A family study of obsessive-compulsive disorder

Corpus callosal morphology in treatment-naive pediatric obsessive compulsive disorder

1. Abnormalities in association circuits have been described in Obsessive Compulsive Disorder (OCD) and may reflect neurodevelopmental abnormalities. Primary and association cortices are topographically mapped in the corpus callosum (CC). The authors hypothesized alterations in CC subdivisions that connect association, but not primary cortices in pediatric OCD. The authors predicted that normal age-related increases in CC area would be absent in OCD. 2. The authors compared the midsagittal magnetic resonance images of 21 psychotropic-naive, nondepressed OCD patients, 7.2-17.7 years, and 21 case-matched healthy controls. Total CC area as well as that of the anterior, middle and posterior genu, anterior and posterior bodies, isthmus, and the anterior, middle and the posterior splenii were measured. 3. All of the CC regions except the isthmus were significantly larger in OCD patients than in controls. CC area correlated significantly with OCD symptom severity but not illness duration. The age-related increase in CC size seen in normal subjects was absent in OCD patients. 4. These findings support theories of abnormal association cortex development in OCD but also suggest possible abnormalities of other primary cortical regions as well.

Rates for tic disorders and obsessive compulsive symptomatology in families of children and adolescents with Gilles de la Tourette syndrome

The aim of this study was to assess rates for tic disorders and obsessive compulsive psychopathology in families of children and adolescents with Gilles de la Tourette syndrome (TS). Diagnoses were based on the DSM III-R criteria. Obsessive compulsive psychopathology, that did not fulfill the criteria for obsessive compulsive disorder (OCD) was additionally assessed and termed obsessive compulsive symptoms (OCS). The authors hypothesized that comorbid OCD or OCS in TS patients predicts a higher familial loading with obsessive compulsive symptomatology. The study cohort included 87 patients with TS who were evaluated clinically and with the use of a structured psychiatric interview. All available parents (152/174; 87%), several sibs (49/93; 53%) and some second degree relatives (27/659; 4.1%) were also interviewed. For other first and second degree relatives the family history method was used. Familial rates for TS were clearly elevated. Rates for chronic tic disorders (CT) were considerably lower than in previous studies. Additionally, tic disorders not otherwise specified (TDNOS) were diagnosed in a substantial number of first degree (15/267; 5.6%) and second degree relatives (36/659; 5.5%). OCD in parents (4/174; 2.3%) did not occur in an above baseline rate. However, both OCD (14/87; 16.1%) and OCS (15/87; 17.2%) were frequently associated with TS in index patients. Interestingly, 10 of 16 fathers with OCS also had a tic disorder. Obsessive compulsive psychopathology clustered in families. It is concluded that genetic studies in TS could profit from adhering to a conservative diagnostic approach to both tic disorders and OCD. The familial clustering of OCS/OCD in conjunction with the elevated paternal rate for the co-occurrence of tic disorders and OCS might indicate heterogeneity of TS.

Opportunities for psychiatry from genetic findings

BACKGROUND

The opportunities for psychiatry deriving from available or likely genetic advances are reviewed.

METHOD

Clinical implications are considered in the context of both the misconceptions and benefits associated with relevant genetic findings.

RESULTS

Misconceptions include that: heritability estimates have a 'true' fixed value; a high heritability means that environmental interventions will be ineffective; a high heritability within groups means that differences between groups will also be due to genes; genetic effects are determinative; 'genetic' means single abnormal genes; genes associated with disease must be bad and justify eugenic measures; gene therapy will be widely applicable; and genetic screening of the general population will be useful. The benefits include demonstrations that: both genes and environment have an ubiquitous influence; some prevailing diagnostic assumptions are mistaken; genes influence development; the effects of nature and nurture are not separate; and environmental effects tend to be person-specific. The potential value of molecular genetics lies in elucidation of causal processes as they apply to both brain systems and nature-nurture interplay; improving diagnosis and genetic counselling; and the development of improved pharmacological interventions.

