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

Obsessive-Compulsive Disorder: Puzzles and Prospects

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

Early intervention for obsessive compulsive disorder: An expert consensus statement

Obsessive-compulsive disorder (OCD) is common, emerges early in life and tends to run a chronic, impairing course. Despite the availability of effective treatments, the duration of untreated illness (DUI) is high (up to around 10 years in adults) and is associated with considerable suffering for the individual and their families. This consensus statement represents the views of an international group of expert clinicians, including child and adult psychiatrists, psychologists and neuroscientists, working both in high and low and middle income countries, as well as those with the experience of living with OCD. The statement draws together evidence from epidemiological, clinical, health economic and brain imaging studies documenting the negative impact associated with treatment delay on clinical outcomes, and supporting the importance of early clinical intervention. It draws parallels between OCD and other disorders for which early intervention is recognized as beneficial, such as psychotic disorders and impulsive-compulsive disorders associated with problematic usage of the Internet, for which early intervention may prevent the development of later addictive disorders. It also generates new heuristics for exploring the brain-based mechanisms moderating the 'toxic' effect of an extended DUI in OCD. The statement concludes that there is a global unmet need for early intervention services for OC related disorders to reduce the unnecessary suffering and costly disability associated with under-treatment. New clinical staging models for OCD that may be used to facilitate primary, secondary and tertiary prevention within this context are proposed.

Genetic Associations of Serotoninergic and GABAergic Genes in an Extended Collection of Early-Onset Obsessive-Compulsive Disorder Trios

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a debilitating neuropsychiatric disorder whose etiology includes important genetic contributions. In a previous transmission disequilibrium study in which 75 complete trios were included, single-nucleotide polymorphisms (SNPs) in serotoninergic and GABAergic genes were associated with early-onset OCD. Our aim was to assess those findings in an extended collection of early-onset OCD trios.

METHODS

A transmission disequilibrium test for SNPs in HTR1B (rs2000292), SLC18A1 (rs6586896), GAD1 (rs3791860), and GAD2 (rs8190748) was performed in a total of 101 early-onset OCD trios, from which 26 trios were newly recruited for the purpose of the present analysis.

RESULTS

All the SNPs were overtransmitted from parents to OCD probands (p < 0.012, significant after Bonferroni correction).

CONCLUSIONS

These results are consistent with the previous findings and constitute more evidence of the role of genetic factors related to serotoninergic and GABAergic pathways in the pathophysiology of early-onset OCD.

Insomnia in pediatric obsessive-compulsive disorder: prevalence and association with multimodal treatment outcomes in a naturalistic clinical setting

OBJECTIVE

Little is known about the prevalence and impact of insomnia on clinical outcomes in youth with obsessive-compulsive disorder (OCD). This study aimed to investigate this subject.

PATIENTS/METHODS

A total of 193 patients from a specialist pediatric OCD clinic completed a range of diagnostic and clinical measures, including the Insomnia Severity Index (ISI). Patients scoring above a previously validated cut-off on the ISI (score ≥9) were compared to the rest of the sample on sociodemographic and clinical characteristics. In a subsample of 143 (from the initial 193) patients who were treated at the clinic, a mixed-model analysis of variance (ANOVA) was used to compare the outcomes of multimodal OCD treatment in the insomnia (N = 60) vs no insomnia (N = 83) groups. The primary outcome measure was the clinician-administered Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at post-treatment and at three-month follow-up.

RESULTS

The psychometric properties of the ISI in our sample were excellent. At baseline, 42% (81/193) of the sample scored above the ISI cut-off for clinical insomnia. These participants had significantly higher OCD severity, higher rates of psychiatric comorbidities, more severe depressive symptoms, poorer general functioning, and were more likely to take sleep medications, compared to those who scored below the ISI cut-off. In the treated subsample, while the insomnia group remained more severely affected through the three time-points, both groups improved similarly on the CY-BOCS at post-treatment and at three-month follow-up.

CONCLUSION

Insomnia is relatively common in pediatric OCD and is associated with more severe psychopathology. However, with adequate multimodal, evidence-based treatment, these patients can improve as much as those without insomnia.

Genetic variability in the serotoninergic system and age of onset in anorexia nervosa and obsessive-compulsive disorder

The age of onset of some psychiatric disorders may have etiopathogenic and clinical effects and may influence outcome. Following on from previous work by our group where we showed that early onset anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) shared a common genetic background, the aim of the present study is to assess genetic pleiotropy related to the serotonergic system (SLC6A4, 5HTR2A, 5HTR2C, TPH2, SLC18A1), in a common phenotype such as very-early age of onset. One hundred and sixteen adolescents diagnosed with AN and 74 adolescents diagnosed with OCD participated in the present study. We confirmed the existence of a genetic overlap between OCD and AN. Specifically, we described genetic pleiotropy for age at onset across these disorders, associating two SNPs (rs6311, rs4942587) of the HTR2A with the very-early onset phenotype.

Diagnostic Issues in Early-Onset Obsessive-Compulsive Disorder and their Treatment Implications

BACKGROUND

The lifespan approach and recent shift in the conceptualization of Obsessive- Compulsive Disorder (OCD) promoted by the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM5) along with novel insights into the pathogenesis of this heterogeneous disorder are driving the development of new outcome measures and new treatments for a disease that, on the other hand, is characterized by high rates of refractoriness.

OBJECTIVE AND METHODS

The aim of this review is to provide a discussion of the translational evidence about Early Onset OCD (EO) in compliance with a neurodevelopmental and RdoC perspective.

RESULTS AND CONCLUSION

EO might be considered the neurodevelopmental subtype of OCD. Indeed there is evidence that different clusters of symptoms and dimensions at an early stage predict different trajectories in phenotype and that distinct neurocircuit pathways underpin the progression of the disorder. Despite the development of high refractoriness in the course of the disorder, evidence suggests that EO may be particularly treatment responsive in the early stages, thus showing the need for early recognition and additional recovery oriented studies in this subgroup. Consistent with the neurodevelopmental perspective, immunity and glutamate neurotransmission are emerging as novel pathways for parsing out the neurobiology of OCD, the EO form, in particular, supporting the implementation of new multisystemic models of the OCD phenotype. Brain connectivity patterns, immune and microbiome profiles are standing out as promising areas for biomarkers with the potential for targeted personalized therapies in EO.

Prevalence and heritability of body dysmorphic symptoms in adolescents and young adults: a population-based nationwide twin study

BACKGROUND

Body dysmorphic disorder (BDD) usually begins during adolescence but little is known about the prevalence, etiology, and patterns of comorbidity in this age group. We investigated the prevalence of BDD symptoms in adolescents and young adults. We also report on the relative importance of genetic and environmental influences on BDD symptoms, and the risk for co-existing psychopathology.

