A family study of obsessive-compulsive disorder

Genetic and imaging strategies in obsessive-compulsive disorder: potential implications for treatment development

In recent years, advances in brain research have resulted in a striking strategic shift in studies designed to develop new, effective treatments for neuropsychiatric disorders. This involves a multidisciplinary approach with recursive interactions among respective disciplines with the ultimate goal of contributing to treatment development. In this review we focus on treatment implications of brain imaging and molecular and pharmacogenetic studies in obsessive-compulsive disorder. Translational components of this research are addressed, including the potential for integrating advances in brain imaging and molecular and pharmacogenetic assessments as they may potentially relate to neurodiagnostic assessment and treatment development. Studies of putative susceptibility alleles in obsessive-compulsive disorder involving the serotonergic, glutamatergic, and dopaminergic systems may provide a focus for these divergent approaches. Taken together, neuroimaging and genetic methods may ultimately lead to a mechanistic understanding of the pathogenesis and maintenance of neuropsychiatric disorders such as obsessive-compulsive disorder that may, in turn, result in the development of new neurodiagnostic and treatment approaches.

Obsessive and compulsive symptoms in a general population sample of female twins

Obsessive-compulsive disorder (OCD) and obsessive-compulsive symptoms (OCS) exhibit a familial pattern of transmission. The different components of these conditions and the extent to which these components are inherited have not been studied well. A sample of 1,054 female twins, including both members of 527 pairs, from the Virginia Twin Registry returned questionnaires that included 20 items from the Padua Inventory of obsessive-compulsiveness. Their responses were used to estimate the heritability of the different factors of OCS in this population. Principal components analysis suggested two meaningful factors corresponding roughly to obsessions and compulsions. The best-fit model suggested heritabilities of 33 and 26%, respectively. The correlation between additive genetic effects on compulsiveness and obsessiveness was found to be +0.53. Self-report symptoms of obsessions and compulsions in women from the general population are moderately heritable and due, in part, to the same genetic risk factors. An understanding of the etiology of these symptoms is relevant to the study of OCD. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:791-796, 2000.

Association between homozygosity at the COMT gene locus and obsessive compulsive disorder

A functional polymorphism in the coding region of the catechol O-methyltransferase (COMT) gene has been reported in previous studies to be associated with obsessive compulsive disorder (OCD), particularly in males [Karayiorgou et al., 1997, 1999]. Using a family-based population analysis, we attempted to replicate these findings in a group of 72 OCD patient/parent trios collected from Buffalo, New York, and Toronto, Canada. Analysis of allele and genotype frequencies using the haplotype relative risk (HRR) and transmission disequilibrium test (TDT) did not identify an association between a particular allele and OCD as had been previously reported. Furthermore, no evidence was found to support the findings of a gender-based association for COMT when the patients and the parents of the same gender were compared. However, our genotype results (n = 72) demonstrate a tendency for association between homozygosity at the COMT locus and OCD (homozygosity analysis: chi(2) = 5.66, P = 0.017; genotypic analysis: chi(2) = 5.78, P = 0.056). Although these findings do not replicate the previous reports, they do provide limited support to demonstrate a trend for homozygosity at the COMT locus in the OCD patients and, in turn, further implicate a potential role for COMT in the genetic etiology of OCD. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:721-724, 2000.

Onset of obsessive-compulsive disorder: premorbid conditions and prodromal phase

This article focuses on the clinical onset of obsessive-compulsive disorder (OCD), specifically addressing the age of onset, gradual and acute onset, and whether there are some types of premorbid conditions or a prodromal phase that predispose individuals to the onset of OCD. Clinical and epidemiological studies have come to different conclusions regarding age at onset as well as regarding differences between the sexes. Data gleaned from research to date have demonstrated a relationship between OCD and obsessive-compulsive personality disorder (OCPD), although OCPD does not appear to be the more prevalent personality disorder among patients with OCD. Preliminary research has suggested that Axis I disorders may predispose individuals to OCD onset; however, the significance of this relationship remains to be clarified. Evidence of the association between OCD and subthreshold obsessive-compulsive syndrome suggests that these disorders lie on a continuum of severity, with some cases developing OCD while others do not.

Fenfluramine challenge in anxious children

The study objective was to determine if serotonergic challenge with oral racemic fenfluramine would differentiate between childhood anxiety disorders in comparison to normal controls. Subjects were 24 children with anxiety diagnoses (DSM-IIIR) by structured interview, and 14 normal controls (ages 7 - 14 years) matched for age and sex. All subjects were given a standard challenge dose of d,1-fenfluramine (1 mg/kg) followed by serial assessments of cardiovascular, neurohormonal, and mood parameters over a five hour period. In response to fenfluramine, controls demonstrated increases in subjective anxiety and systolic blood pressure relative to anxious subjects. Fenfluramine was safely tolerated and did not induce panic symptoms in any subject. Exaggerated prolactin response to fenfluramine differentiated an obsessive - compulsive disorder (OCD) subset from both controls and other anxiety disorders. Fenfluramine challenge differentiates anxious children from healthy controls by elevated anxiety ratings and systolic blood pressure in controls. Increased prolactin response to fenfluramine discriminates children with obsessive - compulsive disorder from both healthy children and children with other anxiety diagnoses. As adults with OCD appear to demonstrate a blunted prolactin response to fenfluramine challenge, the serotonin pathways involved may differ between 'early' and 'late' onset disorder, or the serotonin substrates tapped by this challenge may change over time. Copyright 2000 John Wiley & Sons, Ltd.