CONCLUSION

Advances in genetics will make a major impact on clinical psychiatry, and should bring practical benefits for both prevention and treatment.

Obsessive compulsive symptoms in Gilles de la Tourette syndrome and obsessive compulsive disorder: differences by diagnosis and family history

The distribution of obsessive compulsive symptoms was compared in 16 individuals with primary obsessive compulsive disorder (OCD) and 16 individuals with Gilles de la Tourette syndrome (GTS) and associated obsessive compulsive behaviors (OCB). The two groups showed significant differences in the distribution of OC symptomatology. Furthermore, those OCD probands who shared a similar symptom profile with GTS individuals all had a positive family history of OCD. All of the other OCD probands were isolated cases. Implications of this finding on the etiology and pathogenesis of the two disorders are discussed.

At risk for anxiety: I. Psychopathology in the offspring of anxious parents

OBJECTIVE AND METHOD

Children of parents with anxiety disorders, depressive disorders, mixed anxiety/depressive disorders, and no psychiatric disorder were assessed with semistructured interviews to determine rates of overall psychopathology and to determine specifically the presence of anxiety disorders.

RESULTS

Children of the three "high-risk" groups were significantly more likely to have a diagnosable disorder (including anxiety disorders) than offspring of normal parents, but there were no differences among the children from the three parental diagnostic groups. However, when examined specifically for anxiety disorders, offspring of anxious parents were significantly more likely to have only anxiety disorders. Offspring of depressed or mixed anxious/depressed parents had a broader range of disorders and more comorbid disorders. Family socioeconomic status was related to the probability that a child would have a disorder.

CONCLUSIONS

Anxiety disorders are common among offspring of anxious and depressed parents. However, when a parent has depression, children exhibit a broader range of psychopathology than when a parent has an anxiety disorder alone.

Tourette syndrome. Medical and surgical treatment of obsessive-compulsive disorder

Current treatment outcomes for obsessive-compulsive disorder patients are far better than in past decades, but variability in treatment response remains. Most obsessive-compulsive disorder patients, but not all, respond to antidepressant agents with prominent serotonin uptake blocking properties. Because clomipramine's usefulness is limited by side effects which often accompany its use, a considerable degree of attention has shifted to selective serotonin reuptake inhibitors. A number of studies have also provided evidence for the effectiveness of medication other than those mainly involving serotonergic function, either as augmenting agents or for comorbid disorders. Neurosurgery may be useful for highly selected subjects.

Genotype determining low catechol-O-methyltransferase activity as a risk factor for obsessive-compulsive disorder

In the present study, we address the role of the gene for catechol-O-methyltransferase (COMT), a key modulator of dopaminergic and noradrenergic neurotransmission, in the genetic predisposition to obsessive-compulsive disorder (OCD). We show that a common functional allele of this gene, which results in a 3- to 4-fold reduction in enzyme activity, is significantly associated in a recessive manner with susceptibility to OCD, particularly in males. This association is further supported by psychiatric evaluation of patients who carry microdeletions encompassing the comt gene. The mechanism underlying this sex-selective association remains to be defined and may include a sexual dimorphism in COMT activity, although close linkage with a nearby disease susceptibility locus cannot be excluded at this point.

Phenomenological differences appearing with repetitive behaviours in obsessive-compulsive disorder and Gilles de la Tourette's syndrome

BACKGROUND

Obsessive-compulsive disorder (OCD) is heterogeneous, with some forms related to Gilles de la Tourette's syndrome (GTS). This is a phenomenological study designed to investigate the nature of these possible OCD subtypes and the relationship between OCD and GTS.

METHOD

We evaluated 20 adult outpatients with OCD, 21 with GTS, and 20 with OCD plus GTS using a semi-structured interview designed to assess cognitive, sensory and autonomic phenomena preceding repetitive behaviours.