METHODS

Prevalence of BDD symptoms was determined by a validated cut-off on the Dysmorphic Concerns Questionnaire (DCQ) in three population-based twin cohorts at ages 15 (n = 6968), 18 (n = 3738), and 20-28 (n = 4671). Heritability analysis was performed using univariate model-fitting for the DCQ. The risk for co-existing psychopathology was expressed as odds ratios (OR).

RESULTS

The prevalence of clinically significant BDD symptoms was estimated to be between 1 and 2% in the different cohorts, with a significantly higher prevalence in females (1.3-3.3%) than in males (0.2-0.6%). The heritability of body dysmorphic concerns was estimated to be 49% (95% CI 38-54%) at age 15, 39% (95% CI 30-46) at age 18, and 37% (95% CI 29-42) at ages 20-28, with the remaining variance being due to non-shared environment. ORs for co-existing neuropsychiatric and alcohol-related problems ranged from 2.3 to 13.2.

CONCLUSIONS

Clinically significant BDD symptoms are relatively common in adolescence and young adulthood, particularly in females. The low occurrence of BDD symptoms in adolescent boys may indicate sex differences in age of onset and/or etiological mechanisms. BDD symptoms are moderately heritable in young people and associated with an increased risk for co-existing neuropsychiatric and alcohol-related problems.

A latent profile analysis of age of onset in pathological skin picking

BACKGROUND

Pathological Skin Picking (PSP) may begin at any age, but the most common age of onset is during adolescence. Age of onset is a potentially useful clinical marker to delineate subtypes of psychiatric disorders. The present study sought to examine empirically defined age of onset groups in adults with PSP and assess whether groups differed on clinical characteristics.

METHOD

Participants were 701 adult respondents to an internet survey, who endorsed recurrent skin picking with tissue damage and impairment. Latent profile analysis (LPA) was conducted to identify subtypes of PSP based on age of onset. Then subgroups were compared on demographic and clinical characteristics.

RESULTS

The best fitting LPA model was a two-class solution comprised of a large group with average age of onset in adolescence (n = 650; 92.9% of the sample; Mean age of onset = 13.6 years) and a small group with average onset in middle adulthood (n = 50; 7.1% of the sample; Mean age of onset = 42.8 years). Relative to the early onset group, the late onset group reported significantly less focused picking, less skin picking-related impairment, lower rates of co-occurring body-focused repetitive behaviors, and trends towards reduced family history of PSP. Individuals in the late onset group also reported increased rates of comorbid depression, anxiety and posttraumatic stress disorder, and were more likely to report that initial picking onset seemed related to or followed depression/anxiety and physical illness.

CONCLUSION

Findings suggest the presence of two distinct PSP age of onset groups: (1) an early onset group with average onset in adolescence, clinical characteristics suggestive of greater picking-related burden and familiality, and a profile more representative of the general PSP population; and (2) a late onset group with average onset in middle adulthood, increased co-occurring affective and trauma conditions, and initial onset associated with or following other mental health and physical problems. Future replication is needed to assess the validity and clinical utility of these subgroups.

Genetic susceptibility in obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is present in 1.5-2.5% of the population and can result in substantial lifelong disability. It is characterized by intrusive thoughts, sensations, and urges and by repetitive behaviors that are difficult to control despite, in most cases, preserved insight as to their excessive or irrational nature. The causes and underlying pathophysiology of OCD are not well understood, which has limited the development of new treatments and interventions. Despite evidence for a substantial genetic contribution to disease risk, identification and replication of genetic variants associated with OCD have been challenging. Decades of candidate gene association studies have provided little insight. They are now being supplanted by modern genomewide approaches to discover both common and rare sequence and structural variants. Studies to date suggest potential novel therapeutic avenues such as modulators of glutamatergic and immune pathways; however, individual genetic findings are not yet statistically robust or replicated. Further efforts are clearly needed to identify specific risk variants and to confirm vulnerable pathways by studying much larger cohorts of patients with comprehensive variant discovery approaches. Mouse knockout models have already made notable inroads into our understanding of OCD pathology; their utility will only increase as specific risk alleles are identified.

Internet-delivered cognitive behavioural therapy for young children with obsessive-compulsive disorder: development and initial evaluation of the BIP OCD Junior programme

BACKGROUND

Internet-delivered cognitive behavioural therapy (ICBT) is a promising approach for increasing access to evidence-based treatments.

AIMS

To develop and evaluate the feasibility and preliminary efficacy of an ICBT programme for young children with obsessive-compulsive disorder (OCD), named BIP OCD Junior.

METHOD

Eleven children aged 7-11 years were enrolled in a 12-week open trial of parent- and therapist-guided ICBT for OCD. The primary outcome measure was the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS).

RESULTS

There was a significant improvement in OCD symptoms post-treatment, with a large within-group effect size on the CY-BOCS (Cohen's d = 1.86, 95% CI 0.83 to 2.86). Results were maintained at 3-month follow-up. Both children and parents rated the treatment as credible and were highly satisfied with the intervention.

CONCLUSIONS

BIP OCD Junior is a feasible and credible treatment option for young children with OCD. Randomised controlled trials are needed to further establish its efficacy and cost-effectiveness relative to gold standard face-to-face CBT.

DECLARATION OF INTEREST

None.

Factor analysis of symptom profile in early onset and late onset OCD

This study aimed to assess the factor structure of early and late onset OCD. Additionally, cluster analysis was conducted in the same sample to assess the applicability of the factors. 345 participants were assessed with Yale Brown Obsessive Compulsive Scale symptom checklist. Patients were classified as early onset (onset of symptoms at age ≤ 18 years) and late onset (onset at age > 18 years) OCD depending upon the age of onset of the symptoms. Factor analysis and cluster analysis of early-onset and late-onset OCD was conducted. The study sample comprised of 91 early onset and 245 late onset OCD subjects. Males were more common in the early onset group. Differences in the frequency of phenomenology related to contamination related, checking, repeating, counting and ordering/arranging compulsions were present across the early and late onset groups. Factor analysis of YBOCS revealed a 3 factor solution for both the groups, which largely concurred with each other. These factors were named as hoarding and symmetry (factor-1), contamination (factor-2) and aggressive, sexual and religious factor (factor-3). To conclude this study shows that factor structure of symptoms of OCD seems to be similar between early-onset and late-onset OCD.

Clinical profile and outcome in a large sample of children and adolescents with obsessive-compulsive disorder: A chart review from a tertiary care center in India

BACKGROUND

Obsessive-compulsive disorder (OCD) is a common psychiatric illness in children and adolescents. Till date, the sample sizes in the Indian studies have been relatively small.

METHODOLOGY

The present study is a retrospective chart review of a large sample of children and adolescents diagnosed with OCD in a tertiary care center.

OBJECTIVES

The objectives of this study were to characterize the clinical profile and to evaluate outcome of OCD in children and adolescents.