Complex segregation analysis provides compelling evidence for a major gene underlying obsessive-compulsive disorder and for heterogeneity by sex

Evidence from twin and family studies supports a genetic etiology for obsessive-compulsive disorder (OCD). The purpose of this study was to test whether a major gene is implicated in a proportion of families with OCD. Complex segregation analyses of 153 families (80 case and 73 control), ascertained in the Johns Hopkins OCD Family Study, provided strong evidence for a major gene. A Mendelian-dominant model, with significant sex effects and with residual familial effects, best explained the observed data. Stratification of the sample by the sex of probands provided further evidence of heterogeneity with respect to familial aggregation. Segregation analyses of 86 families with a female proband and of the 67 families with a male proband suggested that a Mendelian-dominant model with familial residual effects was the most parsimonious model explaining the inheritance of OCD in both subgroups.

Genetic aspects of obsessive-compulsive disorder

Developments in molecular genetic methods have proved to be powerful tools in the search for genes involved in complex diseases, and they hold the promise of understanding the genetic basis of OCD. The next step in understanding the genetics of OCD is the localization and characterization of the genes that confer susceptibility. A more complete understanding of the genetic basis of OCD and of the interactions between relevant genotypes and relevant environmental factors is important for clarification of the cause, pathogenesis, and treatment of this complex disorder. These genetic methods must be combined with careful clinical and epidemiologic work to correctly elucidate the cause of OCD. Future research also should define subsets of endophenotypes of the disorder. Factors such as neuropsychological functioning, personality testing, comorbidity, and age of onset are extremely useful in the continued study of genetic mechanisms involved in the cause of OCD.

Obsessive-compulsive disorder in children

Childhood OCD is a chronic and commonly disabling disorder with a lifetime prevalence of 2% to 3%. Traditionally OCD was a neglected diagnosis, but renewed research interest over the past decade has led to significant advances in the understanding of the disorder in young people. OCD is relatively consistent across the age span in terms of prevalence, phenomenology, etiology, and response to treatment. Comorbidity, especially depression and other anxiety disorders, is common in children with OCD and may exert a negative influence on treatment response and long-term outcome. Nevertheless, CBT and SSRI therapy have been shown to be effective and well-tolerated therapies for children with OCD.

The role of the family in childhood obsessive-compulsive disorder

While obsessive-compulsive disorder is widely recognized to have a strong genetic component, psychosocial factors are also acknowledged to be important. The primary focus of this paper is on familial factors associated with OCD in children and adolescents. It explores the family context as a possible risk factor in the development and maintenance of the disorder, including parental modeling, expressed emotion, parenting style, and family accommodation of the child's symptoms. The involvement of the family in the treatment of the disorder is also reviewed. Finally, future directions for research investigating familial factors in childhood OCD are presented.

Clinical features of obsessive-compulsive disorder

The past decade has seen tremendous strides in the knowledge about the cause, epidemiology, and treatment of OCD. Research on clinical characteristics of the disorder have focused on several areas, including identification of subtypes, the role of insight, and patterns of comorbidity. Several studies looking at course of illness in OCD have found that, for adults with this disorder, the course is usually chronic, but increasing evidence shows that a subtype of OCD characterized by an episodic course may exist, and research is focusing on delineating that subtype more specifically. Another hypothesized subtype, which may be related to rheumatic fever, involves patients with both OCD and chronic tic disorders. Certain obsessions and compulsions are more common in patients with these two disorders; together with the familial transmission and treatment data, this suggests that these patients may represent a meaningful subtype. Another area of focus over the past 10 years has been the role of insight. Increasing evidence shows that a range of insight exists in patients with OCD. Whether patients with poor insight have a different treatment response or different course than do patients with better insight remains to be seen. Finally, comorbidity between OCD and schizophrenia has been an area of interest. Emerging evidence shows that obsessions and compulsions are more common in patients with schizophrenia than was previously thought. The effect of obsessions and compulsions on schizophrenia in terms of treatment response and course is being investigated. Despite tremendous advances in treatment of this potentially debilitating disorder, a significant percentage of patients do not respond to standard treatment. Continued research to identify meaningful subtypes in OCD is necessary to unravel important questions concerning cause and to develop specific treatment strategies for refractory patients.

Advances in the neurobiology of obsessive-compulsive disorder. Implications for conceptualizing putative obsessive-compulsive and spectrum disorders

Several approaches to the spectrum of obsessive-compulsive spectrum disorders have been put forward, each based on a rather different framework. To some extent, overlaps exist among these approaches, indicating that the neurobiology of OCD and related disorders is increasingly consolidated; however, important differences exist between these approaches, and many questions are unanswered, demonstrating that more work is necessary to fully delineate OCD and its subtypes and their relationships to other putative obsessive compulsive spectrum disorders. Despite the need for substantial additional research on the neurobiology of the obsessive-compulsive spectrum, this construct already has heuristic value in the clinical and research setting. It reminds clinicians to ask OCD patients about comorbid spectrum disorders, and it suggests the possible value of anti-OCD agents and behavioral techniques in patients for whom treatments were previously unavailable. It reminds investigators to consider possibly overlapping and differentiating mechanisms in several disorders. Ultimately, the delineation of such mechanisms will allow for a more rigorous approach to the putative obsessive-compulsive spectrum disorders.

Psychiatric disorders in first-degree relatives of children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)

OBJECTIVE

To determine the rates of psychiatric disorders in the first-degree relatives of children with infection-triggered obsessive-compulsive disorder (OCD) and/or tics (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections; PANDAS).

METHOD

The probands of this study were 54 children with PANDAS (n = 24 with a primary diagnosis of OCD; n = 30 with a primary diagnosis of a tic disorder). One hundred fifty-seven first-degree relatives (100 parents [93%] and 57 siblings [100%]) were evaluated for the presence of a tic disorder. One hundred thirty-nine first-degree relatives (100 parents [93%] and 39 of 41 siblings over the age of 6 [95%]) were evaluated with clinical and structured psychiatric interviews to determine the presence of subclinical OCD, OCD, and other DSM-IV Axis I disorders.