RESULTS

More cognitions and autonomic anxiety and fewer sensory phenomena were reported in OCD than in GTS. Like the GTS group, the OCD plus GTS group reported more sensory phenomena and fewer cognitions than the OCD group.

CONCLUSIONS

The presence or absence of cognitions, sensory phenomena, and autonomic anxiety distinguishes repetitive behaviours in patients with OCD from those with OCD plus GTS, and GTS. These subjective experiences may be useful in subtyping OCD and may represent valid predictors of prognosis and treatment response.

A putative poststreptococcal case of OCD with chronic tic disorder, not otherwise specified

A 12-year-old girl presented with an atypical, recurrent, increasingly treatment-resistant case of obsessive-compulsive disorder and chronic tic disorder associated with profound separation anxiety, learning difficulty, and intermittent upper respiratory symptoms. In addition to detailed reviews of history and findings from many clinical caretakers from the prior 7 years, current pediatric, psychiatric, neuropsychological, neuroimaging, and clinical laboratory data were also available. Treatment options were considered from multiple perspectives: psychoanalytically oriented psychotherapy, conventional pharmacotherapy, family interventions, cognitive-behavioral therapy, and learning-supportive strategies. Psychological, neuropsychiatric, and neuroimmunological formulations of etiology were considered. Subsequent treatments included supportive psychotherapy, neuroleptic augmentation of selective serotonin reuptake inhibitors, prophylactic penicillin, and a course of six sessions of plasmapheresis over a 2-week period. The case raises questions for ongoing consideration that juxtapose dynamic, neuropsychiatric, and neuroimmunological perspectives.

Platelet serotonin transporter in children and adolescents with obsessive-compulsive disorder or Tourette's syndrome

Previous studies of serotonin transporter protein (5HTPR) indexed in platelets by 3H-imipramine demonstrate reduction in children with comorbid obsessive-compulsive disorder (OCD) and Tourette's syndrome (TS).

OBJECTIVE

To use the 5HTPR selective ligand 3H-paroxetine and homogeneous diagnostic groups to reevaluate these findings.

METHOD

Platelet Kinetic binding parameters were evaluated using standard techniques from medication-free child and adolescent patients with OCD (n = 18), with TS (n = 10), and normal controls (n = 19).

RESULTS

Baseline binding capacity (Bmax) was significantly reduced in patients with OCD (1,342 +/- 952 fmol/mg; protein p < .01) compared with normal controls (2,486 +/- 1309 fmol/mg) and TS patients (2,420 +/- 1,069 fmol/mg; p < .05). Among OCD patients who were subsequently treated on an open-label basis with selective serotonin reuptake inhibitor (SSRI), Bmax values at baseline differentiated between responders (1,718 +/- 1,041 fmol/mg) and nonresponders (802 +/- 713 fmol/mg protein; p < .05). Response to SSRI was greatest in patients with a positive family history of OCD. Among responders (n = 10), baseline Yale-Brown Obsessive Compulsive Scale and Bmax were positively correlated (r = .76, p = .01), as was Clinical Global Impression (r = .67, p = .03).

CONCLUSIONS

Platelet 5HTPR capacity (Bmax) is reduced in children and adolescents with OCD, but not in those with TS. 5HTPR may be an indirect measure of basal serotonergic tone.

Comorbidity of juvenile obsessive-compulsive disorder with disruptive behavior disorders

OBJECTIVE

To examine the full spectrum of psychiatric comorbidity in juvenile obsessive-compulsive disorder (OCD) in a naturalistic manner when no exclusionary criteria are used for sample selection.

METHOD

Consecutive referrals to a specialized pediatric OCD clinic were evaluated by means of structured diagnostic interviews and rating scales. No exclusionary criteria were used for sample selection. Findings were compared with those of previously published reports of juvenile OCD.

RESULTS

Compared with previous studies, our sample of juveniles with OCD had high rates of comorbidity not only with tic, mood, and anxiety disorders but also with disruptive behavior disorders.