RESULTS

Fear of contamination and washing/cleaning compulsions were the most common presenting symptoms. Most of the patients were male with two-thirds having a comorbid disorder. Major depressive disorder was the most common comorbid disorder. The rates of attention deficit hyperactivity disorder, disruptive behavioral disorders, and tic disorders were low when compared to Western studies. One-third of the patients received adequate trial of serotonin reuptake inhibitors and 36% received cognitive behavior therapy. Fifty-four percent of patients had a poor outcome with hospitalization, longer duration of illness, earlier onset of OC symptoms, and family history of OCD being the predictors of poor outcome.

CONCLUSION

The present study of a large sample of patients with juvenile OCD highlights the low rate of comorbid disruptive behavior disorders as reported in the earlier Indian studies and a favorable short-term outcome in approximately 56% of the patients.

Differential binding of antibodies in PANDAS patients to cholinergic interneurons in the striatum

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus, or PANDAS, is a syndrome of acute childhood onset of obsessive-compulsive disorder and other neuropsychiatric symptoms in the aftermath of an infection with Group A beta-hemolytic Streptococcus (GABHS). Its pathophysiology remains unclear. PANDAS has been proposed to result from cross-reactivity of antibodies raised against GABHS with brain antigens, but the targets of these antibodies are unclear and may be heterogeneous. We developed an in vivo assay in mice to characterize the cellular targets of antibodies in serum from individuals with PANDAS. We focus on striatal interneurons, which have been implicated in the pathogenesis of tic disorders. Sera from children with well-characterized PANDAS (n = 5) from a previously described clinical trial (NCT01281969), and matched controls, were infused into the striatum of mice; antibody binding to interneurons was characterized using immunofluorescence and confocal microscopy. Antibodies from children with PANDAS bound to ∼80% of cholinergic interneurons, significantly higher than the <50% binding seen with matched healthy controls. There was no elevated binding to two different populations of GABAergic interneurons (PV and nNOS-positive), confirming the specificity of this phenomenon. Elevated binding to cholinergic interneurons resolved in parallel with symptom improvement after treatment with intravenous immunoglobulin. Antibody-mediated dysregulation of striatal cholinergic interneurons may be a locus of pathology in PANDAS. Future clarification of the functional consequences of this specific binding may identify new opportunities for intervention in children with this condition.

Association between COMT Val158Met and psychiatric disorders: A comprehensive meta-analysis

Catechol-O-methyltransferase (COMT) Val158Met is widely regarded as potentially important for understanding the genetic etiology of many different psychiatric disorders. The present study appears to be the first comprehensive meta-analysis of COMT genetic association studies to cover all psychiatric disorders for which there were available data, published in any language, and with an emphasis on investigating disorder subtypes (defined clinically or by demographic or other variables). Studies were included if they reported one or more datasets (i.e., some studies examined more than one clinical group) in which there were sufficient information to compute effect sizes. A total of 363 datasets were included, consisting of 56,998 cases and 74,668 healthy controls from case control studies, and 2,547 trios from family based studies. Fifteen disorders were included. Attention-deficit hyperactivity disorder and panic disorder were associated with the Val allele for Caucasian samples. Substance-use disorder, defined by DSM-IV criteria, was associated with the Val allele for Asian samples. Bipolar disorder was associated with the Met allele in Asian samples. Obsessive-compulsive disorder tended to be associated with the Met allele only for males. There was suggestive evidence that the Met allele is associated with an earlier age of onset of schizophrenia. Results suggest pleiotropy and underscore the importance of examining subgroups-defined by variables such as age of onset, sex, ethnicity, and diagnostic system-rather than examining disorders as monolithic constructs.

White matter alterations associate with onset symptom dimension in obsessive-compulsive disorder

AIM

The high heterogeneity of obsessive-compulsive disorder (OCD) is best described by a multidimensional model involving symptom dimensions. We aimed to investigate white matter alterations associated with OCD, focusing on the impact of long-lasting effect of symptom dimensions assessed at onset of illness. Furthermore, we investigated white matter alterations associated with this disorder, controlling for the impact of medications and for the prevailing current symptom dimension.

METHODS

We studied 58 patients affected by OCD and 58 age- and sex-matched healthy controls. We divided patients according to symptom dimension at onset of illness, assessed with the five-factor model. T-tests were performed in order to investigate differences between subgroups. Similar analyses were performed considering the prevailing current symptom dimension. Analyses were conducted with tract-based spatial statistics on diffusion tensor imaging.

RESULTS

Doubt/checking and rituals/superstition symptom dimensions at onset and symmetry/perfectionism current symptom dimensions were characterized by significant alterations in diffusion tensor imaging measures. An association of white matter alterations and symmetry/perfectionism current dimension was found only when controlling for the effect of doubt/checking dimension at onset. Finally, results pointed out that the observed differences between patients and healthy controls were carried by the effect of previous and current medications.

CONCLUSION

Our findings evidenced that onset symptom dimensions are associated with enduring alterations of white matter microstructure. Onset symptom dimensions may reflect underlying endophenotypes. In addition, present results confirm the effect of medications on white matter in OCD, showing a large effect of current treatment on myelination.

Inflammatory dysregulation of monocytes in pediatric patients with obsessive-compulsive disorder

BACKGROUND

Although the exact etiology of obsessive-compulsive disorder (OCD) is unknown, there is growing evidence of a role for immune dysregulation in the pathophysiology of the disease, especially in the innate immune system including the microglia. To test this hypothesis, we studied inflammatory markers in monocytes from pediatric patients with OCD and from healthy controls.

METHODS

We determined the percentages of total monocytes, CD16+ monocytes, and classical (CD14^highCD16-), intermediate (CD14^highCD16^low), and non-classical (CD14^lowCD16^high) monocyte subsets in 102 patients with early-onset OCD and in 47 healthy controls. Moreover, proinflammatory cytokine production (GM-CSF, IL-1β, IL-6, IL-8, and TNF-α) was measured by multiplex Luminex analysis in isolated monocyte cultures, in basal conditions, after exposure to lipopolysaccharide (LPS) to stimulate immune response or after exposure to LPS and the immunosuppressant dexamethasone.

RESULTS

OCD patients had significantly higher percentages of total monocytes and CD16+ monocytes than healthy controls, mainly due to an increase in the intermediate subset but also in the non-classical monocytes. Monocytes from OCD patients released higher amounts of GM-CSF, IL-1β, IL-6, IL-8, and TNF-α than healthy controls after exposure to LPS. However, there were no significant differences in basal cytokine production or the sensitivity of monocytes to dexamethasone treatment between both groups. Based on monocyte subset distribution and cytokine production after LPS stimulation, patients receiving psychoactive medications seem to have an intermediate inflammatory profile, that is, lower than non-medicated OCD individuals and higher than healthy controls.