RESULTS

Twenty-one probands (39%) had at least one first-degree relative with a history of a motor or vocal tic; 6 mothers (11%), 9 fathers (19%), and 8 siblings (16%) received this diagnosis. Fourteen probands (26%) had at least one first-degree relative with OCD; 10 mothers (19%), 5 fathers (11%), and 2 siblings (5%), received this diagnosis. An additional 8 parents (8%) and 3 siblings (8%) met criteria for subclinical OCD. Eleven parents (11%) had obsessive-compulsive personality disorder.

CONCLUSIONS

The rates of tic disorders and OCD in first-degree relatives of pediatric probands with PANDAS are higher than those reported in the general population and are similar to those reported previously for tic disorders and OCD. Further study is warranted to determine the nature of the relationship between genetic and environmental factors in PANDAS.

The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study

BACKGROUND

The familial relationship between obsessive-compulsive disorder (OCD) and "obsessive-compulsive spectrum" disorders is unclear. This study investigates the relationship of OCD to somatoform disorders (body dysmorphic disorder [BDD] and hypochondriasis), eating disorders (e.g., anorexia nervosa and bulimia nervosa), pathologic "grooming" conditions (e.g., nail biting, skin picking, trichotillomania), and other impulse control disorders (e.g., kleptomania, pathologic gambling, pyromania) using blinded family study methodology.

METHODS

Eighty case and 73 control probands, as well as 343 case and 300 control first-degree relatives, were examined by psychiatrists or Ph.D. psychologists using the Schedule for Affective Disorders and Schizophrenia-Lifetime Anxiety version. Two experienced psychiatrists independently reviewed all diagnostic information and made final consensus diagnoses using DSM-IV criteria.

RESULTS

Body dysmorphic disorder, hypochondriasis, any eating disorder, and any grooming condition occurred more frequently in case probands. In addition, BDD, either somatoform disorder, and any grooming condition occurred more frequently in case relatives, whether or not case probands also had the same diagnosis.

CONCLUSIONS

These findings indicate that certain somatoform and pathologic grooming conditions are part of the familial OCD spectrum. Though other "spectrum" conditions may resemble OCD, they do not appear to be important parts of the familial spectrum.

Thalamic volume in pediatric obsessive-compulsive disorder patients before and after cognitive behavioral therapy

BACKGROUND

Neurobiologic abnormalities in the thalamus have been implicated in the pathophysiology of obsessive-compulsive disorder. We recently reported increased thalamic volume in treatment-naive pediatric obsessive-compulsive disorder patients versus case-matched healthy comparison subjects that decreased to levels comparable to control subjects after effective paroxetine therapy. To our knowledge, no prior study has measured neuroanatomic changes in the thalamus of obsessive-compulsive disorder patients near illness onset before and after cognitive behavioral therapy.

METHODS

Volumetric magnetic resonance imaging studies were conducted in 11 psychotropic drug-naive 8-17-year-old children with obsessive-compulsive disorder before and after 12 weeks of effective cognitive behavioral therapy monotherapy (> or =30% reduction in obsessive-compulsive disorder symptom severity).

RESULTS

No significant change in thalamic volume was observed in obsessive-compulsive disorder patients before and after cognitive behavioral therapy.

CONCLUSIONS

Our findings suggest that reduction in thalamic volume after paroxetine therapy may be specific to paroxetine treatment and not the result of a general treatment response or spontaneous improvement. These results are preliminary in view of the small sample studied.

Childhood obsessive-compulsive disorder: a review

Obsessive-compulsive disorder (OCD) holds a particular interest for child psychiatrists because of the high proportion of cases with onset in childhood and adolescence. Over the last two decades, substantial progress has been made in describing OCD in children and adolescents and in developing and implementing effective treatments. In addition, research on the phenomenology, neurobiology, and psychopharmacology of OCD has led to its current conceptualization as a developmental neuropsychiatric disorder. In this article, the fourth in a series on OCD, the authors summarize the most recent data on the phenomenology, etiology, neurobiology, and treatment of OCD in children and adolescents.

Biological therapies for obsessive-compulsive disorder

Two treatments have demonstrated efficacy in OCD, exposure and response (ritual) prevention (EX/RP) and pharmacotherapy with serotonin reuptake inhibitors (SRIs). In this article, which is the third in a three-part series, the authors present an overview of the role of biological treatments for OCD. The evidence for the efficacy of the serotonin reuptake inhibitors (clomipramine and the five selective serotonin reuptake inhibitors "SSRIs" fluvoxamine, fluoxetine, paroxetine, sertraline, and citalopram) as monotherapy for OCD is reviewed. The authors also discuss the rationale for choosing among these agents for specific patients. Research on other types of medication monotherapies for OCD is also discussed. The authors then cover strategies for treatment-resistant OCD, including combining EX/RP and SRI medication treatment, combining clomipramine and an SSRI, use of augmenting medications, and use of intravenous clomipramine. Findings concerning the use of other somatic therapies for treatment-resistant OCD, including electroconvulsive therapy, neurosurgery, plasma exchange/IV immunoglobulin/maintenance antibiotics, and transcranial magnetic stimulation, are also reviewed. Finally, the authors discuss what is known about matching treatments to patients with certain specific symptom clusters, how long to continue maintenance medication treatment, and how to terminate treatment.

Proton spectroscopic imaging of the thalamus in treatment-naive pediatric obsessive-compulsive disorder

BACKGROUND

Neurobiological abnormalities in the thalamus, particularly the dorsomedial nucleus of the thalamus, are believed to be involved in the pathophysiology of obsessive-compulsive disorder. Although obsessive-compulsive disorder commonly arises in childhood and adolescence, no prior study has examined the thalamus in pediatric obsessive-compulsive disorder patients.