CONCLUSIONS

Our findings indicate that in the naturalistic setting, juvenile OCD is heavily comorbid with both internalizing and externalizing disorders. The presence of such a complex comorbid state has important clinical and research implications and stresses the relevance of limiting exclusionary criteria in studies of juvenile OCD.

Obsessions and compulsions in Prader-Willi syndrome

This study examines the nature, severity and correlates of non-food obsessions and compulsions in 91 people with Prader-Willi syndrome (PWS) aged 5-47 years (mean age = 19 years). Prominent symptoms, seen in 37-58% of the sample, included hoarding; ordering and arranging; concerns with symmetry and exactness; rewriting; and needs to tell, know or ask. A remarkably high proportion of participants had moderate to severe symptom severity ratings; 64% showed symptom-related distress, and 80% showed symptom-related adaptive impairment. The study also compared obsessive-compulsive symptoms in 43 adults with PWS to age- and sex-matched non-retarded adults with obsessive-compulsive disorder (OCD). The PWS and OCD groups showed similar levels of symptom severity and numbers of compulsions; they also showed more areas of symptom similarity than difference. Increased risks of OCD in persons with PWS are strongly indicated. Implications are discussed for pharmacotherapy, behavioral therapy and family support.

Obsessive-compulsive disorder in children and adolescents: a review of the past 10 years

OBJECTIVE

To review the literature on pediatric obsessive-compulsive disorder (OCD) from the perspective of information relevant to American Board of Psychiatry and Neurology recertification in child and adolescent psychiatry.

METHOD

The clinical and research literatures were systematically searched or articles that address the diagnosis and treatment of pediatric OCD.

RESULTS

Drawing from the literature and their own clinical experience, the authors note that (1) OCD is a common neuropsychiatric disorder; (2) comorbidity is common, especially with tic, attention-deficit, anxiety, and affective disorders; (3) OCD following group A beta-hemolytic streptococcal infection may define an autoimmune sub-grouping calling for immunomodulatory treatments; and (4) OCD-specific cognitive-behavioral psychotherapy and pharmacotherapy with a serotonin reuptake inhibitor define the psychotherapeutic and pharmacotherapeutic treatments of choice, respectively.

CONCLUSION

Child psychiatrists should be familiar with the differential diagnosis and treatment of OCD.

Intact coding region of the serotonin transporter gene in obsessive-compulsive disorder

Epidemiologic studies indicate that obsessive-compulsive disorder is genetically transmitted in some families, although no genetic abnormalities have been identified in individuals with this disorder. The selective response of obsessive-compulsive disorder to treatment with agents which block serotonin reuptake suggests the gene coding for the serotonin transporter as a candidate gene. The primary structure of the serotonin-transporter coding region was sequenced in 22 patients with obsessive-compulsive disorder, using direct PCR sequencing of cDNA synthesized from platelet serotonin-transporter mRNA. No variations in amino-acid sequence were found among the obsessive-compulsive disorder patients or healthy controls. These results do not support a role for alteration in the primary structure of the coding region of the serotonin-transporter gene in the pathogenesis of obsessive-compulsive disorder.

Obsessive-compulsive characteristics: from symptoms to syndrome

OBJECTIVE

To assess the distribution and severity of obsessions and compulsions in a nonclinical adolescent population.

METHOD

During preinduction military screening, 861 sixteen-year-old Israelis completed a questionnaire regarding the lifetime presence of eight obsessive-compulsive (OC) symptoms and three severity measures. The presence or absence of obsessive-compulsive disorder (OCD) or subclinical OCD was ascertained by an independent interview.

RESULTS

Although only 8.0% and 6.3% of respondents reported disturbing and intrusive thoughts, respectively, 27% to 72% of subjects endorsed the six remaining OCD symptoms. Twenty percent of subjects regarded the symptoms they endorsed as senseless and 3.5% found them disturbing; 8% reported spending more than an hour daily on symptoms. OCD and subclinical OCD cases differed significantly from non-OCD cases, but not from each other, in distress and mean number of symptoms. Although the distribution of nine of the items differed for noncases, compared with OCD and subclinical OCD cases, the distributions for all items overlapped markedly across the three groups.

