsive disorder (OCD) and many phenomenological similarities exist between tics and obsessive–compulsive symptoms (OCS). Therefore, due to the clinical importance of comorbid OCD, the goal of this study was to investigate the neural substrates of OCS in TS using functional magnetic resonance imaging.

Methods

Forty patients with TS and 20 healthy controls underwent functional magnetic resonance imaging while viewing blocks of OCS-provoking pictures relating to washing, checking and symmetry symptoms, as well as generally disgusting and neutral scenes. Statistical comparisons were made between patients with moderate/severe OCS, absent/mild OCS and healthy controls. As well, within the entire TS patient group, significant associations with clinical measures were assessed for each of the provocation conditions.

Results

Group differences in the insula, sensorimotor cortex, supramarginal gyrus and visual processing regions were common among the checking, washing and disgust conditions. In the patient group, negative associations between OCS severity and activity in the supramarginal gyrus, inferior frontal gyrus, sensorimotor cortex, precuneus and visual processing regions were common among the provocation conditions. Tic severity was only associated with activity in the anterior cingulate cortex for the symmetry condition.

Conclusion

Our findings implicate areas previously reported to be involved in OCD, as well as areas not typically implicated in OCD, suggesting that the neurobiological profile of TS+OCD is intermediate to pure TS and pure OCD.

Psychopharmacotherapy of Obsessive-Compulsive Symptoms within the Framework of Tourette Syndrome

While Behavioral Therapy (BT) should be recommended as the first step in the treatment of OCD as well as TS, medication can be added for augmentation and in certain situations (e.g. family preference, BT not available or feasible) the priority may even reverse. This narrative review is given on the complexity of drug treatment in patients comorbid with obsessive-compulsive disorder (OCD) and Tourette syndrome (TS) and other tic problems. OCD with TS is a co-occurring combination of the two generally delimitable, but in detail, also overlapping disorders which wax and wane with time but have different courses as well as necessities and options of treatment. Distinct subtypes like “tic-related OCD” are questionable. Obsessive-compulsive symptoms (OCS) and tics are frequently associated (OCS in TS up to 90%, tics in OCD up to 37%). Sensory-motor phenomena like urges and just-right feelings reflect some behavioral overlap. The main additional psychopathologies are attention-deficit hyperactivity disorder (ADHD), mood problems and anxiety. Also, hair pulling disorder and skin picking disorder are related to OCD with TS. Hence, the assessment and drug treatment of its many psychopathological problems need high clinical experience, careful planning, and ongoing evaluation/adaptation. Drugs are able to reduce clinical symptoms but cannot cure the disorders, which should be treated in parallel in their own right; i.e. for OCD serotonin reuptake inhibitors (SSRI) and for TS (tics), certain antipsychotics can be successfully prescribed. In cases of OCD with tics, when OCS responds only partially, an augmentation with antipsychotics (recommended: risperidone and aripiprazole) may improve OCS as well as tics. Also, the benzamide sulpiride, an atypical antipsychotics, may be beneficial in treating the combination of OCS, tics and anxious-depressive problems.

Probably, any additional psychopathologies of OCD might attenuate the effectiveness of SSRI on OCS; on the other hand, in cases of OCD with tics, SSRI may reduce not only OCS but also stress sensitivity and emotional problems and thus leading to better selfregulatory abilities, useful to improve tic suppression.

In sum, some clinical guidance can be given, but there remain many uncertainties because of a scarce database for psychopharmacotherapy in OCD with TS.

Neurological Soft Signs and Clinical Features of Tic-Related Obsessive-Compulsive Disorder Indicate a Unique Subtype

Tic-related obsessive-compulsive disorder (OCD) may be a unique OCD subtype. This study examined whether neurological soft signs (NSSs) of patients with tic-related and tic-free OCD enable discrimination of these subgroups. We used the Neurological Evaluation Scale to assess 32 patients with tic-related and 94 with tic-free OCD, as well as 84 controls. Most patients with tic-related OCD were male, with earlier illness onset and poorer insight scores than those of patients with tic-free OCD. Patients with tic-related OCD had poorer motor coordination, sensory integration, and motor sequencing than did tic-free patients. Logistic regression using NSS subscale scores predicted tic-related OCD. Patients with tic-related OCD displayed greater neurodevelopmental abnormalities than did tic-free patients. NSSs of the former group suggest the need to separate this subgroup. Our results also support the newly introduced tic-related specifier in the fifth edition of the Diagnostic and statistical manual of mental disorders.