CONCLUSIONS

These results strongly support the involvement of an enhanced proinflammatory innate immune response in the etiopathogenesis of early-onset OCD.

Oxytocin receptor gene polymorphisms exert a modulating effect on the onset age in patients with obsessive-compulsive disorder

The oxytocin receptor (OXTR) is a potential candidate in the pathophysiology of obsessive-compulsive disorder (OCD). The present study investigated the association between common single-nucleotide polymorphism (SNPs) of the OXTR gene and the affected status of OCD or distinct clinical subtypes of OCD including the age at onset and symptom dimensions. Ten SNPs of OXTR were examined in 615 patients with OCD and 581 healthy controls. Single-marker and haplotype-based association analyses were conducted. While OXTR variants were not associated with the affected status of OCD or its clinical symptom dimensions, rs2268493 (p=0.00185) and rs13316193 (p=0.00461) of the OXTR gene were associated with the age at onset in patients with OCD. In addition, in haplotype-based association analyses, there was a significant association between the OXTR gene and the onset age in patients with OCD. In particular, the G-C-G haplotype of rs2268493-rs2254298-rs11316193 and the T-G-A haplotype of rs237887-rs2268490-rs4686301 were positively associated with late-onset OCD. Our results suggest that common variants of OXTR may exert a modulating effect on the onset age in OCD pathophysiology. The potential involvement of the oxytocin system in the development and expression of OCD warrants further longitudinal research.

High resolution chromosomal microarray analysis in paediatric obsessive-compulsive disorder

Background

Obsessive-Compulsive Disorder (OCD) is a common and chronic disorder in which a person has uncontrollable, reoccurring thoughts and behaviours. It is a complex genetic condition and, in case of early onset (EO), the patients manifest a more severe phenotype, and an increased heritability. Large (>500 kb) copy number variations (CNVs) previously associated with autism and schizophrenia have been reported in OCD. Recently, rare CNVs smaller than 500 kb overlapping risk loci for other neurodevelopmental conditions have also been reported in OCD, stressing the importance of examining CNVs of any size range. The aim of this study was to further investigate the role of rare and small CNVs in the aetiology of EO-OCD.

Methods

We performed high-resolution chromosomal microarray analysis in 121 paediatric OCD patients and in 124 random controls to identify rare CNVs (>50 kb) which might contribute to EO-OCD.

Results

The frequencies and the size of the observed rare CNVs in the patients did not differ from the controls. However, we observed a significantly higher frequency of rare CNVs affecting brain related genes, especially deletions, in the patients (OR = 1.98, 95% CI 1.02–3.84; OR = 3.61, 95% CI 1.14–11.41, respectively). Similarly, enrichment-analysis of CNVs gene content, performed with three independent methods, confirmed significant clustering of predefined genes involved in synaptic/brain related functional pathways in the patients but not in the controls. In two patients we detected de-novo CNVs encompassing genes previously associated with different neurodevelopmental disorders (NRXN1, ANKS1B, UHRF1BP1).

Conclusions

Our results further strengthen the role of small rare CNVs, particularly deletions, as susceptibility factors for paediatric OCD.

Electronic supplementary material

The online version of this article (10.1186/s12920-017-0299-5) contains supplementary material, which is available to authorized users.

Age at symptom onset is not associated with reduced action cancelation in adults with obsessive-compulsive disorder

The aim of the current study was to examine the association between age at symptom onset and action cancelation in adults with obsessive-compulsive disorder (OCD). Performance on the stop-signal task was compared among adult patients with early-onset OCD (n=63, onset age ≤19), late-onset OCD (n=33, onset age ≥20), and healthy controls (n=51). Stop-signal reaction time (SSRT) was significantly longer in both OCD groups compared to the control group. However, no significant differences were found between the two OCD groups. In addition, age at symptom onset was not associated with response inhibition performance in adults with OCD. The study findings support the existence of reduced performance on action cancelation in patients with OCD compared to healthy controls with no difference between early- and late-onset OCD subtypes.

A review of the role of serotonin system genes in obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a debilitating neuropsychiatric disorder that causes the patient to experience intrusive thoughts and/or to carry out repetitive, ritualized behaviors that are time consuming and impairing. OCD is familial and heritable. The genetic factors responsible for pathogenesis, however, remain largely unknown despite the numerous candidate gene studies conducted. Based on efficacy of serotonin reuptake inhibitors (SRIs) in treating OCD, serotonin system genes have been a dominant focus in OCD candidate gene studies. We review the most commonly studied candidate serotonin system gene variants (specifically in SLC6A4, HTR2A, HTR1B, and HTR2C) and their association with OCD. Although findings to date are mixed, serotonin transporter polymorphism 5-HTTLPR and HTR2A polymorphism rs6311 (or rs6313) are most consistently associated with OCD. Mixed findings may be the result of genetic complexity and phenotypic heterogeneity that future studies should account for. Homogenous patient subgroups reflecting OCD symptom dimensions, OCD subtypes, and sex should be used for gene discovery.

Register-based study of the incidence, comorbidities and demographics of obsessive-compulsive disorder in specialist healthcare

BACKGROUND

Incidence of obsessive-compulsive disorder (OCD) has been suspected to increase but nationwide epidemiological studies are limited. This study aims to examine sex-specific incidence time trends and characterize psychiatric and neurodevelopmental comorbidities and sociodemographic risk factors of OCD in specialist healthcare in Finland.

METHODS

A nationwide register-based study using data from four Finnish registers identified 3372 OCD cases and 13,372 matched controls (1:4). Cumulative incidence in subjects born between 1987 and 2001 was estimated at ages of 10, 15, 20 and 23 years. Conditional logistic regression was used to examine the sociodemographic factors.

RESULTS

The cumulative incidence of OCD was 0.4% by age 23. Incidence by age 15 among three cohorts increased from 12.4 to 23.7 /10000 live born males and 8.5 to 28.0 /10000 live born females. 73% of the sample had a comorbid condition. Males were significantly more comorbid with psychotic and developmental disorders; females were more comorbid with depressive and anxiety disorders (p <0.001). Higher maternal SES was associated with an increased risk of OCD (OR 1.4; 95% CI 1.1-1.6).

CONCLUSIONS

These findings suggest that incidence of treated OCD in specialist healthcare has increased. The reason may be increased awareness and rate of referrals but a true increase cannot be ruled out. Further research on risk factors of OCD is warranted.

Therapist-Guided, Internet-Delivered Cognitive-Behavioral Therapy for Adolescents With Obsessive-Compulsive Disorder: A Randomized Controlled Trial

OBJECTIVE

Cognitive-behavioral therapy (CBT) is the first-line treatment for young people with obsessive-compulsive disorder (OCD), but most patients do not have access to this treatment. Thus, innovative ways to increase the accessibility of CBT are needed. The objective of this trial was to evaluate the efficacy of therapist-guided internet-based CBT (ICBT) for adolescents with OCD.