METHODS

In this study, N-acetyl-aspartate, a putative marker of neuronal viability, creatine/phosphocreatine, and choline levels were measured in the lateral and medical subregions of the left and right thalami using a multislice proton magnetic resonance spectroscopic imaging sequence in 11 treatment-naive, nondepressed obsessive-compulsive disorder outpatients, 8-15 years old, and 11 case-matched control subjects.

RESULTS

A significant reduction in N-acetyl-aspartate/choline and N-acetyl-aspartate/(creatine/phosphocreatine + choline) was observed in both the right and left medial thalami in obsessive-compulsive disorder patients compared with control subjects. The N-acetyl-aspartate/choline and N-acetyl-aspartate/(creatine/phosphocreatine + choline) levels did not differ significantly between case-control pairs in either the left or the right lateral thalamus. Reduction in N-acetyl-aspartate levels in the left medial thalamus was inversely correlated with increased obsessive-compulsive disorder symptom severity.

CONCLUSIONS

These findings provide new evidence of localized functional neurochemical marker abnormalities in the thalamus in pediatric obsessive-compulsive disorder. Our results must be considered preliminary, however, given the small sample size.

Self-help and guided self-help treatments for bulimia nervosa and binge eating disorder

This article reviews the use of self-help and guided self-help treatments for bulimia nervosa (BN) and binge eating disorder (BED). Available data suggest that self-help and guided self-help treatments based on empirically-supported cognitive behavioral therapies (CBT) have efficacy for binge eating problems. Emerging findings from initial studies suggest that the magnitude of the differences in outcomes between certain guided-self-help CBT programs and therapist-led CBT may not be substantial, although further research is clearly indicated. Initial data suggest that self-help and guided self-help CBT programs may not only demonstrate "efficacy" but also "effectiveness"-i.e., utility in "real-world" primary care or community settings. Implications for clinical practice and for future research are discussed.

Segregation analysis of obsessive-compulsive disorder using symptom-based factor scores

Obsessive-compulsive disorder (OCD) is a complex psychiatric disorder characterized by recurring obsessions or compulsions that cause significant distress to the patient or significantly interfere with the patient's normal home, work, or social activities [Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Association, 1994]. Twin and family studies have suggested that OCD has a significant genetic component. We performed complex segregation analyses using POINTER with families ascertained through an OCD-affected proband. In an attempt to resolve the phenotypic heterogeneity observed among individuals with OCD these segregation analyses used four factor-analytic symptom dimensions to subset the family sample based upon probands' symptom factor scores. Analysis of the entire sample allowed rejection of only the no transmission model; that model was also rejected in all subsequent analyses. Limiting the analyses to families with at least one OCD-affected member in addition to the proband (the demonstrably familial form of OCD) allowed rejection of all models except the mixed model. Analyses limited to families of high-factor-3 (symmetry and ordering symptoms) probands led to rejection of the polygenic model, indicating the involvement of a major locus. Additionally, the relative risk of OCD or subclinical OCD was 1.7 for relatives of probands with a factor 3 score greater than zero compared with relatives of probands with a low factor score. The symptoms attributed to high factor 3 scores (symmetry and ordering) may constitute a genetically significant symptomatic subtype of OCD. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 88:669-675, 1999.

Is there sexual dimorphism in obsessive-compulsive disorder?

The present review addresses the question of sexual dimorphism in obsessive-compulsive disorder. It enumerates examples that could be interpreted to suggest the existence of such dimorphism from the fields of epidemiology, phenomenology, pharmacology, neuropsychology, neuroimaging and genetics. We conclude that data, at this point, are too scarce to warrant a firm conclusion. On the contrary it seems that there are enough indications in the literature that hint at the possibility of sexual dimorphism to stimulate further research in the field.

Gender-related clinical differences in obsessive-compulsive disorder

The purpose of the present study was to investigate the gender-related differences of clinical features in a sample of obsessive-compulsive (OCD) patients. One hundred and sixty outpatients with a principal diagnosis of obsessive-compulsive disorder (DSM-IV, Y-BOCS = 16) were admitted. Patients were evaluated with a semi-structured interview covering the following areas: socio-demographic data, Axis I diagnoses (DSM-IV), OCD clinical features (age at onset of OC symptoms and disorder, type of onset, life events and type of course). For statistical analysis the sample was subdivided in two groups according to gender. We found an earlier age at onset of OC symptoms and disorder in males; an insidious onset and a chronic course of illness were also observed in that group of patients. Females more frequently showed an acute onset of OCD and an episodic course of illness; they also reported more frequently a stressful event in the year preceding OCD onset. A history of anxiety disorders with onset preceding OCD and hypomanic episodes occurring after OCD onset was significantly more common among males, while females showed more frequently a history of eating disorders. We found three gender-related features of OCD: males show an earlier age at onset with a lower impact of precipitant events in triggering the disorder; OCD seems to occur in a relative high proportion of males who already have phobias and/or tic disorders; and a surfeit of chronic course of the illness in males in comparison with females.

Obsessive-compulsive syndromes in older adolescents

OBJECTIVE

This report presents data on the prevalence of both obsessive-compulsive disorder (OCD) and subthreshold obsessive-compulsive syndrome (sOCS) in a representative sample of older male adolescents living in Piedmont, Italy.

METHOD

A total of 1,883 recruits to the Italian Defence Force were interviewed using the OC portion of the Diagnostic Interview Schedule. A diagnosis of sOCS was made for individuals who had obsessive and/or compulsive symptoms but who failed to meet one of the severity criteria of impairment.

RESULTS

The point and lifetime prevalence rates of OCD were 2.0% and 2.6%, respectively. In total, 12.3% of the subjects received a current diagnosis of sOCS. No differences were found when examining prevalence rates according to area of residence or occupational status of the subjects.

CONCLUSION

Our findings suggest that OCD is as common in older male adolescents as it is in adults, and that sOCS, being commonly endorsed in a general adolescent population, may represent a normal phenomenon in older adolescents.