Overlap of obsessive-compulsive personality disorder and autism spectrum disorder traits among OCD outpatients: an exploratory study

Background: Whereas the phenomenology of obsessive-compulsive personality disorder (OCPD) shows similarities to that of obsessive compulsive and related disorders (OCRDs) as well as with autism spectrum disorder (ASD), the relationship between these disorders is poorly understood.Aims: Within a clinical sample, we aimed to investigate the distribution of OCD, OCPD and ASD symptoms and traits and their interrelationship, as well as to evaluate insight and treatment refractoriness.Methods: Consecutive adult OCD outpatients were assessed for OCPD traits (Compulsive Personality Assessment Scale (CPAS)), OCD symptoms (Yale-Brown Obsessive Compulsive Scale (Y-BOCS)), ASD traits (Autism Spectrum Quotient (AQ)), insight (Brown Assessment of Beliefs Scale (BABS)) and treatment resistance (clinical records). Those scoring highly on the AQ underwent a diagnostic interview for ASD.Results: Sixty-seven consenting individuals completed the CPAS, BABS and AQ, and 65 completed the Y-BOCS. Twenty-four patients (35.8%) were diagnosed with OCPD. Patients with OCPD were less likely to be employed (p=.04). They demonstrated elevated AQ scores (p=.004) and rates of ASD diagnosis (54.2%) (p <.001). OCPD traits (CPAS) showed a highly significant correlation with ASD traits (AQ) (p<.001), and no association with Y-BOCS, BABS or treatment resistance.Conclusions: In an OCD cohort limited by small size, OCPD associated strongly with unemployment and ASD, with implications for diagnosis, treatment and outcome.KEY POINTSClinicians should exercise a high level of vigilance for OCPD and ASD in patients presenting with obsessive compulsive symptoms.The presence of OCPD may indicate a likelihood of disabling ASD traits, including cognitive inflexibility, poor central coherence and poor social communication.These neuropsychological factors may require separate clinical intervention strategies.

Course and outcome of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is generally believed to follow a chronic waxing and waning course. The onset of illness has a bimodal peak - in early adolescence and in early adulthood. Consultation and initiation of treatment are often delayed for several years. Studies over the past 2-3 decades have found that the long-term outcomes in OCD are not necessarily bleak and that at least half the treatment-seeking patients with OCD show symptomatic remission over long term. A short duration illness, of low severity that is treated early and intensively, with continued maintenance treatment over long term possibly has a good outcome. Recent studies have also identified neuroimaging and neuropsychological correlates of good outcome, but these need further replication. This paper presents an overview of conceptual issues and studies on long-term outcome of OCD and predictors of outcome.

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.

Mapping Compulsivity in the DSM-5 Obsessive Compulsive and Related Disorders: Cognitive Domains, Neural Circuitry, and Treatment

Compulsions are repetitive, stereotyped thoughts and behaviors designed to reduce harm. Growing evidence suggests that the neurocognitive mechanisms mediating behavioral inhibition (motor inhibition, cognitive inflexibility) reversal learning and habit formation (shift from goal-directed to habitual responding) contribute toward compulsive activity in a broad range of disorders. In obsessive compulsive disorder, distributed network perturbation appears focused around the prefrontal cortex, caudate, putamen, and associated neuro-circuitry. Obsessive compulsive disorder-related attentional set-shifting deficits correlated with reduced resting state functional connectivity between the dorsal caudate and the ventrolateral prefrontal cortex on neuroimaging. In contrast, experimental provocation of obsessive compulsive disorder symptoms reduced neural activation in brain regions implicated in goal-directed behavioral control (ventromedial prefrontal cortex, caudate) with concordant increased activation in regions implicated in habit learning (presupplementary motor area, putamen). The ventromedial prefrontal cortex plays a multifaceted role, integrating affective evaluative processes, flexible behavior, and fear learning. Findings from a neuroimaging study of Pavlovian fear reversal, in which obsessive compulsive disorder patients failed to flexibly update fear responses despite normal initial fear conditioning, suggest there is an absence of ventromedial prefrontal cortex safety signaling in obsessive compulsive disorder, which potentially undermines explicit contingency knowledge and may help to explain the link between cognitive inflexibility, fear, and anxiety processing in compulsive disorders such as obsessive compulsive disorder.

Motor Abnormalities: From Neurodevelopmental to Neurodegenerative Through "Functional" (Neuro)Psychiatric Disorders

Background

Motor abnormalities (MAs) of severe mental disorders have been traditionally neglected both in clinical practice and research, although they are an increasing focus of attention because of their clinical and neurobiological relevance. For historical reasons, most of the literature on MAs has been focused to a great extent on schizophrenia, and as a consequence their prevalence and featural properties in other psychiatric or neuropsychiatric disorders are poorly known. In this article, we evaluated the extent to which catatonic, extrapyramidal and neurological soft signs, and their associated clinical features, are present transdiagnostically.

Methods

We examined motor-related features in neurodevelopmental (schizophrenia, obsessive compulsive disorder, autism spectrum disorders), "functional" (nonschizophrenic nonaffective psychoses, mood disorders) and neurodegenerative (Alzheimer's disease) disorders. Examination of the literature revealed that there have been very few comparisons of motor-related features across diagnoses and we had to rely mainly in disorder-specific studies to compare it transdiagnostically.

Results

One or more motor domains had a substantial prevalence in all the diagnoses examined. In "functional" disorders, MAs, and particularly catatonic signs, appear to be markers of episode severity; in chronic disorders, although with different degree of strength or evidence, all motor domains are indicators of both disorder severity and poor outcome; lastly, in Alzheimer's disease they are also indicators of disorder progression.

Conclusions

MAs appear to represent a true transdiagnostic domain putatively sharing neurobiological mechanisms of neurodevelopmental, functional or neurodegenerative origin.