Early versus late onset obsessive-compulsive disorder: evidence for distinct subtypes

Developmental Considerations in Obsessive Compulsive Disorder: Comparing Pediatric and Adult-Onset Cases

There appear to be two peaks of incidence of Obsessive Compulsive Disorder (OCD), one with a pre-adolescent onset and another in early adulthood. As new cases are added, the cumulative prevalence of OCD increases, but the great majority of cases have an onset in youth. The notion that early onset OCD represents a unique developmental subtype of the disorder has been considered by many researchers based on several specific age-related factors. Ascertainment and early intervention in affected youth is critical to abbreviate the functional impairments associated with untreated illness. In this paper we review the clinical, familial and translational biomarker correlates seen in early onset OCD that support the notion of a developmental subtype and discuss implications for research and treatment aimed at this cohort. The importance of cognitive, academic and social development tasks of childhood and adolescence, illness-specific and familial factors, and immune-mediated inflammatory factors are discussed, with their implications for management.

The impact of generalized anxiety disorder in obsessive-compulsive disorder patients

Despite generalized anxiety disorder (GAD) being one of the most prevalent comorbidities in obsessive-compulsive disorder (OCD), few studies have researched its impact on the OCD phenotype. The present study investigated how the sociodemographic and clinical profile of people with OCD with comorbid GAD differs from people with OCD without comorbid GAD. We hypothesised that the phenotype of the comorbid group would be closely related to GAD, in that it would more likely be female, have an earlier age at onset of OCD, and show an increased severity of fear-related OCD symptoms (aggressive, sexual/religious, and contamination dimensions), more avoidant behaviours, greater suicidality, more severe anxiety symptoms, and increased rates of comorbid anxiety and mood disorders. The study included 867 participants with OCD, with GAD being comorbid in 33.56%. Mann-Whitney U tests, chi-square tests with continuity correction, and logistic regressions were performed. Results showed that comorbid GAD was uniquely associated with an increased number of avoidant behaviours, greater anxiety severity, panic disorder without agoraphobia, social phobia, specific phobia, and type II bipolar disorder. These results illustrate the clinical severity associated with this comorbidity and highlight markers that can aid diagnosis of GAD in OCD. Future studies should investigate whether this comorbidity has an impact on the treatment of OCD.

Effect of an Internet-Delivered Stepped-Care Program vs In-Person Cognitive Behavioral Therapy on Obsessive-Compulsive Disorder Symptoms in Children and Adolescents: A Randomized Clinical Trial

IMPORTANCE

In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment.

OBJECTIVE

To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder.

DESIGN, SETTING AND PARTICIPANTS

A randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020.

INTERVENTIONS

Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment.

MAIN OUTCOMES AND MEASURES

The primary outcome was the masked assessor-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS.

RESULTS

Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, -∞ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group).

CONCLUSIONS AND RELEVANCE

Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03263546.

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.

Smaller volume of posterior thalamic nuclei in patients with obsessive-compulsive disorder

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Thalamic subregional volumes were compared between medication-free OCD and HC groups.

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Left posterior thalamic nuclei volumes were smaller in OCD patients compared to HCs.

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The smaller thalamic subregional volumes were associated with later onset of OCD.

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Posterior thalamic nuclei volume may reflect OCD subtype related to the age of onset.

Aim

Although the thalamus is a key structure in the pathophysiology of obsessive–compulsive disorder (OCD), reports regarding thalamic volume alterations in OCD patients have been inconsistent. Because the thalamus has a complex structure with distinct functions, we investigated subregional volume changes in the thalamus and their relationship with clinical attributes in a large sample of medication-free OCD patients.

Methods

We collected T1-weighted magnetic resonance imaging data from 177 OCD patients and 152 healthy controls (HCs). Using FreeSurfer, we segmented the thalamus into 12 nuclei groups; subregional volumes were compared between groups using an analysis of covariance. The relationships between altered thalamic volumes and OC symptom severity and OCD onset age were investigated.

Results

Compared to HCs, OCD patients showed a smaller volume of the left posterior thalamic nuclei. Other thalamic subregions did not show significant group differences. There was a significant negative correlation between the volume of the left posterior thalamic nuclei and the age of OCD onset but no significant correlation with OC symptom severity.

Conclusions

This is the first study to report reduced volume of the posterior thalamic nuclei in a large sample of medication-free OCD patients. Our results suggest that the volume of posterior thalamic nuclei may reflect different pathophysiological mechanisms of OCD subtypes related to the age of onset. Additional studies with pediatric samples are required to clarify the relationship between thalamic alterations and the onset age of OCD.

The correlates of social phobia in OCD: Findings from a large clinical sample

OBJECTIVES

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder, often complicated with comorbidities. Social phobia (SP) is the most frequent co-occurring anxiety disorder in OCD, associated with increased clinical severity. However, no study had examined the relevance of interpersonal processes in this comorbidity, which are at the core of SP. This study characterized the clinical (i.e., symptom profile, age of onset, chronicity, and comorbidity), vulnerability (i.e., childhood trauma, negative life events), and interpersonal (attachment style, expressed emotion, and social support) correlates of comorbid SP in a large sample of OCD patients.

METHODS

We analysed the data of 382 OCD patients participating in the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. We examined the correlates of SP in OCD using self-report questionnaires and structured clinical interviews. In addition, data of 312 non-OCD SP patients were drawn from the Netherlands Study of Depression and Anxiety (NESDA), to compare the age of onset of SP between groups. Descriptive univariate analyses were followed by backward stepwise logistic regression analyses.

RESULTS

Social phobia was present among approximately 20% of OCD patients. Social phobia in OCD was associated with increased depression severity and decreased ratings of secure attachment style. Among OCD patients, SP had a significantly earlier age onset as compared to SP in non-OCD patients.

CONCLUSION

Social phobia in OCD might render a vulnerable clinical picture, characterized with early onset of SP symptoms, insecure attachment style, and increased depressive symptoms. Future studies should use prospective designs to better understand the nature of comorbid SP in OCD.

PRACTITIONER POINTS

Approximately one fifth of OCD patients were diagnosed with comorbid social phobia in a large representative clinical sample. OCD patients with comorbid social phobia presented with a vulnerable clinical picture, characterized with increased depression severity and decreased ratings of secure attachment style. Social phobia in OCD was associated with an earlier AOO as compared to the AOO of social phobia without OCD. The findings are limited by a cross-sectional design; thus, causality could not be assessed. Research is needed to further examine the mechanisms of comorbid social phobia in OCD.

Characteristics of patients who received deep brain stimulation in obsessive-compulsive disorder versus major depressive disorder

OBJECTIVE

Deep brain stimulation (DBS) is cleared for treatment of obsessive-compulsive disorder (OCD) but is an investigational treatment for major depressive disorder (MDD). The aim of this study is to compare the characteristics of patients who received DBS as part of standard care for OCD versus those who received it a part of a research protocol for MDD.

METHODS

The inpatient sample (N = 110) was drawn from the 2012-2014 Nationwide Inpatient Sample (NIS), and included adults with a primary discharge diagnosis of MDD (N = 50) or OCD (N = 60) and primary procedure of DBS. The study compared various patient demographics, clinical, hospital and insurance variables between the 2 groups.

RESULTS

DBS recipients with OCD were younger compared to those with MDD. DBS recipients with MDD tended to be from high-income families compared to those with OCD. DBS patients with MDD were in the South region, while DBS patients with OCD were in the Midwest and South regions of the United States (US). The study did not detect a significant difference in the length of stay and total charges among DBS recipients with OCD versus MDD.