A complete genome screen in sib pairs affected by Gilles de la Tourette syndrome. The Tourette Syndrome Association International Consortium for Genetics

Gilles de la Tourette syndrome is a neuropsychiatric disorder characterized by waxing and waning multiple motor and phonic tics with a complex mode of inheritance. Previous attempts, which used large multigenerational families to localize susceptibility loci, have been unsuccessful. In this report, the results of the first systematic genome scan, using 76 affected-sib-pair families with a total of 110 sib pairs, are summarized. While no results reached acceptable statistical significance, the multipoint maximum-likelihood scores (MLS) for two regions (4q and 8p) were suggestive (MLS > 2.0). Four additional genomic regions also gave multipoint MLS scores between 1.0 and 2.0.

Paroxetine open-label treatment of pediatric outpatients with obsessive-compulsive disorder

OBJECTIVE

Paroxetine is a selective serotonin reuptake inhibitor with demonstrated efficacy in treating obsessive-compulsive disorder (OCD) in adults. This study evaluates the safety and effectiveness of paroxetine in pediatric OCD patients.

METHOD

In a 12-week, open-label trial of paroxetine, 20 OCD outpatients, aged 8 to 17 years, were treated for OCD with daily doses ranging from 10 to 60 mg. Target symptoms were rated at regular intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the Children's Global Assessment Scale, the Clinical Global Impression Scale, the Hamilton Anxiety Rating Scale, and the Yale Global Tic Severity Scale.

RESULTS

Paroxetine proved relatively safe in this brief trial with a small sample and appeared to be effective in patients with OCD; mean CY-BOCS scores decreased significantly (z = 3.49, p = .0005) from 30.6 +/- 3.5 to 21.6 +/- 6.8 on medication. The most common side effects (n > or = 2) were hyperactivity/behavioral activation, headache, insomnia, nausea, and anxiety. Paroxetine did not have to be discontinued in any of the patients because of side effects; the most serious side effects included hyperactivity/behavioral activation in 3 younger patients (< 10 years) necessitating dosage reduction but not discontinuation.

CONCLUSIONS

Preliminary evidence suggests that short-term treatment of pediatric OCD outpatients with paroxetine may be relatively safe and effective.

Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder

OBJECTIVE

No consistent predictors of outcome have been identified for the pharmaco-therapy of obsessive-compulsive disorder (OCD). Recent factor analytic studies have identified meaningful symptom dimensions that may be related to response to serotonin reuptake inhibitors and other treatments.

METHOD

A total of 354 outpatients with primary OCD were administered the Yale-Brown Obsessive Compulsive Scale Symptom Checklist, and its 13 main symptom categories were factor analyzed by using principal components analysis. The identified symptom dimensions were then entered into multiple regression models as outcome predictors of response to serotonin reuptake inhibitors and placebo response in a group of 150 nondepressed subjects who completed six double-blind, placebo-controlled trials with a serotonin reuptake inhibitor (clomipramine, fluvoxamine, fluoxetine, sertraline, and paroxetine). Eighty-four patients received a serotonin reuptake inhibitor and 66, placebo.

RESULTS

The principal components analysis identified five factors that explained 65.5% of variance in outcome: symmetry/ordering, hoarding, contamination/cleaning, aggressive/checking, and sexual/religious obsessions. Serotonin reuptake inhibitors were significantly superior to placebo on all outcome measures. Initial severity of OCD was related to greater posttreatment severity of OCD. Higher scores on the hoarding dimension predicted poorer outcome following treatment with serotonin reuptake inhibitors, after control for baseline severity. No predictors of placebo response were identified. Exclusion of clomipramine did not modify the overall results, suggesting a cross-serotonin reuptake inhibitor effect.

CONCLUSIONS

The identified symptom dimensions are largely congruent with those identified in earlier reports. Patients with OCD vary in their response to treatment with serotonin reuptake inhibitors. The presence of hoarding obsessions and compulsions is associated with poorer response to serotonin reuptake inhibitors.

Orbitofrontal cortex dysfunction in obsessive-compulsive disorder? I. Alternation learning in obsessive-compulsive disorder: male-female comparisons

BACKGROUND

We have previously reported a significant negative correlation between severity of symptoms and performance of an alternation learning task in female obsessive-compulsive disorder (OCD) patients. The present study was aimed at exploring this relationship between alternation learning and OCD symptom severity in male OCD patients.

METHODS AND RESULTS

Eighteen female obsessive-compulsive disorder patients and 14 male non-depressed, drug free, OCD patients participated in the study. Measures of dorsolateral prefrontal function (Wisconsin Card Sorting Test) and orbitofrontal cortex function (object alternation learning) showed no significant differences between the sexes. The relationship between orbitofrontal cortex function and severity of OC symptoms was significantly different between the sexes (z=2.44. P=0.007). While this correlation was negative in the females it was positive in the males.

CONCLUSIONS

These results may indicate sexual dimorphism in OCD.

Orbitofrontal cortex dysfunction in obsessive-compulsive disorder? II. Olfactory quality discrimination in obsessive-compulsive disorder

BACKGROUND

Olfactory quality discrimination is a putative marker of orbitofrontal cortex function in mammals. As this portion of the cerebral cortex was repeatedly implicated in the pathophysiology of obsessive-compulsive disorder (OCD) this study was designed in an attempt to quantify this behavioural function in OCD patients.