METHOD

Sixty-seven adolescents (12-17 years old) with OCD were randomly assigned to a 12-week clinician- and parent-supported ICBT program (BiP OCD) or a waitlist condition. The primary outcome was the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) administered by blinded assessors before and after the intervention. All patients were followed up 3 months after the intervention.

RESULTS

In intention-to-treat analyses, BiP OCD was superior to waitlist on the CY-BOCS (time-by-group interaction, B = -4.53, z = -3.74, p < .001; Cohen's d = 0.69; 95% CI 0.19-1.18) and on most secondary outcome measurements. Patients randomized to BiP OCD also showed further improvement from post-treatment to 3-month follow-up, with a within-group pretreatment to follow-up effect size (Cohen's d) equal to 1.68 (95% CI 1.00-2.36). Patient satisfaction with BiP OCD was high. There were no relevant adverse events. Average clinician support time was 17.5 minutes per patient per week.

CONCLUSION

Therapist-guided ICBT is a promising low-intensity intervention for adolescents with OCD and has the potential to increase access to CBT. It might be particularly useful in a stepped-care approach, in which a large proportion of patients with moderately severe OCD could first be offered ICBT, thus freeing limited resources for more complex cases. Clinical trial registration information-Internet-Delivered CBT for Adolescents With OCD: A Randomized Controlled Study (BiPOCD); http://clinicaltrials.gov; NCT02191631.

Which factors influence onset and latency to treatment in generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder?

Anxiety disorders are common, comorbid, and disabling conditions, often underdiagnosed and under-treated, typically with an early onset, chronic course, and prolonged duration of untreated illness. The present study aimed to explore the influence of sociodemographic and clinical factors in relation to onset and latency to treatment in patients with generalized anxiety disorder (GAD), panic disorder (PD), and obsessive-compulsive disorder (OCD). A total of 157 patients with a Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision (DSM-IV-TR) diagnosis of PD (n=49), GAD (n=68), and OCD (n=40) were recruited, and epidemiological and clinical variables were collected through a specific questionnaire. Statistical analyses were carried out to compare variables across diagnostic groups. PD, GAD, and OCD patients showed a duration of untreated illness of 53.9±81.5, 77.47±95.76, and 90.6±112.1 months, respectively. Significant differences between groups were found with respect to age, age of first diagnosis, age of first treatment, family history of psychiatric illness, onset-related stressful events, benzodiazepine prescription as first treatment, antidepressant prescription as first treatment, and help-seeking (self-initiated vs. initiated by others). Patients with GAD, PD, and OCD showed significant differences in factors influencing onset and latency to treatment, which may, in turn, affect condition-related outcome and overall prognosis. Further studies with larger samples are warranted in the field.

Childhood, adolescent and adult age at onset and related clinical correlates in obsessive-compulsive disorder: a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

OBJECTIVE

Many studies suggest that age at onset (AAO) is an important factor for clinically differentiating patients with juvenile and adult onset of obsessive-compulsive disorder (OCD). The present international study aimed to assess the prevalence of different AAO groups and compare related socio-demographic and clinical features in a large sample of OCD patients.

METHODS

A total of 431 OCD outpatients, participating in the ICOCS network, were first categorised in groups with childhood (≤12 years), adolescent (13-17 years) and adult-onset (≥18 years), then in pre-adult and adult onset (≥18 years) and their socio-demographic and clinical features compared.

RESULTS

Twenty-one percent (n = 92) of the sample reported childhood onset, 36% (n = 155) adolescent onset, and 43% (n = 184) adult onset. Patients with adult onset showed a significantly higher proportion of females compared with the other subgroups (χ(2 )=( )10.9, p< 0.05). Childhood- and adolescent-onset patients had been more frequently treated with cognitive behavioural therapy (CBT), compared to adult-onset patients (χ(2 )=( )11.5; p < 0.05). The pre-adult- versus adult-onset analysis did not show any additional significant difference.

CONCLUSIONS

The present international multicentre study confirms that OCD onset occurs more frequently before adult age, with approximately one out of five patients showing childhood onset. Pre-adult onset was associated with higher rate of CBT, while adult onset was more prevalent in females.

Pediatric Obsessive-Compulsive Disorder Exacerbation and Obstructive Hydrocephalus: A Case Report

We present the case of an 11 year-old boy with a previous history of obsessive-compulsive disorder (OCD), who experienced a dramatic and acute worsening of OCD symptoms in temporal association with obstructive hydrocephalus secondary to a tectal low-grade glioma. Management and resolution of the hydrocephalus was temporally associated with an improvement in his OCD compulsion symptoms. The present case does not establish proof of cause and effect, but highlights potential multifactorial influences on OCD onset and clinical course. Cortico-striatal-thalamic-cortical pathways, physically distorted by hydrocephalus in this case, have long been implicated in OCD etiology. Clinical implications include the importance of conducting an appropriate neurologic work-up to rule out biological causes for acute and dramatic OCD exacerbations with neurologic signs, even in the context of preexisting OCD. Given that neurologic lesions may exist in the absence of typical signs and symptoms, that they may further disrupt OCD circuitry, and that treatment may lead to resolution of associated psychiatric symptoms, it is important to remain cognizant of these differential diagnoses.

Prenatal Maternal Smoking and Increased Risk for Tourette Syndrome and Chronic Tic Disorders

OBJECTIVE

We assessed the role of prenatal maternal smoking in risk for Tourette syndrome and chronic tic disorder (TS/CT) and pediatric-onset obsessive-compulsive disorder (OCD).

METHOD

In an analysis of 73,073 singleton pregnancies from the Danish National Birth Cohort, we calculated incidence rates (IR) per 1,000 person-year for TS/CT and OCD. We then determined crude and adjusted hazard ratios and 95% CIs associated with prenatal maternal smoking, considering smoking as a dichotomous (yes/no) variable or a stratified variable (no smoking, light smoking, and heavy smoking [≥10 cigarettes/day]). Additional analyses examined the effect of maternal smoking on risk for TS/CT with other comorbid psychiatric conditions.

RESULTS

In final adjusted analyses, heavy smoking was associated with a 66% increased risk for TS/CT (adjusted hazard ratio = 1.66, 95% CI = 1.17-2.35). In addition, heavy smoking was associated with a 2-fold increased risk for TS/CT with comorbid attention-deficit/hyperactivity disorder (ADHD), and both light and heavy smoking were associated with a more than 2-fold increased risk for TS/CT with any non-ADHD psychiatric comorbidity. Our parallel analyses of pediatric-onset OCD were likely underpowered but showed similar relationships.

CONCLUSION

Prenatal maternal smoking was associated with increased risk for TS/CT as well as TS/CT with comorbid psychiatric conditions, even after adjustment for several important variables, including maternal psychiatric history, socioeconomic status, and partner smoking. Our findings point to a pathway linking prenatal tobacco exposure and altered brain development to TS/CT.