CONCLUSIONS

DBS patients with MDD are typically older with more financial resources compared to those with OCD. DBS is federally cleared for OCD, but not for MDD, demonstrating the need for further investigation to establish DBS as a federally cleared treatment for difficult to treat MDD if well-powered randomized trials further support its use.

Dissection of the Genetic Association between Anorexia Nervosa and Obsessive-Compulsive Disorder at the Network and Cellular Levels

Anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) exhibit a high co-morbidity rate, similar symptoms, and a shared genetic basis. However, an understanding of the specific underlying mechanisms of these commonalities is currently limited. Here, we collected Genome-Wide Association Analysis results for AN and OCD, and obtained genes hit by the top SNPs as the risk genes. We then carried out an integrative coexpression network analysis to explore the convergence and divergence of AN and OCD risk genes. At first, we observed that the AN risk genes were enriched in coexpression modules that involved extracellular matrix functions and highly are expressed in the postnatal brain, limbic system, and non-neuronal cell types, while the OCD risk genes were enriched in modules of synapse function, the prenatal brain, cortex layers, and neurons. Next, by comparing the expressions from the eating disorder and OCD postmortem patient brain tissues, we observed both disorders have similar prefrontal cortex expression alterations influencing the synapse transmission, suggesting that the two diseases could have similar functional pathways. We found that the AN and OCD risk genes had distinct functional and spatiotemporal enrichment patterns but carried similar expression alterations as a disease mechanism, which may be one of the key reasons they had similar but not identical clinical phenotypes.

Very Late Onset of Obsessive-Compulsive Disorder: Case Report and Review of Published Cases in Those More Than 60 Years Old

ABSTRACT

It is widely agreed that obsessive-compulsive disorder (OCD) is less common among the elderly. However, several studies suggest that a third peak of OCD onset may occur after the age of 65. The onset of OCD in the elderly is unusual and mostly related to nonpsychiatric diagnoses. Nonetheless, some reports have documented late-onset OCD in older adults with no detection of cerebral abnormalities. Such differences in age of onset may be associated with phenotypical differences in disease severity, comorbidity, and treatment response across patients. In this report, we describe the case of late-onset OCD in an 80-year old man with no specific focal brain structural abnormality. The report could improve awareness of the disorder in the elderly and contribute to a better identification of clinical characteristics and additional risk factors of OCD.

Searching for host immune-microbiome mechanisms in obsessive-compulsive disorder: A narrative literature review and future directions

Obsessive-compulsive disorder (OCD) is disabling and often treatment-refractory. Host immunity and gut microbiota have bidirectional communication with each other and with the brain. Perturbations to this axis have been implicated in neuropsychiatric disorders, but immune-microbiome signaling in OCD is relatively underexplored. We review support for further pursuing such investigations in OCD, including: 1) gut microbiota has been associated with OCD, but causal pathogenic mechanisms remain unclear; 2) early environmental risk factors for OCD overlap with critical periods of immune-microbiome development; 3) OCD is associated with increased risk of immune-mediated disorders and changes in immune parameters, which are separately associated with the microbiome; and 4) gut microbiome manipulations in animal models are associated with changes in immunity and some obsessive-compulsive symptoms. Theoretical pathogenic mechanisms could include microbiota programming of cytokine production, promotion of expansion and trafficking of peripheral immune cells to the CNS, and regulation of microglial function. Immune-microbiome signaling in OCD requires further exploration, and may offer novel insights into pathogenic mechanisms and potential treatment targets for this disabling disorder.

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.

Higher volumes of hippocampal subfields in pediatric obsessive-compulsive disorder

Differences in hippocampus volume have been identified in adult patients with obsessive-compulsive disorder (OCD). However, the role of this limbic structure in pediatric patients is unclear. This study aimed to investigate the hippocampus and its subregions in a sample of 29 children and adolescents with OCD compared to 28 healthy controls, matched for age, sex, education, and IQ. Volumetric segmentation was performed using the Freesurfer software to calculate the volumes of the subregions that reflect the hippocampal cytoarchitecture. The volumes of three anatomic subregions (tail, body, and head) were also calculated. ANCOVA was performed to investigate differences of these volumes between patients and controls, controlling for total gray matter volume. After Bonferroni correction for multiple comparisons (p-value < 0.00556 for the body and < 0.00625 for the head structures), patients presented statistically significant larger volumes of the following structures: left subiculum body; left CA4 body; left GC-DG body; left molecular layer body; right parasubiculum; left CA4 head; left molecular layer head; right subiculum head and right molecular layer head. These enlarged volumes resulted in larger left and right whole hippocampi in patients, as well as bilateral hippocampal heads and left hippocampal body (all p-values < 0.00625). There were no associations between OCD severity and hippocampal volumes. These findings diverge from previous reports on adults and may indicate that larger hippocampal volumes could reflect an early marker of OCD, not present in adults.

Symmetry Dimension in Obsessive-Compulsive Disorder: Prevalence, Severity and Clinical Correlates

Background: Obsessive–compulsive disorder (OCD) is a very heterogeneous condition that frequently includes symptoms of the “symmetry dimension” (i.e., obsessions and/or compulsions of symmetry, ordering, repetition, and counting), along with aggressive, sexual/religious, contamination/cleaning, and hoarding dimensions. Methods: This cross-sectional study aimed to investigate the prevalence, severity, and demographic and clinical correlates of the symmetry dimension among 1001 outpatients from the Brazilian Research Consortium on Obsessive–Compulsive Spectrum Disorders. The main assessment instruments used were the Dimensional Yale–Brown Obsessive–Compulsive Scale, the Yale–Brown Obsessive–Compulsive Scale, the USP-Sensory Phenomena Scale, the Beck Depression and Anxiety Inventories, the Brown Assessment of Beliefs Scale, and the Structured Clinical Interview for DSM-IV Axis I Disorders. Chi-square tests, Fisher’s exact tests, Student’s t-tests, and Mann–Whitney tests were used in the bivariate analyses to compare patients with and without symptoms of the symmetry dimension. Odds ratios (ORs) with confidence intervals and Cohen’s D were also calculated as effect size measures. Finally, a logistic regression was performed to control for confounders. Results: The symmetry dimension was highly prevalent (86.8%) in this large clinical sample and, in the logistic regression, it remained associated with earlier onset of obsessive–compulsive symptoms, insidious onset of compulsions, more severe depressive symptoms, and presence of sensory phenomena. Conclusions: A deeper knowledge about specific OCD dimensions is essential for a better understanding and management of this complex and multifaceted disorder.