METHODS AND RESULTS

Olfactory quality discrimination was compared in OCD patients and healthy controls. Thirty two subjects participated in the study: 16 (13 women and 3 men) medication free OCD outpatients and 16 sex and age matched healthy controls. Olfactory tests consisted of determination of detection thresholds to isoamyl acetate, and a three way forced choice quality discrimination task, using isoamyl acetate, citral and eugenol as stimuli. No significant differences in sensitivity and performance of the quality discrimination task between the two groups were found. Within the OCD group the more severely affected patients (Y-BOCS>29) performed significantly better than the less severely affected (Y-BOCS<30) patients on the more difficult part of the quality discrimination task. Within this subgroup of patients the correlation between performance on the olfactory task and a previously reported alternation task tended to be negative as compared to a significantly positive correlation in the control group.

CONCLUSIONS

It seems that olfactory quality discrimination may prove to be a useful noninvasive marker of prefrontal cortex function in OCD. Furthermore, the organization of functional modules within the orbitofrontal cortex, rather than a simple dysfunction, may prove to characterize OCD.

Preoccupations and behaviors associated with romantic and parental love. Perspectives on the origin of obsessive-compulsive disorder

This article first examines the hypothesis that the early phases of romantic love and early parental love share phenomenologically an overlapping set of mental states and behaviors. Second, the authors consider what is known of the neurobiologic substrates of these behaviors. Third, the authors evaluate the hypothesis that these highly conserved behavioral and neural systems and the genetic messages that guide their development are intimately involved in the pathogenesis of OCD.

The genetics of anxiety disorders

The common denominator of anxiety disorders is that they share inappropriate levels of emotions and cognitions that affect rather than enable adaptive behaviours. The variety of symptoms include 'spontaneous' panic attacks with mental and physical symptoms, stimulus bound anxiety associated with avoidance behaviour, and almost constant 'generalized' anxious feelings. According to the DSM-IV criteria the anxiety disorders are classified as shown in Table I.

Corpus callosal signal intensity in treatment-naive pediatric obsessive compulsive disorders

1. Obsessive compulsive disorder (OCD) is increasingly recognized as a severe, highly prevalent and chronically disabling disorder, emerging during childhood in as many as 80% of cases. The authors previously found significant abnormalities in the region of the corpus callosum (CC) connecting ventral prefrontal cortex and striatum in pediatric OCD patients compared to controls that correlated significantly with OCD symptom severity. We speculated that this abnormality might reflect aberrant myelinization in OCD patients. 2. In order to better characterize the abnormality, the authors examined CC signal intensity (SI), believed to be a reliable index of myelinization of the CC. Lower numbers would indicate a greater concentration of white matter, while higher numbers indicate higher concentrations of gray matter. We compared the SI from midsagittal magnetic resonance images of 21 treatment-naive OCD patients, 7.2-17.7 years, and 21 case-matched healthy controls to examine regional CC signal intensity of the anterior, middle and posterior genu, body, isthmus, and the anterior, middle and the posterior splenii. 3. Mean total genu SI for the patient group (.993 + .006) was significantly less than the total genu SI of controls (.994 + .006) at F(1,37) = 4.73; p = .036. This abnormality in SI was localized to the CC region connecting ventral PFC and striatum, the anterior genu for the OCD group (.991 + .007) which was also less than control (.995 + .007) at F(1,37) = 5.47; p = .025., with no abnormality observed in middle or posterior genu regions. Genu SI was also inversely correlated with OCD symptom severity (r = -.55, p = .013) but not illness duration. Genu SI also correlated positively with genu area (r = .52, p = .020) in OCD patients but not controls. 4. Developmental abnormalities in genu size may arise from abnormalities in myelination in early onset OCD patients. The increased genu myelination observed in OCD patients may alter signal transduction and function of VPFC-striatal association circuits.

Family-based association studies support a sexually dimorphic effect of COMT and MAOA on genetic susceptibility to obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a common and severe psychiatric illness that affects 1-3% of the population and presents a well-established co-morbidity with major depressive disorder (MDD). Twin and family studies have suggested a genetic component in the etiology of OCD, although the mode of inheritance is unknown. Pharmacotherapy of the disease implicates both serotonergic and dopaminergic pathways. Previously, guided by the 22q11 microdeletion-related psychiatric phenotype, we provided evidence for a sexually dimorphic association between OCD and the gene for catechol-O-methyltransferase (COMT). In this report, we use 110 nuclear OCD families to analyze the inheritance of variants of COMT and monoamine oxidase-A (MAOA), another gene modulating monoamine metabolism.

METHODS

A sample of 110 nuclear OCD families was collected, and lifetime diagnoses were ascertained using the Diagnostic Interview for Genetic Studies (DIGS). DNA was genotyped for functional variants of the COMT and MAO genes, and allele inheritance was examined using the Transmission Disequilibrium Test (TDT) and Haplotype-based Haplotype Relative Risk (HHRR) test.

RESULTS

We provide evidence supporting the previously reported sexually dimorphic association between low COMT enzymatic activity and OCD. We also provide evidence for a similar sexually dimorphic association between OCD and an allele of the MAOA gene, previously linked to high MAO-A enzymatic activity. In agreement with the well-established action of MAO-A inhibitors as antidepressants, this association is particularly marked among male OCD probands with co-morbid MDD, who represent more than 50% of our male OCD sample.

CONCLUSIONS

Our analysis indicates that variants of two genes modulating monoamine metabolism contribute significantly to OCD susceptibility. Most importantly, an unexpected sexually dimorphic pattern of genetic susceptibility to OCD is revealed and suggests the possibility that profound gender differences in genetic predisposition may exist not only for other OCD susceptibility genes, but for an array of other psychiatric disorders as well.