Does cognitive self-consciousness link older adults' cognitive functioning to obsessive-compulsive symptoms?

To elucidate how obsessional symptoms might develop or intensify in late-life, we tested a risk model. We posited that cognitive self-consciousness (CSC), a tendency to be aware of and monitor thinking, would increase reactivity to aging-related cognitive changes and mediate the relationship between cognitive functioning and obsessive-compulsive disorder (OCD) symptoms. Older adults (Mage = 76.7 years) completed the Dementia Rating Scale-2 (DRS-2), a CSC measure, and an OCD symptom measure up to four times over 18 months. A model that included DRS-2 age and education adjusted total score as the indicator of cognitive functioning fit the data well, and CSC score change mediated the relationship between initial cognitive functioning and changes in OCD symptoms. In tests of a model that included DRS-2 Initiation/Perseveration (I/P) and Conceptualization subscale scores, the model again fit the data well. Conceptualization scores, but not I/P scores, were related to later OCD symptoms, and change in CSC scores again mediated the relationship. Lower scores on initial cognitive functioning measures predicted increases in CSC scores over time, which in turn predicted increases in OCD symptoms over the 18 months of the study. Implications for understanding late-life obsessional problems are discussed.

Executive functions in obsessive-compulsive disorder: An activation likelihood estimate meta-analysis of fMRI studies

OBJECTIVES

To identify activation changes assessed in functional magnetic resonance imaging (fMRI) studies of obsessive-compulsive disorder (OCD) through Activation Likelihood Estimate meta-analysis.

METHODS

We included 28 peer-reviewed standard stereotactic space studies assessing adult OCD patients (OCDpts) vs. healthy controls (HCs) with fMRI during executive task performance.

RESULTS

In within-group analyses, HCs showed task-related activations in bilateral inferior frontal gyri, right middle frontal gyrus, right inferior parietal lobule, right claustrum, bilateral cingulate gyri, and left caudate body. OCDpts showed task-related left-sided activations in the superior, medial, and inferior frontal gyri, and thalamus, and bilateral activations in the middle frontal gyri, inferior parietal lobule, and insular cortices. Subtraction analysis showed increased left middle frontal gyrus activation in OCDpts. In between-groups analyses, OCDpts hypoactivated the right caudate body, left putamen, left ACC, and right medial and middle frontal gyri. Right caudate hypoactivation persisted also after applying Family-wise error algorithms.

CONCLUSIONS

This meta-analysis confirms that during executive functioning OCDpts show a functional deficit of the right caudate body, which could represent a major neural functional correlate of their illness.

The need for inclusion of sex and age of onset variables in genetic association studies of obsessive-compulsive disorder: Overview

Obsessive-compulsive disorder (OCD) is a heterogeneous mental disorder that significantly impairs an individual's functioning. The candidate gene approach has proven to be a useful tool in investigating potential risk genes for OCD, but genetic studies have been largely inconclusive. Etiologically distinct forms of obsessive-compulsive disorder based on sex and age of onset have been identified, yet many genetic studies fail to examine the association by these subtypes. Due to the sexually dimorphic nature of the disorder, positive associations have been found with OCD in males only, suggesting the potential for identifying risk genes that contribute to OCD in women, such as perinatal OCD. This review includes a brief overview of the disorder and its subtypes, with a current update on candidate genes that may contribute to OCD using single nucleotide polymorphisms (SNPs) and genome wide association studies (GWAS).

Clinical significance of psychiatric comorbidity in children and adolescents with obsessive-compulsive disorder: subtyping a complex disorder

A promising approach in relation to reducing phenotypic heterogeneity involves the identification of homogeneous subtypes of OCD based on age of onset, gender, clinical course and comorbidity. This study aims to assess the sociodemographic characteristics and clinical features of OCD patients in relation to gender and the presence or absence of another comorbid disorder. The sample comprised 112 children and adolescents of both sexes and aged 8-18 years, all of whom had a diagnosis of OCD. Overall, 67 % of OCD patients had one comorbid diagnosis, 20.5 % had two such diagnoses and 2.6 % had three comorbid diagnoses. The group of OCD patients with a comorbid neurodevelopmental disorder had significantly more family history of OCD in parents (p = .049), as compared with the no comorbidity group and the group with a comorbid internalizing disorder, and they also showed a greater predominance of males (p = .013) than did the group with a comorbid internalizing disorder. The group of OCD patients with internalizing comorbidity had a later age of onset of OCD (p = .001) compared with both the other groups. Although the initial severity was similar in all three groups, the need for pharmacological treatment and for hospitalization due to OCD symptomatology was greater in the groups with a comorbid neurodevelopmental disorder (p = .038 and p = .009, respectively) and a comorbid internalizing disorder (p = .008 and p = .004, respectively) than in the group without comorbidity. Our findings suggest that two subtypes of OCD can be defined on the basis of the comorbid pathology presented. The identification of different subtypes according to comorbidity is potentially useful in terms of understanding clinical variations, as well as in relation to treatment management and the use of therapeutic resources.

Comparing two basic subtypes in OCD across three large community samples: a pure compulsive versus a mixed obsessive-compulsive subtype

Due to its heterogeneous phenomenology, obsessive-compulsive disorder (OCD) has been subtyped. However, these subtypes are not mutually exclusive. This study presents an alternative subtyping approach by deriving non-overlapping OCD subtypes. A pure compulsive and a mixed obsessive-compulsive subtype (including subjects manifesting obsessions with/without compulsions) were analyzed with respect to a broad pattern of psychosocial risk factors and comorbid syndromes/diagnoses in three representative Swiss community samples: the Zurich Study (n = 591), the ZInEP sample (n = 1500), and the PsyCoLaus sample (n = 3720). A selection of comorbidities was examined in a pooled database. Odds ratios were derived from logistic regressions and, in the analysis of pooled data, multilevel models. The pure compulsive subtype showed a lower age of onset and was characterized by few associations with psychosocial risk factors. The higher social popularity of the pure compulsive subjects and their families was remarkable. Comorbidities within the pure compulsive subtype were mainly restricted to phobias. In contrast, the mixed obsessive-compulsive subtype had a higher prevalence and was associated with various childhood adversities, more familial burden, and numerous comorbid disorders, including disorders characterized by high impulsivity. The current comparison study across three representative community surveys presented two basic, distinct OCD subtypes associated with differing psychosocial impairment. Such highly specific subtypes offer the opportunity to learn about pathophysiological mechanisms specifically involved in OCD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Is late-onset OCD a distinct phenotype? Findings from a comparative analysis of "age at onset" groups

OBJECTIVE

Significant differences in clinical profile and comorbidity patterns have been observed between "juvenile-onset" and "adult-onset" obsessive-compulsive disorder (OCD). There is little systematic research on onset of OCD after the fourth decade. The current study aims to compare the demographic, clinical, and comorbidity patterns of patients with "juvenile-onset" (<18 years), "adult-onset" (18-39 years), and "late-onset" (≥40 years) OCD.