Visuomotor Activation of Inhibition-Processing in Pediatric Obsessive Compulsive Disorder: A Magnetoencephalography Study

Background: Response inhibition engages the cortico-striato-thalamo-cortical (CSTC) circuit, which has been implicated in children, and youth with obsessive compulsive disorder (OCD). This study explored whether CSTC engagement during response inhibition, measured using magnetoencephalography (MEG), differed in a sample of medication-naïve youth with OCD, compared to typically developing controls (TDC). Methods: Data was analyzed in 17 medication-naïve children and youth with OCD (11.7 ± 2.2 SD years) and 13 TDC (12.6 ± 2.2 SD years). MEG was used to localize and characterize neural activity during a Go/No-Go task. Task performance on Go/No-Go conditions and regional differences in amplitude of activity during Go and No-Go condition between OCD vs. TDC were examined using two-sample t-tests. Post-hoc analysis with Bayesian t-tests was used to estimate the certainty of outcomes. Results: No differences in Go/No-Go performance were found between OCD and TDC groups. In response to the visual cue presented during the Go condition, participants with OCD showed significantly increased amplitude of activity in the primary motor (MI) cortex compared to TDC. In addition, significantly reduced amplitude of PCu was found following successful stopping to No-Go cues in OCD vs. TDC during No-Go task performance. Bayesian t-tests indicated high probability and large effect sizes for the differences in MI and PCu amplitude found between groups. Conclusion: Our preliminary study in a small medication-naïve sample extends previous work indicating intact response inhibition in pediatric OCD. While altered neural response in the current study was found during response inhibition performance in OCD, differences localized to regions outside of the CSTC. Our findings suggest that additional imaging research in medication-naïve samples is needed to clarify regional differences associated with OCD vs. influenced by medication effects, and suggest that MEG may be sensitive to detecting such differences.

Harmonizing the Neurobiology and Treatment of Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a common, chronic, and oftentimes disabling disorder. The only established first-line treatments for OCD are exposure and response prevention, and serotonin reuptake inhibitor medications (SRIs). However, a subset of patients fails to respond to either modality, and few experience complete remission. Beyond SRI monotherapy, antipsychotic augmentation is the only medication approach for OCD with substantial empirical support. Our incomplete understanding of the neurobiology of OCD has hampered efforts to develop new treatments or enhance extant interventions. This review focuses on several promising areas of research that may help elucidate the pathophysiology of OCD and advance treatment. Multiple studies support a significant genetic contribution to OCD, but pinpointing the specific genetic determinants requires additional investigation. The preferential efficacy of SRIs in OCD has neither led to discovery of serotonergic abnormalities in OCD nor to development of new serotonergic medications for OCD. Several lines of preclinical and clinical evidence suggest dysfunction of the glutamatergic system in OCD, prompting testing of several promising glutamate modulating agents. Functional imaging studies in OCD show consistent evidence for increased activity in brain regions that form a cortico-striato-thalamo-cortical (CSTC) loop. Neuromodulation treatments with either noninvasive devices (e.g., transcranial magnetic stimulation) or invasive procedures (e.g., deep brain stimulation) provide further support for the CSTC model of OCD. A common substrate for various interventions (whether drug, behavioral, or device) may be modulation (at different nodes or connections) of the CSTC circuit that mediates the symptoms of OCD.

Differentiation of 2 Obsessive-Compulsive Disorder Subgroups with Regard to Demographic and Phenomenological Characteristics Combining Multiple Correspondence and Latent Class Analysis

INTRODUCTION

Classic factor analysis of obsessive-compulsive disorder (OCD) dimensions and attempts to identify valid subgroups have not yet produced definitive conclusions.

OBJECTIVE AND METHODS

This study aims to examine possible homogeneous subgrouping of demographic and phenomenological characteristics in 134 treatment-seeking OCD patients. A combination of multiple correspondence analysis (MCA) and latent class analysis (LCA) was used.

RESULTS

MCA showed 2 distinct subgroups of OCD patients and LCA confirmed this result by a two-class solution. Both analyses demonstrated (a) a clear subgroup of female patients with washing compulsions, obsessions related to contamination, and late age of onset and (b) a subgroup comprised mostly of male patients with earlier onset of OCD, checking rituals, and doubts or aggressive obsessions. Mental, ordering, hoarding compulsions, religious, or sexual obsessions and images appeared exclusively in this subgroup.

CONCLUSIONS

Using 2 different analytic methods, we confirmed at least 2 subgroups in a clinical sample of Greek OCD patients. Future research combining dimensional and latent approaches could facilitate our understanding of the heterogeneous phenotype of OCD.

On the Development of OCD

OCD most often arises before adulthood with adolescence being a particularly vulnerable period. This is also a time when both brain and cognition undergo fundamental developmental change and reorganisation. However, the neurocognitive mechanisms that drive the emergence of OCD during development are still largely unknown. In this chapter, I review the relatively sparse literature on the developmental aspects of OCD and I discuss the symptomatic, cognitive and neural patterns in OCD and the developing mind. I highlight how we need to understand the emergence of cognitive impairments and neural alteration in a developmental context if we want to understand more about the mechanisms that give rise to OCD. Moreover, I outline how we best approach this challenge to overcome the current limitations in research.

Tourette syndrome research highlights from 2019

This is the sixth yearly article in the Tourette Syndrome Research Highlights series, summarizing research from 2019 relevant to Tourette syndrome and other tic disorders. The highlights from 2020 is being drafted on the Authorea online authoring platform; readers are encouraged to add references or give feedback on our selections comments feature on this page. After the calendar year ends, this article is submitted as the annual update for the Tics collection F1000Research.

The immediate effect of COVID-19 pandemic on children and adolescents with obsessive compulsive disorder

BACKGROUND

Obsessive compulsive disorder (OCD) is a distressing psychiatric disorder. Traumas may trigger or aggravate OCD symptoms. COVID-19 pandemic has coursed a global crisis and has been associated with onset of psychiatric disorders in adults. Little is known about children/adolescents with OCD. The present study aimed to examine how children/adolescents with OCD react towards COVID-19 crisis.

METHODS

A questionnaire was distributed to two separate groups of children/adolescents. One group was a clinical group newly diagnosed at a specialized OCD clinic. All the children/adolescents had a current close contact to a therapist or doctor. The other group was a survey group identified through the Danish OCD Association. Most of these children/adolescents were diagnosed years ago, and their primary treatment was completed. For the clinical group, data from patient files was available.

RESULTS

In both groups, but most pronounced in the survey group, participants experienced a worsening of their OCD, anxiety, and depressive symptoms. The aggravation of OCD correlated with the worsening of anxiety, depressive symptoms, and the extent of avoidance behavior. For both groups, OCD aggressive symptoms predicted a significant worsening. Poor baseline insight showed a trend to predict a symptom worsening. The worsening was most pronounced in children with early age of onset and a family history of attention deficit hyperactivity disorder.

CONCLUSIONS

To our knowledge, this is one of the first studies examining the effect of COVID-19 in children/adolescents with OCD. The effect was examined in two separate populations strengthening the findings. The study points towards an influence of the OCD phenotype, baseline insight suggesting a continued vulnerability, and a family history of psychiatric disorders.

TRIAL REGISTRATION

The study is approved by the Danish Data Protection Agency (1-16-02-147-20) registered 1st of April 2020. Oral and written information was given to parents and patients and written consent from patients over 15 years and parents were received.

The association of HTR2A polymorphisms with obsessive-compulsive disorder and its subtypes: A meta-analysis

BACKGROUND

Genetic risk factors that contribute to obsessive-compulsive disorder (OCD) have yet to be elucidated. Historically, serotonergic dysfunction has been implicated. Evidence from the literature points towards the serotonin receptor 2A gene (HTR2A) as a primary candidate. Our meta-analysis investigated whether polymorphisms in HTR2A are associated with OCD or its subtypes, based on sex and age of onset.

METHODS

Studies employing case-control or family-based designs were systematically searched, and those meeting eligibility underwent quality assessment, resulting in 18 studies. A random-effects meta-analysis using standard inverse-variance weighting to compute odds ratio (OR) was conducted. To examine sensitivity, results were also obtained using a more conservative statistical method.