Complex segregation analysis for obsessive compulsive disorder and related disorders

Complex segregation analysis was applied to a sample of 107 Italian families with probands with obsessive compulsive disorder (OCD), using regressive logistic models to test for possible models of genetic transmission. We used two different phenotypic definitions of affection: 1) OCD; and 2) OCD plus Tourette's syndrome/chronic motor tics (CMT). Because of the potential relationship between OCD, Tourette's syndrome (TS), and other tic disorders, we considered these diagnoses to be determined by the same liability in subsequent steps of the analysis. For the 107 OCD families, the best fit was a dominant model of transmission (with a higher penetrance for females). When the phenotype boundaries were widened (OCD + CMT + TS), an unrestricted model of transmission became the best fit. We concluded that additional data are needed to support the hypothesis that Tourette's syndrome and OCD share a common etiology: on the basis of clinical and epidemiological considerations, the OCD phenotype probably presents a higher level of heterogeneity than the TS phenotype, and it could be regulated through different etiologic pathways.

Hallucinogens, serotonin and obsessive-compulsive disorder

The serotonin (5-HT) neurotransmitter system has been implicated in the pathophysiology of several neuropsychiatric disorders, especially obsessive-compulsive disorder (OCD). Blockade of 5-HT reuptake appears to be an important initial neurobiological event in the therapeutic mechanism of action of antiobsessional drugs. However, for reasons that continue to be poorly understood, clinical improvement following initiation of treatment with 5-HT reuptake inhibitors can take up to eight to 12 weeks, and most patients do not fully improve. Recent data suggest that activation of 5-HT2A and/or 5-HT2C receptors may be important for the improvement of OCD symptoms. Most psychedelic drugs are potent agonists at 5-HT2A and 5-HT2C receptors and their binding potency to these receptors is strongly correlated with their human potency as hallucinogens. This article will briefly review the relevant clinical and preclinical studies relating to the effects of hallucinogens on OCD. These data suggest that activation of 5-HT2 receptors by hallucinogens may lead to acute reduction of, as well as possible longer-lasting beneficial effects on, the symptoms of OCD. Evidence for and against involvement of 5-HT2A and/or 5-HT2C receptors in the therapeutic effects of drug therapies for OCD are reviewed. Issues related to the pharmacological properties and safety of psychedelic drugs, when considered as potential treatments for patients with OCD, are summarized. The authors suggest that controlled trials of potent 5-HT2 agonists in people suffering from OCD are warranted.

Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. AACAP

These practice parameters describe the assessment and treatment of obsessive-compulsive disorder based on a detailed literature review and expert consultation. Obsessive-compulsive disorder is a disorder of heterogeneous origin characterized by intrusive thoughts or compulsive urges or behaviors that are distressing, time-consuming, or functionally impairing. In children and adolescents, the disorder often is accompanied by a wide range of comorbidity, including mood, anxiety, attentional, and learning difficulties, and/or tic disorder. These parameters describe the relevant areas of assessment, especially symptomatology, onset, and course, other associated psychopathology, and developmental, family, and medical history (including postinfectious onset or exacerbations). Two modalities have been systematically assessed and empirically shown to ameliorate core symptoms: cognitive-behavioral therapy (primarily exposure/response prevention) and serotonin reuptake inhibitor medication. Data regarding the indications, efficacy, and implementation of these modalities are reviewed. Because OCD frequently occurs in the context of other psychopathology and adaptive difficulties, additional individual and family psychotherapeutic, pharmacological, and educational interventions often are necessary. Treatment planning guidelines are provided.

Identification of genetic markers associated with Gilles de la Tourette syndrome in an Afrikaner population

Because gene-mapping efforts, using large kindreds and parametric methods of analysis, for the neurologic disorder Tourette syndrome have failed, efforts are being redirected toward association studies in young, genetically isolated populations. The availability of dense marker maps makes it feasible to search for association throughout the entire genome. We report the results of such a genome scan using DNA samples from Tourette patients and unaffected control subjects from the South African Afrikaner population. To optimize mapping efficiency, we chose a two-step strategy. First, we screened pools of DNA samples from both affected and control individuals, using a dense collection of 1,167 short tandem-repeat polymorphisms distributed throughout the genome. Second, we typed those markers displaying evidence of allele frequency-distribution shifts, along with additional tightly linked markers, using DNA from each affected and unaffected individual. To reduce false positives, we tested two independent groups of case and control subjects. Strongest evidence for association (P values 10-2 to 10-5) were obtained for markers within chromosomal regions encompassing D2S1790 near the chromosome 2 centromere, D6S477 on distal 6p, D8S257 on 8q, D11S933 on 11q, D14S1003 on proximal 14q, D20S1085 on distal 20q, and D21S1252 on 21q.

No association between anxiety disorders and catechol-O-methyltransferase polymorphism

Several studies have shown that the morbidity risk for anxiety disorders is increased among the relatives of patients with obsessive-compulsive disorder (OCD). Recently, it was reported that a polymorphism of the catechol-O-methyltransferase (COMT) gene is significantly associated with OCD. The purpose of this study was to determine the association, if any, between the COMT polymorphism and anxiety disorders. We undertook an association study of the COMT polymorphism in 108 patients who met DSM-IV criteria for anxiety disorders and 135 healthy controls. All subjects were unrelated Japanese. The subdiagnostic groups did not differ significantly from the control group in either the genotypic or allelic frequencies. There were no statistically significant differences between the genotype and males, females, or a family history. The mean age of onset did not significantly differ among the genotypes. Our results suggest this functional COMT polymorphism does not make an important contribution to anxiety disorders in the Japanese population.

A.E. Bennett Research Award. Toward a neurodevelopmental model of of obsessive--compulsive disorder

BACKGROUND

Neurobiological models for obsessive-compulsive disorder (OCD) have consistently implicated ventral prefrontal cortical and striatal circuits in the pathophysiology of this disorder, but typically have not utilized a developmental framework for conceptualizing the illness.

METHODS

We describe an integrated series of neurobiologic studies aimed at testing the hypothesis that neurodevelopmental abnormalities of ventral prefrontal-striatal circuits may be involved in and contribute to the etiology and presentation of the illness.