CONCLUSIONS

OC phenomena appear to be on a continuum with few symptoms and minimal severity at one end and many symptoms and severe impairment on the other. Defining optimal cutoff points for distinguishing between psychiatric disorder and OC phenomena that are common in the general population remains an open question.

Assessing risk for the Tourette spectrum of disorders among first-degree relatives of probands with Tourette syndrome

Previous studies have indicated that genetic investigations of Tourette syndrome (TS) should focus on a phenotype that includes not only TS, but chronic tics (CT) and obsessive-compulsive disorder (OCD) as well. These studies have shown that sex may play a role in determining which of the disorders in the TS spectrum is expressed in a susceptible individual. Female relatives of TS probands far more often express OCD, while male relatives more often express TS or CT. Data from the Yale Family Study of TS were used to model risk to first-degree relatives of probands with TS for a variety of TS disease phenotypes. Risk to relatives was modeled using multivariate Cox regression analysis, a method appropriate for assessing risk when there is correlation among disease onsets. This is the first known application of this method to family data. The study identified two proband characteristics that increase the risk for disease onset among both male and female relatives for all TS spectrum disorders, lending credence to the hypothesis that TS spectrum disorders share a common etiology. These were a relatively younger age-at-onset, and no experience of simple motor tics. The predictive ability of two additional factors varied by both sex and disease phenotype. These characteristics, i.e., proband onset with compulsive tics, and proband onset with range, appear to increase risk primarily in female relatives, and for the OCD part of the spectrum.

Contemporary approaches to pharmacotherapy in Tourette's syndrome and obsessive-compulsive disorder

TOPIC

Contemporary approaches used in the pharmacological treatment of children and adolescents with Tourette's syndrome or obsessive-compulsive disorder.

BACKGROUND

Tourette's syndrome (TS) and obsessive-compulsive disorder (OCD) now are recognized as more common than previously believed. Moreover, there is accumulating evidence that these two disorders may share common neurobiological underpinnings. Nonetheless, pharmacologic approaches to treatment may be quite different.

SOURCES

Using recently published information, this paper reviews current treatment for TS and OCD.

CONCLUSION

There have been major advances in the understanding of the pathophysiology of OCD and TS. These advances provides guidance for the treatment of children and adolescents with these disorders. However, additional research is needed to refine current treatment approaches.

Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics

OBJECTIVE

DSM-IV defines trichotillomania as an impulse disorder with rising tension followed by relief or gratification. Alternative formulations view trichotillomania as an internalizing disorder or variant of obsessive-compulsive disorder (OCD). This study addresses this controversy by examining the phenomenology, comorbidity, and family genetics of childhood trichotillomania.

METHOD

Fifteen chronic hair-pullers (13 girls), aged 9 through 17 years (mean 12.3 +/- 2.3 years), were systematically assessed. Child Behavior Checklist (CBCL) profiles of the hair-pulling girls were compared with those of 37 girls from a general child psychiatry clinic and of 15 girls with OCD.

RESULTS

All the hair-pullers had impairing cosmetic disfigurement; however, 4 subjects (26.7%) denied rising tension or relief. All three groups had comparable global CBCL problem scores. The CBCL symptom profile of the hair-pulling group differed significantly from that of the general clinic group but strongly resembled that of the OCD group. The hair-pulling group, however, had few obsessions or compulsions aside from hair-pulling; two (13%) subjects met criteria for OCD. As a group, hair-pulling subjects had substantial comorbid psychopathology, and a parental history of tics, habits, or obsessive-compulsive symptoms was common.

CONCLUSIONS

These findings lend only partial support to the notion of trichotillomania as an OCD-spectrum disorder. Rising tension followed by relief or gratification may not be an appropriate diagnostic criterion for trichotillomania.