RESULTS

Three HTR2A variants were identified: T102C, G-1438A, and C516T. T102C and G-1438A were analyzed together due to strong linkage disequilibrium, where the 102T allele co-occurs with -1438A allele. Results reported as OR [95%CI] showed that the T/A allele were significantly associated with OCD, 1.14 [1.01, 1.29]. After stratification, results remained significant for females, 1.20 [1.00, 1.45], and early-onset OCD, 1.27 [1.02, 1.58], but not males, 1.06 [0.91, 1.23]. No associations were found for late-onset OCD, 0.98 [0.70, 1.37], or C516T, 1.22 [0.14, 10.37], but conclusions cannot be drawn from two studies.

LIMITATIONS

Associations no longer reached significance with the conservative statistical approach. HTR2A alone cannot explain OCD complexity and limited samples reporting genetic data according to subtypes.

CONCLUSIONS

These results suggest a possible association of HTR2A polymorphisms with OCD, but further investigations considering sex and age of onset with larger samples is needed.

The polygenic risk for obsessive-compulsive disorder is associated with the personality trait harm avoidance

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a complex psychiatric disorder with a substantial genetic contribution. While the specific variants underlying OCD's heritability are still unknown, findings from genome-wide association studies (GWAS) corroborate the importance of common SNPs explaining the phenotypic variance in OCD. Investigating associations between the genetic liability for OCD, as reflected by a polygenic risk score (PRS), and potential endophenotypes of the disorder, such as the personality trait harm avoidance, may aid the understanding of functional pathways from genes to diagnostic phenotypes.

METHODS

We derived PRS for OCD at several P-value thresholds based on the latest Psychiatric Genomics Consortium OCD GWAS (2688 cases, 7037 controls) in an independent sample of OCD patients (n = 180), their unaffected first-degree relatives (n = 108) and healthy controls (n = 200). Using linear regression, we tested whether these PRS are associated with the personality trait harm avoidance.

RESULTS

Results showed that OCD PRS significantly predicted OCD status, with patients having the highest scores and relatives having intermediate scores. Furthermore, the genetic risk for OCD was associated with harm avoidance across the entire sample, and among OCD patients. As indicated by mediation analyses, harm avoidance mediated the association between the OCD PRS and OCD caseness. These results were observed at multiple P-value thresholds and persisted after the exclusion of patients with a current comorbid major depressive or anxiety disorder.

CONCLUSION

Our findings support the polygenic nature of OCD and further validate harm avoidance as a candidate endophenotype and diathesis of OCD.

Towards a computational psychiatry of juvenile obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) most often emerges during adolescence, but we know little about the aberrant neural and cognitive developmental mechanisms that underlie its emergence during this critical developmental period. To move towards a computational psychiatry of juvenile OCD, we review studies on the computational, neuropsychological and neural alterations in juvenile OCD and link these findings to the adult OCD and cognitive neuroscience literature. We find consistent difficulties in tasks entailing complex decision making and set shifting, but limited evidence in other areas that are altered in adult OCD, such as habit and confidence formation. Based on these findings, we establish a neurocomputational framework that illustrates how cognition can go awry and lead to symptoms of juvenile OCD. We link these possible aberrant neural processes to neuroimaging findings in juvenile OCD and show that juvenile OCD is mainly characterised by disruptions of complex reasoning systems.

Neural mechanisms of persistent avoidance in OCD: A novel avoidance devaluation study

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We investigated goal-directed processing in OCD and healthy controls using a rule-based devaluation paradigm.

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OCD patients with longer illness duration showed poorer goal-directed performance.

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Neural differences were observed in orbitofrontal cortex, premotor cortex, inferior frontal gyrus and the caudate, relating to group and individual differences in devaluation performance.

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Together the findings identify neural correlates of goal-directed deficits in OCD, and support a dual-process model of actions and habits.

Obsessive-Compulsive Disorder (OCD) is characterized by repetitive avoidance behavior which is distressing and associated with marked impairment of everyday life. Recently, paradigms have been designed to explore the hypothesis that avoidance behavior in OCD is consistent with a formal conception of habit. Such studies have involved a devaluation paradigm, in which the value of a previously rewarded cue is altered so that avoidance is no longer necessary. We employed a rule-based avoidance task which included a devaluation, examining behavioral performance on the task and their neural correlates using functional MRI in groups of participants with OCD (n = 44) and healthy control participants (n = 46). Neuroimaging data were analyzed using a general linear model (GLM), modelling valued, devalued and control cues, as well as feedback events. First, while no overall effect of OCD was seen on devaluation performance, patients with longer illness duration showed poorer devaluation performance (χ² = 13.84, p < 0.001). Reduced devaluation was related to impaired learning on the overtraining phase of the task, and to enhanced feedback activation in the caudate and parietal lobe during within-scanner retraining (T = 5.52, p_FWE = 0.003), across all participants. Second, a significant interaction effect was observed in the premotor cortex (F = 29.03, p_FWE = 0.007) coupled to the devalued cue. Activations were divergent in participants with OCD (lower activation) and healthy controls (higher activation) who did not change responding to the devalued cue following devaluation, and intermediate in participants who did change responding (T = 5.39, p_FWE = 0.003). Finally, consistent with previous work, medial orbitofrontal cortex activation coupled to valued cues was reduced in OCD compared to controls (T = 3.49, p_FWE = 0.009). The findings are discussed in terms of a prediction error-based model of goal-directed and habitual control: specifically, how goal-directed control might be diminished in OCD in favor of habits. They suggest that illness duration might be significant determinant of variation in impaired goal-directed learning in OCD, and be a factor relevant for understanding discrepancies across studies. Overall, the study shows the potential of conceptual replication attempts to provide complementary insights into compulsive behavior and its associated neural circuitry in OCD.

The definition and measurement of heterogeneity

Heterogeneity is an important concept in psychiatric research and science more broadly. It negatively impacts effect size estimates under case-control paradigms, and it exposes important flaws in our existing categorical nosology. Yet, our field has no precise definition of heterogeneity proper. We tend to quantify heterogeneity by measuring associated correlates such as entropy or variance: practices which are akin to accepting the radius of a sphere as a measure of its volume. Under a definition of heterogeneity as the degree to which a system deviates from perfect conformity, this paper argues that its proper measure roughly corresponds to the size of a system's event/sample space, and has units known as numbers equivalent. We arrive at this conclusion through focused review of more than 100 years of (re)discoveries of indices by ecologists, economists, statistical physicists, and others. In parallel, we review psychiatric approaches for quantifying heterogeneity, including but not limited to studies of symptom heterogeneity, microbiome biodiversity, cluster-counting, and time-series analyses. We argue that using numbers equivalent heterogeneity measures could improve the interpretability and synthesis of psychiatric research on heterogeneity. However, significant limitations must be overcome for these measures-largely developed for economic and ecological research-to be useful in modern translational psychiatric science.

Cognitive performance in children and adolescents at high-risk for obsessive-compulsive disorder

BACKGROUND

Cognitive performance has been studied in adults with obsessive-compulsive symptoms (OCS) and in adult relatives of patients with obsessive-compulsive disorder (OCD) Meanwhile, few studies have been conducted with children under the same conditions. This study compared the neurocognitive domains previously associated with dysfunction in OCD, especially visuoconstructive ability, visuospatial memory, executive functions, and intelligence, in children and adolescents at high risk (HR) for OCD (n = 18) and non-OCD controls (NOC) (n = 31).