RESULTS

Using studies of oculomotor physiology, we have identified a selective deficit in neurobehavioral response suppression in OCD that may be related to failures in the developmental maturation of frontostriatal circuitry. Magnetic resonance imaging studies showed that treatment-naive pediatric OCD patients had significant volumetric abnormalities in ventral prefrontal cortical and striatal regions but no abnormalities in dorsolateral prefrontal cortex. Severity of OCD symptoms but not illness duration was related to ventral prefrontal cortical and striatal volumes.

CONCLUSIONS

Critical neurodevelopmental changes in ventral prefrontal-striatal circuitry may be associated with the initial presentation of OCD, and a developmentally mediated network dysplasia may underlie OCD. Such dysplasia in ventral prefrontal cortical circuits could manifest clinically by disrupting brain functions that mediate ongoing purposive behaviors.

Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature

OBJECTIVE

To examine the clinical correlates of obsessive-compulsive disorder (OCD) in children and adolescents.

METHOD

A systematic review of the extant literature on juvenile OCD was conducted examining age at onset, gender distribution, symptom phenomenology, psychiatric comorbidity, neurological and perinatal history, family psychiatric history, cognitive and neuropsychological profiles, and treatment and outcome in juvenile OCD subjects.

RESULTS

Juvenile OCD was associated with a unique peak of age at onset indicating a bimodal incidence of the disorder, male preponderance, a distinct pattern of comorbidity with attention-deficit/hyperactivity disorder and other developmental disorders as well as frequent associated neuropsychological deficits, an increased familial loading for OCD, and frequent absence of insight.

CONCLUSION

These findings show that juvenile OCD is associated with a unique set of correlates that appear to differ from findings reported in studies of adult OCD subjects. Although in need of confirmation, these findings suggest that juvenile OCD may be a developmental subtype of the disorder. Since juvenile OCD is likely to continue into adulthood, these findings stress the importance of considering age at onset in clinical and research studies of adults with OCD.

Comorbidity of anxiety and unipolar mood disorders

Research on relationships between anxiety and depression has proceeded at a rapid pace since the 1980s. The similarities and differences between these two conditions, as well as many of the important features of the comorbidity of these disorders, are well understood. The genotypic structure of anxiety and depression is also fairly well documented. Generalized anxiety and major depression share a common genetic diathesis, but the anxiety disorders themselves are genetically hetergeneous. Sophisticated phenotypic models have also emerged, with data converging on an integrative hierarchical model of mood and anxiety disorders in which each individual syndrome contains both a common and a unique component. Finally, considerable progress has been made in understanding cognitive aspects of these disorders. This work has focused on both the cognitive content of anxiety and depression and on the effects that anxiety and depression have on information processing for mood-congruent material.

Psychiatric genetics: search for phenotypes

Failure to obtain convincing results in psychiatric genetics can partly be attributed to the fact that progress in molecular biology and genetic epidemiology has not been followed by an equivalent development in phenotypic description. Instead of relying entirely on classical nosological approaches, we argue that identifying more homogeneous forms of diseases through a'candidate symptom approach' among affected subjects and an endophenotype approach that identifies sub-clinical traits among non-affected relatives might yield better results. Examples where these strategies have already been fruitful when applied to complex diseases are presented in this review. Focusing on vulnerability traits might stimulate the redefinition of traditional psychiatric syndromes and help to bridge the gap between clinical and experimental approaches.

5HT2C CYS23/SER23 polymorphism is not associated with obsessive-compulsive disorder

A great deal of evidence suggests that a genetic component underlies obsessive-compulsive disorder (OCD). The response to serotonergic medications and the worsening of obsessive symptoms after administration of serotonergic agonists indicate that serotonergic mechanisms are involved in OCD. We investigated the role of the Cys23Ser mutation of the 5HT2C receptor gene in the etiology of this disorder by performing an association study comparing a sample of 109 OCD patients with a sample of 107 healthy control subjects. No allelic or genotypic association of OCD with the 5HT2C receptor gene mutation was revealed in our data. We also extended the association analysis to a subsample of 39 OCD patients that had previously been submitted to a challenge test with clomipramine. In the subsample of OCD patients that received the challenge with clomipramine, no association between the 5HT2C receptor gene mutation and response to the challenge test was found. Our results exclude any specific role of the Cys23Ser mutation of 5HT2C receptor gene in the etiology of OCD: it seems probable that more complex genetic models are needed to explain the involvement of serotonergic elements in the etiology of this disorder.

Neuroimaging and neuropsychology of the striatum. Bridging basic science and clinical practice

Neuroimaging and neuropsychology are complementary disciplines that provide powerful means for assessing the structure and function of corticostriatal systems. Findings from four model basal ganglia disorders--OCD, TS, HD, and PD--are reviewed. This survey is intended as a vehicle for illustrating the breadth of current clinical and research applications, as well as the potential for future advances. The perspectives brought by neuroimaging and neuropsychology serve as a natural bridge from the basic neuroscience to the clinical practice articles in this issue.

Normative and pathological obsessive-compulsive behavior and ideation in childhood: a question of timing

This study was designed to test whether obsessive-compulsive behavior declines over development. A cross-sectional design was used on a large community sample of children. Children in grades four, six, and eight (N = 1083), 8 to 14 years of age, were administered the Maudsley Obsessive Compulsive Inventory (MOCI) and the Spielberger State Trait Anxiety Scales. Whereas the mean MOCI score was significantly lower in the eighth grade than in the sixth and fourth, there was an elevation of children with very high MOCI scores in the eighth grade. Obsessive ideas and compulsive behaviors that were common for fourth-grade children were present in only a minority of children in the eighth grade, and were associated with high levels of anxiety. No gender differences were observed for overall obsessive-compulsive behavior, but checking behavior was higher in boys, and cleaning behavior in girls. State anxiety was higher in girls than in boys, and was also higher in older than in younger children.