METHOD

Eight hundred two consecutive patients who consulted a specialty OCD clinic at a tertiary care hospital in India were evaluated with the Mini International Neuropsychiatric Interview, the Yale-Brown Obsessive-Compulsive Scale, and the Clinical Global Impression scale.

RESULTS

37.4%, 57.4%, and 5.2% of patients had juvenile-, adult-, and late-onset OCD, respectively. Late-onset OCD was associated with female gender (χ2=42, p<0.001); negative family history of OCD in first-degree relatives (χ2=20.4, p<0.001); and less aggressive obsessions (χ2=18.16, p<0.001), sexual obsessions (χ2=26.68, p<0.001), pathological doubts (χ2=19.41; p<0.001), and repeating rituals (χ2=44.28; p<0.001). On multinomial logistic regression, late-onset OCD was significantly associated with female gender, collecting compulsions, and less aggressive obsessions, in comparison with adult-onset OCD. In comparison with juvenile-onset, late-onset OCD was significantly associated with female gender, presence of precipitating factors, and less aggressive obsessions, sexual obsessions, and repeating compulsions.

CONCLUSION

Late-onset OCD is characterized by female gender, lesser familial loading for OCD, and presence of precipitating factors, suggesting that it may have a distinct pathophysiology compared to juvenile- and adult-onset OCD. Systematic research is required to understand the family-genetic, neuropsychological, and neurobiological correlates of late-onset OCD.

ASSOCIATION STUDY BETWEEN OLIGODENDROCYTE TRANSCRIPTION FACTOR 2 GENE AND OBSESSIVE-COMPULSIVE DISORDER IN A CHINESE HAN POPULATION

BACKGROUND

Oligodendrocyte transcription factor 2 (OLIG2) is primarily concentrated in the brain and spinal cord ventricular zone, where this protein stimulates oligodendrocytes and specific neurons, determines motor neuron and oligodendrocyte differentiation, and sustains replication in early development. Recent studies have demonstrated that OLIG2 gene is associated with mental disorders, such as schizophrenia, mood disorder, and obsessive-compulsive disorder (OCD).

METHODS

The aim of the present study was to explore whether OLIG2 gene is associated with OCD in a Chinese Han population through the assessment and analysis of three single nucleotide polymorphisms (SNPs), namely, rs762178, rs1059004, and rs9653711, selected from OLIG2 gene sequences from 400 OCD samples and 459 healthy controls in a case-controlled association study.

RESULTS

We demonstrated three principal results. First, SNP rs762178 was associated with OCD, female OCD, and early-onset OCD; rs1059004 was associated with OCD and early-onset OCD; and rs9653711 was also associated with OCD and early-onset OCD. Second, the pairs of loci rs762178 and rs1059004, rs1059004 and rs9653711, and rs762178 and rs9653711 exhibited linkage disequilibrium. Third, the three-locus A-C-G haplotype was associated with early-onset OCD.

CONCLUSIONS

The present study is the first to verify the associations of SNPs rs762178, rs1059004, and rs9653711 of the OLIG2 gene with OCD in a Chinese Han population. Thus, OLIG2 might serve as a potential target for OCD treatment in future studies. Further studies should verify the current findings.

Developmental emergence of an obsessive-compulsive phenotype and binge behavior in rats

RATIONALE

Obsessive-compulsive disorder (OCD) gradually emerges and reaches clinical significance during early adulthood. Whether a predisposition for OCD manifests as binge eating disorder earlier during adolescence is proposed.

OBJECTIVES

To further characterize how OCD-like behaviors increase across maturation and to determine whether an OCD-like predisposition increases the likelihood of binge eating during adolescence.

METHODS

Male and female Sprague-Dawley rats were injected with the tricyclic antidepressant clomipramine (CMI, 15 mg/kg) or saline vehicle twice daily between postnatal days 9-15. Both groups were tested for perseverative (spontaneous alternation) and anxiety-like (elevated plus maze; marble burying) behaviors during juvenility (day 28), adolescence (day 60), and adulthood (day 90). Both motivations to eat sucrose pellets and binge eating on fat were investigated.

RESULTS

Sex- and age-dependent increases in anxiety-like and perseverative behavior were observed in CMI subjects. Differences in consummatory behaviors emerged during late adolescence, while no significant differences in alternation or anxiety-like behaviors were detected between CMI and vehicle animals until adulthood. Adolescent CMI females consumed more sucrose pellets in 30 min relative to vehicle females, whereas adolescent CMI males consumed approximately half as much as vehicle males. Sucrose consumption did not differ between groups in adulthood. Adolescent CMI rats demonstrated more fat bingeing than vehicles, independent of sex.

CONCLUSIONS

OCD-like behaviors are emerging during adolescence, but sucrose consumption and fat bingeing in CMI-treated animals significantly precedes the appearance of anxiety and perseveration. This OCD-like phenotype emerges fully during adulthood, suggesting that eating may likely serve as a coping strategy in these animals.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Is serotonin transporter polymorphism (5-HTTLPR) allele status a predictor for obsessive-compulsive disorder? A meta-analysis

The serotonin transporter polymorphism has been implicated in obsessive-compulsive disorder (OCD). However, molecular genetic association studies have yielded inconsistent results. Variation may be due to lack of OCD subtype classification. The goal of this systematic review is to investigate the association of the S-allele of the serotonin transporter polymorphism with OCD and OCD subtypes. A total of 69 studies were initially found through a systematic search of the literature but only 13 with sufficient information to compute odds ratios were suitable for review. A total of 1991 participants with OCD and their 5-HTTLPR allele status were examined. The primary outcome measures were allele frequency and OCD diagnosis. A full meta-analysis was completed comparing the L- and S-alleles using a random effects model in RevMan 5.2.1. Further, a secondary meta-analysis stratified by sex and late-onset was conducted for S- versus L-allele frequency. In the primary meta-analysis, OCD was not associated with the S-allele of the 5-HTTLPR polymorphism (Z = 0.07, p = 0.94). Moreover, late-onset OCD was not associated with the S-allele (Z = 1.45, p = 0.15). However, when stratified by sex, there is an emerging sex-specific relationship. There was a trending association between the S-allele and OCD status in females (Z = 1.62, p = 0.10) but not in males (Z = 0.69, p = 0.49). The findings provide further support for the need of subtype classification of this heterogeneous disorder. Future studies should clearly examine sex differences and OCD age-of-onset. In particular, emphasis should be placed on the effect of female reproductive milestones on OCD onset and symptom exacerbation.