METHODS

For the HR group, we considered the first-degree relatives of patients with OCD that present OCS, but do not meet diagnostic criteria for OCD. Psychiatric diagnosis was assessed by experienced clinicians using the Structured Clinical Interview for DSM-IV and OCS severity was measured by the Yale-Brown Obsessive-Compulsive Scale. Neurocognitive assessment was performed with a comprehensive neuropsychological battery. Performance on the cognitive domains was compared between groups using Multivariate Analysis of Variance, whereas performance on the neuropsychological variables was compared between groups using independent t-tests in a cognitive subdomain analysis.

RESULTS

The cognitive domain analysis revealed a trend towards significance for impairments in the motor and processing speed domain (p = 0.019; F = 3.12) in the HR group. Moreover, the cognitive subdomain analysis identified a statistically significant underperformance in spatial working memory in the HR group when compared to the NOC group (p = 0.005; t = - 2.94), and a trend towards significance for impairments in non-verbal memory and visuoconstructive tasks in the HR group.

CONCLUSIONS

Our results suggest impairments in spatial working memory and motor and processing speed in a non-clinical sample of HR participants. Considering the preliminary nature of our findings, further studies investigating these neurocognitive domains as potential predictors of pediatric OCD are warranted.

Obsessive compulsive disorder in very young children - a case series from a specialized outpatient clinic

BACKGROUND

Paediatric obsessive-compulsive disorder (OCD) is a chronic condition often associated with severe disruptions of family functioning, impairment of peer relationships and academic performance. Mean age of onset of juvenile OCD is 10.3 years; however, reports on young children with OCD show that the disorder can manifest itself at an earlier age. Both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD. There seems to be difficulty for health professionals to recognize and diagnose OCD in young children appropriately, which in turn may prolong the interval between help seeking and receiving an adequate diagnosis and treatment. The objective of this study is to enhance knowledge about the clinical presentation, diagnosis and possible treatment of OCD in very young children.

CASE PRESENTATION

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old). At the moment of first presentation, all children were so severely impaired that attendance of compulsory Kindergarten was uncertain. Parents were deeply involved in accommodating their child's rituals. Because of the children's young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. Parents were asked to bring video tapes of critical situations that were watched together. They were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level / class.

CONCLUSIONS

Disseminating knowledge about the clinical presentation, diagnosis and treatment of early OCD may shorten the long delay between first OCD symptoms and disease-specific treatment that is reported as main predictor for persistent OCD.

The Centrality of Doubting and Checking in the Network Structure of Obsessive-Compulsive Symptom Dimensions in Youth

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a heterogeneous condition with well-established symptom dimensions across the lifespan. The objective of the present study was to use network analysis to investigate the internal structure of these dimensions in unselected schoolchildren and in children with OCD.

METHOD

We estimated the network structure of OCD symptom dimensions in 6,991 schoolchildren and 704 children diagnosed with OCD from 18 sites across 6 countries. All participants completed the Obsessive-Compulsive Inventory-Child Version.

RESULTS

In both the school-based and clinic-based samples, the OCD dimensions formed an interconnected network with doubting/checking emerging as a highly central node, that is, having strong connections to other symptom dimensions in the network. The centrality of the doubting/checking dimension was consistent across countries, sexes, age groups, clinical status, and tic disorder comorbidity. Network differences were observed for age and sex in the school-based but not the clinic-based samples.

CONCLUSION

The centrality of doubting/checking in the network structure of childhood OCD adds to classic and recent conceptualizations of the disorder in which the important role of doubt in disorder severity and maintenance is highlighted. The present results suggest that doubting/checking is a potentially important target for further research into the etiology and treatment of childhood OCD.

Greater history of traumatic event exposure and PTSD associated with comorbid body dysmorphic disorder in a large OCD cohort

The present study examined whether or not there are differential rates of traumatic event exposure and presumed Post-Traumatic Stress Disorder (PTSD) between individuals with OCD without comorbid presumed BDD (OCD-Non-BDD) and individuals with OCD with comorbid presumed BDD (OCD+BDD) within a large cohort of OCD participants (N = 605). Individuals in the OCD+BDD group had significantly higher rates of endorsing at least one lifetime traumatic event and presumed PTSD than individuals with OCD-Non-BDD. Additionally, individuals in the OCD+BDD group with comorbid presumed PTSD had significantly higher rates of major depressive disorder (MDD) and presumed panic disorder (PD). A logistic regression analysis revealed that presumed PTSD significantly predicted the presence of BDD symptoms among individuals who experienced at least one lifetime traumatic event in our sample. These findings suggest that individuals in the OCD+BDD group were more likely to have experienced a traumatic event in their lives, to experience presumed PTSD, and to have MDD and presumed PD than individuals in the OCD-Non-BDD group. Clinical implications and possible mechanistic pathways from trauma exposure to OCD and BDD symptomatology are discussed.

Neural bases of the clinical and neurocognitive differences between earlyand late-onset obsessive–compulsive disorder

BACKGROUND

Using biological evidence to define subtypes within the heterogeneous population with obsessive–compulsive disorder (OCD) is important for improving treatment response. Based on age at onset, OCD can be clustered into 2 groups, each of which is more homogeneous with respect to clinical and cognitive phenotype. However, the neural bases for these phenotypic differences need to be established to construct evidence-based homogeneous groups.

METHODS

We compared brain volumes, clinical symptoms, and neurocognitive function for 49 people with early-onset OCD and 52 with late-onset OCD (participants in both groups were unmedicated or drug-naïve), and 103 healthy controls. We performed regression analyses to examine group × volume interaction effects on clinical outcomes or neurocognitive function in people with OCD.

RESULTS

We observed larger volumes in the precentral, orbitofrontal, middle frontal, and middle temporal gyri in people with early-onset OCD compared to those with late-onset OCD. Poorer visuospatial construction in early-onset OCD was correlated with a larger left middle frontal gyrus volume. Impaired visuospatial memory in people with early-onset OCD and cognitive inflexibility in people with late-onset OCD were correlated with increased and decreased volume in the left middle frontal gyrus, respectively. We found group × volume interactions for obsessive–compulsive symptom scores in the left middle temporal gyrus of people with OCD.

LIMITATIONS

Although we divided the subtypes using the commonly adopted criterion of age at onset, this criterion is still somewhat controversial.

CONCLUSION

We provided the neural bases for clinical and neurocognitive differences to demonstrate that biological evidence underlies the distinctions between early- and late-onset OCD. This study suggests that different treatment options should be considered for the OCD subtypes, because their neurobiology differs and is related to distinct phenotypic profiles.

Implementation of internet-delivered cognitive behaviour therapy for pediatric obsessive-compulsive disorder: Lessons from clinics in Sweden, United Kingdom and Australia

Obsessive-compulsive disorder (OCD) can be successfully treated with cognitive behaviour therapy (CBT). However, as few patients have access to CBT, there is a strong push to develop and evaluate scalable and cost-effective internet-delivered interventions. BIP OCD is a therapist-guided online CBT intervention for pediatric OCD that has shown promise in trials conducted at a single site in Stockholm, Sweden. In this study, we evaluated if BIP OCD is an acceptable, feasible, and effective treatment in other countries and clinical contexts. Thirty-one patients were recruited at three different sites; a specialist OCD clinic in Gothenburg (Sweden), a specialist OCD clinic in London (United Kingdom), and a university-based clinic in Brisbane (Australia). Acceptability and feasibility measures included treatment adherence and feedback from therapists. Clinician assessments were conducted at baseline, post-treatment, and 3-month follow-up. The average module completion for the participants was 8.1/12 (SD = 3.2) and the majority of patients completed the BIP OCD treatment (100% in Gothenburg, and 55.6% in both London and Brisbane). Pooling data from the three sites, the within-group effect sizes from baseline to post-treatment on the Children's Yale-Brown Obsessive-Compulsive Scale were in the expected range (bootstrapped Cohen's d = 1.78; 95% CI 1.18-2.39), with an additional symptom reduction to the 3-month follow-up (bootstrapped Cohen's d = 0.27; 95% CI 0.02-0.51). Participating therapists identified both advantages and difficulties supporting patients in this digital format. The results of this study suggest that the treatment effects obtained in the original BIP OCD trials can be generalized to other clinical contexts nationally and internationally. Lessons learned provide important information for successful implementation of BIP OCD in regular healthcare contexts.

Structural and functional MRI of altered brain development in a novel adolescent rat model of quinpirole-induced compulsive checking behavior

Obsessive-compulsive disorder (OCD) is increasingly considered to be a neurodevelopmental disorder. However, despite insights in neural substrates of OCD in adults, less is known about mechanisms underlying compulsivity during brain development in children and adolescents. Therefore, we developed an adolescent rat model of compulsive checking behavior and investigated developmental changes in structural and functional measures in the frontostriatal circuitry. Five-weeks old Sprague Dawley rats were subcutaneously injected with quinpirole (n = 21) or saline (n = 20) twice a week for five weeks. Each injection was followed by placement in the middle of an open field table, and compulsive behavior was quantified as repeated checking behavior. Anatomical, resting-state functional and diffusion MRI at 4.7T were conducted before the first and after the last quinpirole/saline injection to measure regional volumes, functional connectivity and structural integrity in the brain, respectively. After consecutive quinpirole injections, adolescent rats demonstrated clear checking behavior and repeated travelling between two open-field zones. MRI measurements revealed an increase of regional volumes within the frontostriatal circuits and an increase in fractional anisotropy (FA) in white matter areas during maturation in both experimental groups. Quinpirole-injected rats showed a larger developmental increase in FA values in the internal capsule and forceps minor compared to control rats. Our study points toward a link between development of compulsive behavior and altered white matter maturation in quinpirole-injected adolescent rats, in line with observations in pediatric patients with compulsive phenotypes. This novel animal model provides opportunities to investigate novel treatments and underlying mechanisms for patients with early-onset OCD specifically.

The speed of progression towards obsessive-compulsive disorder

BACKGROUND

There is current interest in the elaboration of early intervention programs for obsessive-compulsive disorder (OCD). To this end, it is important to investigate the speed of progression from subthreshold symptoms to diagnosable OCD. In this study, we have retrospectively investigated the speed of progression towards full-blown OCD and sociodemographic and clinical factors associated with a faster transition.

METHODS

Patients enrolled in the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (N = 954) were interviewed with a comprehensive assessment battery that included the interval (in years) between the onset of subthreshold OCD symptoms and the onset of full-blown OCD.

RESULTS

It took a median of 7 years (interquartile range: 2-13 years) for subthreshold symptoms to convert to diagnosable OCD. Faster OCD onset was associated with lower age at the time of assessment, male gender, being in new romantic states as precipitants for compulsions, greater severity of sexual/religious symptoms and lower severity of hoarding and YBOCS compulsions severity scores, greater rates of generalized anxiety disorder and agoraphobia without panic disorder, and negative family history for OCD.

LIMITATIONS

The retrospective design of this study allowed for susceptibility to memory bias about age at onset of OCD symptoms. We were unable to capture progressions taking less than 12 months.

CONCLUSIONS

We could identify a specific phenotype that was more likely to escalate rapidly to clinical levels within this large clinical sample. This phenomenon may be particularly relevant in the context of selecting individuals for early intervention initiatives in situations when resources are scarce.

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.

Validity and clinical utility of the obsessive compulsive inventory - child version: further evaluation in clinical samples

BACKGROUND

Obsessive-compulsive disorder (OCD) is a clinically heterogeneous disorder. Currently, the Obsessive Compulsive Inventory-Child Version (OCI-CV) is the only self-report measure that fully captures this symptom heterogeneity in children and adolescents. The psychometric properties of the OCI-CV are promising but evaluations in large clinical samples are few. Further, no studies have examined whether the measure is valid in both younger and older children with OCD and whether scores on the measure are elevated in youths with OCD compared to youths with other mental disorders.

METHODS

To address these gaps in the literature, we investigated the psychometric properties and validity of a Swedish version of the OCI-CV in a large clinical sample of youth aged 6-18 years with OCD (n = 434), anxiety disorders (n = 84), and chronic tic disorders (n = 45).

RESULTS

Internal consistency coefficients at the total scale and subscale level were consistent with the English original and in the acceptable range. Confirmatory factor analyses revealed an adequate fit for the original six-factor structure in both younger and older children with OCD. Correlations between total scores on the OCI-CV and the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) were small at pre-treatment (r = 0.19) but large at post-treatment (r = 0.62). Youth with OCD scored higher than those with anxiety and chronic tic disorders, and the OCI-CV was sensitive to symptom change for youth undergoing treatment for OCD.

CONCLUSIONS

This Swedish version of the OCI-CV appears to be a valid and reliable measure of the OCD symptom dimensions across age groups and has good clinical utility.

Treatment Gains Are Sustainable in Pediatric Obsessive-Compulsive Disorder: Three-Year Follow-Up From the NordLOTS

OBJECTIVE

This study evaluated the long-term outcomes of a stepped care treatment for pediatric obsessive-compulsive disorder (OCD) and investigated whether response to first-step cognitive-behavioral therapy (CBT) is an important indicator of 3-year outcomes.

METHOD

This study is a part of the Nordic Long-term OCD Treatment Study (NordLOTS), in which 269 children and adolescents were treated with CBT. Nonresponders to CBT were randomized to extended treatment with continued CBT or pharmacotherapy with sertraline. Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) scores no higher than 15 and no higher than 10 were defined as treatment response and remission, respectively. Participants were assessed 2 and 3 years after first-step CBT. Linear mixed-effects models were used to analyze the outcomes.

RESULTS

Intent-to-treat analyses showed a significant decrease in CY-BOCS total score from baseline (24.6) to 3-year follow-up (5.0; p = .001), with a mean decrease of 5.9 from after treatment to 3-year follow-up. Three years after treatment, 90% (n = 242) of participants were rated as responders and 73% were in clinical remission. The duration of treatment did not influence the symptom level at 3-year follow-up (p = .998) and no significant difference was found (p = .169) between the extended treatment conditions.

CONCLUSION

The results suggest that evidence-based treatment for pediatric OCD has long-term positive effects, whether a first step of manual-based CBT or extended treatment with CBT or sertraline. The improvements were maintained, and the symptoms decreased further during follow-up and were, after 3 years, similarly independent of treatment duration and form of extended treatment.

CLINICAL TRIAL REGISTRATION INFORMATION

Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com; ISRCTN66385119.

Sexual dysfunction and satisfaction in obsessive compulsive disorder: protocol for a systematic review and meta-analysis

BACKGROUND

Obsessive compulsive disorder (OCD) is a chronic mental health condition recognized as one of the most serious causes of disability and impaired quality of life. In the literature, there is no review about sexual dysfunction and satisfaction in OCD. The current paper presents the protocol for a systematic review and meta-analysis aimed to summarize data (1) comparing the presence of sexual dysfunction between groups with OCD and non-clinical groups, (2) investigating prevalence of each one of the sexual dysfunctions in patients with OCD, (3) comparing risk for sexual dysfunction in OCD groups with the prevalence in control groups, (4) comparing sexual satisfaction between OCD groups and non-clinical groups, and (5) investigating moderators of sexual dysfunction in OCD groups as compared with control groups. Gender, age, marital status, OCD symptom severity and subtypes, comorbid depressive disorders, comorbid anxiety disorders, concurrent psychiatric medications, comorbid general medical disease, and study quality will be investigated as moderators.

METHODS

The protocol is reported according to PRISMA-P guidelines. The search will be conducted by independent reviewers during the second week of December 2019 by using electronic databases (Scopus, PubMed, EMBASE, PsycINFO, CINAHL, and the Cochrane Library), by contacting the authors of the included studies to identify further data, by examining the references of the included studies, and by handsearching conference proceedings and theses/doctoral dissertations. The study quality will be independently evaluated using the Newcastle-Ottawa Quality Assessment Scale. Random-effect meta-analyses will be computed. If there is insufficient data for a specific outcome, only a systematic review will be performed.

DISCUSSION

This review may support clinical practice highlighting the importance of the assessment of sexuality in patients with OCD and suggesting the use of therapeutic strategies dedicated to sexuality in this clinical population with the aim of improving patients' quality of life. Potential limitations will regard the heterogeneity of the studies in terms of the instruments used to assess sexual dysfunction/satisfaction and of the definitions used to conceptualize sexual dysfunction.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42019132264.

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

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

Caudate volume differences among treatment responders, non-responders and controls in children with obsessive-compulsive disorder

Treatment response in obsessive-compulsive disorder (OCD) is heterogeneous and the neurobiological underpinnings of such variability are unknown. To investigate this issue, we looked for differences in brain structures possibly associated with treatment response in children with OCD. 29 children with OCD (7-17 years) and 28 age-matched controls underwent structural magnetic resonance imaging. Patients then received treatment with fluoxetine or group cognitive-behavioral therapy during 14 weeks, and were classified as treatment responders or non-responders. The caudate nucleus, thalamus and orbitofrontal cortex were selected a priori, according to previous evidence of their association with OCD and its treatment. Gray matter (GM) volume comparisons between responders, non-responders and controls were performed, controlling for total GM volume. 17 patients were classified as responders. Differences among responders, non-responders and controls were found in both caudate nuclei (both p-values = 0.041), but after Bonferroni correction for multiple comparisons, these findings were non-significant. However, after excluding the effect of an outlier, findings were significant for the right caudate (p = 0.004). Pairwise comparisons showed larger caudate GM volume in responders versus non-responders and controls, bilaterally. The right caudate accounted for 20.2% of the variance in Y-BOCS changes after treatment in a linear regression model, with a positive correlation (p = 0.016). We present a possible neural substrate for treatment response in pediatric OCD, which is in line with previous evidence regarding the caudate nucleus. Considering the limitations, further research is needed to replicate this finding and elucidate the heterogeneity of treatment response in children with OCD (National Clinical Trials Registration Number: NCT01148316).

Characteristic alteration of subcortical nuclei shape in medication-free patients with obsessive-compulsive disorder

•

The study established a subregional-level anatomic alteration profile of subcortical structures in patients with obsessive-compulsive disorder (OCD).

•

The OCD patients showed an expansion of the lateral amygdala (right hemisphere) and right pallidum.

•

Deformities in pallidum were associated with illness duration and symptom severity of OCD.

•

Gender difference in OCD-related morphometric alterations were found in amygdala and caudate.

Background

Subcortical nuclei are important components in the pathology model of obsessive-compulsive disorder (OCD), and subregions of these structures subserve different functions that may distinctively contribute to OCD symptoms. Exploration of the subregional-level profile of structural abnormalities of these nuclei is needed to develop a better understanding of the neural mechanism of OCD.

Methods

A total of 83 medication-free, non-comorbid OCD patients and 93 age- and sex-matched healthy controls were recruited, and high-resolution T1-weighted MR images were obtained for all participants. The volume and shape of the subcortical nuclei (including the nucleus accumbens, amygdala, caudate, pallidum, putamen and thalamus) were quantified and compared with an automated parcellation approach and vertex-wise shape analysis using FSL-FIRST software. Sex differences in these measurements were also explored with an exploratory subgroup analysis.

Results

Volumetric analysis showed no significant differences between patients and healthy control subjects. Relative to healthy control subjects, the OCD patients showed an expansion of the lateral amygdala (right hemisphere) and right pallidum. These deformities were associated with illness duration and symptom severity of OCD. Exploratory subgroup analysis by sex revealed amygdala deformity in male patients and caudate deformity in female patients.

Conclusions

The lateral amygdala and the dorsal pallidum were associated with OCD. Neuroanatomic evidence of sexual dimorphism was also found in OCD. Our study not only provides deeper insight into how these structures contribute to OCD symptoms by revealing these subregional-level deformities but also suggests that gender effects may be important in OCD studies.

Obsessive-compulsive disorder and growth factors: A comparative review

The goal of this article is to clarify the role of various growth factors in the establishment and progression of obsessive-compulsive disorder (OCD). OCD is a chronic mental disorder with recurrent intrusive thoughts and/or repetitive compulsive behaviors that increase during stressful periods. Growth and neurotrophic factors may be contributing factors in the pathophysiology of OCD. Many of them are synthesized and released within the central nervous system and act as trophic agents in neurons; some of them are involved in brain growth, development, neurogenesis, myelination and plasticity, while others take part in the protection of the nervous system following brain injuries. This paper attempts to identify all articles investigating the relationship between OCD and neurotrophic and growth factors, in both animal and human studies, with a focus on adult brain studies. Based on the PubMed and Scopus and Science Direct search tools, the available articles and studies are reviewed. Out of 230 records in total, the ones related to our review topic were taken into account to further understand the pathophysiological mechanism(s) of OCD, providing methods to improve its symptoms via the modification of neurotrophins and growth factor imbalances.

Frontostriatal functional connectivity correlates with repetitive behaviour across autism spectrum disorder and obsessive-compulsive disorder

BACKGROUND

Autism spectrum disorder (ASD) and obsessive-compulsive disorder (OCD) are neurodevelopmental disorders with considerable overlap in terms of their defining symptoms of compulsivity/repetitive behaviour. Little is known about the extent to which ASD and OCD have common versus distinct neural correlates of compulsivity. Previous research points to potentially common dysfunction in frontostriatal connectivity, but direct comparisons in one study are lacking. Here, we assessed frontostriatal resting-state functional connectivity in youth with ASD or OCD, and healthy controls. In addition, we applied a cross-disorder approach to examine whether repetitive behaviour across ASD and OCD has common neural substrates.

METHODS

A sample of 78 children and adolescents aged 8-16 years was used (ASD n = 24; OCD n = 25; healthy controls n = 29), originating from the multicentre study COMPULS. We tested whether diagnostic group, repetitive behaviour (measured with the Repetitive Behavior Scale-Revised) or their interaction was associated with resting-state functional connectivity of striatal seed regions.

RESULTS

No diagnosis-specific differences were detected. The cross-disorder analysis, on the other hand, showed that increased functional connectivity between the left nucleus accumbens (NAcc) and a cluster in the right premotor cortex/middle frontal gyrus was related to more severe symptoms of repetitive behaviour.

CONCLUSIONS

We demonstrate the fruitfulness of applying a cross-disorder approach to investigate the neural underpinnings of compulsivity/repetitive behaviour, by revealing a shared alteration in functional connectivity in ASD and OCD. We argue that this alteration might reflect aberrant reward or motivational processing of the NAcc with excessive connectivity to the premotor cortex implementing learned action patterns.

Altered frequencies of Th17 and Treg cells in children and adolescents with obsessive-compulsive disorder

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a debilitating neuropsychiatric disorder with an etiopathophysiology that seems to include immune alterations. Previous studies have suggested that variations in the levels of circulating T cell subpopulations may be involved in psychiatric diseases. However, the role of these cells in OCD remains unexplored. Hence, the present study aimed to examine the levels of T helper 1 (Th1), Th2, Th17 and regulatory T (Treg) cells in patients with early-onset OCD and healthy controls.

METHODS

The assessment was performed in 99 children and adolescents with OCD and 46 control subjects. The percentages of circulating Th1, Th2, Th17 and Treg cells were evaluated using flow cytometry.

RESULTS

OCD patients had significantly higher levels of Th17 cells and lower percentages of Treg cells than healthy controls (p = 0.001 and p = 0.005, respectively). Furthermore, levels of Th17 cells progressively increased with the duration (p = 0.005) and severity of OCD (p = 0.008), whereas the percentages of Treg cells significantly declined with the duration of the disorder (p = 1.8 × 10^-5).

CONCLUSIONS

These results provide more evidence of the involvement of immune dysregulation, specifically an imbalance in the levels of circulating T helper and regulatory T cells, in the pathophysiology of early-onset OCD.

Association study of the PDE4D gene and obsessive-compulsive disorder in a Chinese Han population

OBJECTIVE

Multiple evidence suggests an involvement of the PDE4D in mental disorders. Therefore we investigate the association between obsessive-compulsive disorder and a polymorphism of the single nucleotide polymorphisms of PDE4D gene in the Chinese Han population.

METHODS

We genotyped and performed a case-control association analysis of the PDE4D polymorphism rs1838733 in 400 obsessive-compulsive disorder patients and 459 healthy control subjects.

RESULTS

The site conformed to Hardy-Weinberg (P > 0.05), three genotypes (AA, AG, GG) of PDE4D gene rs1838733 were detected. We demonstrated three principal results. First, there were no significant differences between the case and health controls in the genotype and allele at rs1838733 (P > 0.05). Second, there were no significant differences in the allele and genotype frequency between different genders obsessive-compulsive disorder (P > 0.05). Third, the genotype of single nucleotide polymorphism rs1838733 was associated with late-onset obsessive-compulsive disorder and female late-onset obsessive-compulsive disorder (P < 0.05).

CONCLUSION

The present study is the first to verify the associations of single nucleotide polymorphisms rs1838733 of the PDE4D gene with obsessive-compulsive disorder in a Chinese Han population. We found the genotype of single nucleotide polymorphism rs1838733 was associated with the occurrence of late-onset obsessive-compulsive disorder and female late-onset obsessive-compulsive disorder. Therefore, PDE4D may play a role in the pathogenesis of obsessive-compulsive disorder and may become a potential target for obsessive-compulsive disorder treatment in future research. Further studies should verify the current findings.

A comparison of cluster and factor analytic techniques for identifying symptom-based dimensions of obsessive-compulsive disorder

A growing body of literature suggests that obsessive-compulsive disorder (OCD) is a heterogeneous condition. The studies investigating symptom dimensions have been limited by numerous methodological differences and sample characteristics. The purpose of this study was to compare the two most commonly applied statistical techniques used in addressing this question in the same large cohort of individuals with OCD. Both cluster analysis and factor analysis were used to examine OCD symptom data as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) Symptom Checklist for 355 individuals with a primary diagnosis of OCD. The factor analysis revealed a three-factor model best described as symmetry obsessions/ordering compulsions, contamination obsessions/cleaning compulsions and aggressive obsessions/checking compulsions. In contrast, the cluster analysis yielded a stable four-cluster solution best described as symmetry obsessions/ordering compulsions, contamination obsessions/cleaning compulsions, aggressive-somatic-religious obsessions/checking compulsions and a mixed symptom profile. Although there was overlap in the models resulting from these two statistical approaches, cluster analysis better captured the dimensional nature of OCD by demonstrating the prevalence of symptom categories in each subgroup. Though both analyses are capable of providing similar outputs, the validity of these results is limited given the input of a priori symptom categories from the Y-BOCS.

Interoceptive deficits in patients with obsessive-compulsive disorder in the time course of cognitive-behavioral therapy

Interoception is impaired in different psychiatric disorders and is also associated with emotions. Only one study could show a higher interoceptive accuracy (IAcc) in patients with obsessive-compulsive disorder (OCD). Based on the predictive coding system we assume contrary results, indicating a decreased IAcc in patients with OCD. So far, there is no study investigating the effect of cognitive-behavioral therapy on IAcc in patients with OCD. Therefore, we hypothesize that patients with OCD improve their IAcc during the time course of therapy compared to healthy controls. Twenty-six patients with OCD from the Psychosomatic Clinic in Windach were examined in the time course of cognitive-behavioral therapy. They were compared to 26 matched healthy controls. IAcc via the heartbeat perception task as well as questionnaire data (OCD-, depression- and anxiety symptoms) were assessed. Results showed that IAcc, OCD-, depression- and anxiety symptoms were attenuated in patients with OCD. Patients recovered in the time course of therapy regarding OCD-, depression- and anxiety symptoms. Interoceptive deficits did not change in the time course of cognitive-behavioral therapy. We demonstrated that IAcc is affected in patients with OCD and this deficit does not change during the time course of a standardized therapy. Future studies should investigate, whether an inaccuracy in perceiving one's bodily signals constitutes a risk factor for relapse. Further, it could be examined if IAcc can be increased via self- and body focus interventions in patients with OCD.

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

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

An examination of orbitofrontal sulcogyral morphology in obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) has been consistently associated with structural and functional alteration of the orbitofrontal cortex (OFC) and its subcortical connections. In exploring these alterations, a neurodevelopmental basis to OCD has been suggested. While some studies have examined outcomes of early cortical maturation processes, such as global cortical thickness and gyrification, no work has specifically examined the OFC. Within the OFC, three types of sulcogyral patterns have been identified as a result of variance in cortical folding. The distribution of these patterns has been found to differ in patients of various neuropsychiatric disorders relative to the general population, however no study has yet investigated this distribution in individuals with OCD. Eighty OCD patients and 78 healthy controls were evaluated using magnetic resonance imaging, with identification of the sulcogyral pattern based on the method of Chiavaras and Petrides (2000). While gross changes in OFC sulcogyral patterning did not distinguish OCD patients from healthy controls, expression of both the Type II and Type III patterns was significantly associated with increased OCD illness severity. This finding indicates that early neurodevelopmental factors may influence illness severity.