Psychological Treatment of Obsessive-Compulsive Disorder in Children and Adolescents: a Meta-Analysis

Although several meta-analyses have investigated the efficacy of psychological treatments for pediatric obsessive-compulsive disorder (OCD), there is not yet a consensus on the most efficacious treatment components. A meta-analysis was carried out to examine the efficacy of the different treatment techniques used in the psychological interventions of pediatric OCD. An exhaustive literature search from 1983 to February 2014 enabled us to locate 46 published articles that applied some kind of cognitive-behavioral therapy (CBT). For each group the effect size was the standardized pretest-posttest mean change, and it was calculated for obsessive-compulsive symptoms and for other outcome measures. The results clearly showed large effect sizes for CBT in reducing obsessive-compulsive symptoms and, to a lesser extent, other outcome measures (d+ = 1.860; 95% CI: 1.639; 2.081). The most promising treatments are those based on multicomponent programs comprising ERP, cognitive strategies, and relapse prevention. The analysis of other potential moderator variables and the implications for clinical practice are discussed.

"Not Just Right Experiences" are specific to obsessive-compulsive disorder: further evidence from Italian clinical samples

Not Just Right Experiences (NJREs) are considered to be a perceptually tinged phenomenon mainly related to obsessive-compulsive disorder (OCD). The evidence of an association between NJREs and OCD or OC symptoms have been accumulating in the last few years, whereas there is a paucity of studies about the role of this construct in other clinical conditions considered part of the "OCD spectrum". In the current study, the NJRE-Q-R Severity scale (a well-validated measure of NJREs) was administered to 41 patients with OCD, 53 with hair-pulling disorder (HPD), 38 with gambling disorder (GD) and 43 with eating disorders (ED) along with measures of OC symptoms and general distress. In each group, NJREs were consistently associated with OC symptoms; moreover, the pattern of associations appeared coherent with the main clinical features of each disorder. The OCD group reported higher levels of NJREs severity than GD and ED, whereas there were no differences between the OCD and HPD groups. However, HPD patients did not have higher scores of NJREs severity than GD and ED counterparts. NJREs appear to be specific to OCD, but further study is needed to establish the role of this construct in OCD-related disorders.

Are 5-HT3 antagonists effective in obsessive-compulsive disorder? A systematic review of literature

OBJECTIVE

The purpose of this literature database search-based review was to critically consider and evaluate the findings of literature focusing on efficacy and safety of 5-HT3 antagonists in the treatment of obsessive-compulsive disorder (OCD), so as to test whether preclinical data match clinical therapeutic trials.

DESIGN

The PubMed database has been searched for papers on 5-HT3 antagonists and OCD in humans and for animal models of OCD and 5-HT3 receptors.

RESULTS

Of the clinically tested 5-HT3 receptor antagonists, ondansetron has been used to treat OCD in five therapeutic studies, whereas granisetron only in one recent trial. Both showed some efficacy in open studies and superiority to placebo in double-blind studies, along with fair safety. No animal OCD model directly implicated 5-HT3 receptors.

CONCLUSIONS

Overall, results indicate some utility, but the available literature is too scanty to allow for valid conclusions to be drawn. The mismatch between animal models of obsessive-compulsive disorder and clinical data with 5-HT3 antagonists needs more clinical data to ensure that it is not an artefact.

N2 and P3 potentials in early-onset and late-onset patients with obsessive-compulsive disorder

BACKGROUND

Impaired cognitive control processes may be central in the pathogenesis of obsessive-compulsive disorder (OCD). Our objective was to evaluate cognitive control processes with event-related potentials in early-onset OCD (EO) and late-onset OCD (LO), which are suggested to have distinct characteristics.

METHODS

Participants were unmedicated EO (n = 26) and LO patients (n = 33) without comorbid psychopathology and healthy controls (n = 54). Go/No-go tasks with 50 and 80% Go trial probabilities were implemented to manipulate the strength of response conflict and inhibitory demands.

RESULTS

LO patients had shorter N2 latencies than controls and did not show the N2 amplitude increase seen in controls with the increase in Go trial probability as suggestive of abnormal conflict monitoring processes. Both EO and LO patients showed smaller P3 increase than controls with the increase in Go trial probability, suggesting problems in modifying attentional control with changes in task demands. P3 was more anteriorly distributed in LO patients than controls. Additionally, P3 increase, with the increase in Go trial probability, was larger in frontal and central sites than in parietal sites in controls, whereas in EO patients it was almost homogenous across anteroposterior sites.

CONCLUSIONS

N2 processes were affected only in LO, whereas P3 processes were affected in both EO and LO, although, somewhat differently. P3 distributions suggest that EO and LO patients have differences concerning the contributions of frontal and parietal components of attentional networks to the execution of Go/No-go tasks. Our results imply that EO and LO are distinct subtypes affecting the cognitive control systems differently.

Comparison of clinical characteristics of familial and sporadic obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous condition with evidence of familiality in a considerable proportion of patients. A classification into familial and sporadic forms has been proposed to explain the heterogeneity. The current study aims to compare the demographic, clinical and comorbidity patterns of patients with and without a family history of OCD in first-degree relatives.

METHOD

802 consecutive patients who consulted a specialty OCD Clinic at a tertiary care psychiatric hospital in India were evaluated with the Mini-International Neuropsychiatric Interview, the Yale-Brown Obsessive-Compulsive Scale, and the Clinical Global Impression Scale. Family history was assessed by interviewing patients and at least one first-degree relative.

RESULTS

Family history of OCD was seen in 152 patients (19%). Family history was associated with juvenile onset (Χ(2)=19.472, p<0.001), obsessions of contamination (Χ(2)=6.658, p=0.01), hoarding (Χ(2)=4.062, p=0.032), need for symmetry (Χ(2)=3.95, p=0.047), washing compulsion (Χ(2)=7.923, p=0.005), ordering compulsions (Χ(2)=6.808, p=0.009), repeating compulsions (Χ(2)=4.950, p=0.026) and compulsions by proxy (Χ(2)=7.963, p=0.005). Family history was also associated with greater severity of OCD (t=-2.31, p=0.022) and compulsions (t=-3.09, p=0.002) and longer duration of illness at presentation (t=-2.93, p=0.004).

CONCLUSION

Our findings suggest that familial OCD may have distinctive clinical features. Studying familial forms of OCD may offer unique insight in to understanding the genetic basis of OCD.

The Yale–Brown Obsessive Compulsive Scale

The Yale–Brown Obsessive Compulsive Scale (Y-BOCS) is the most frequently applied test to assess obsessive compulsive symptoms. We conducted a reliability generalization meta-analysis on the Y-BOCS to estimate the average reliability, examine the variability among the reliability estimates, search for moderators, and propose a predictive model that researchers and clinicians can use to estimate the expected reliability of the Y-BOCS. We included studies where the Y-BOCS was applied to a sample of adults and reliability estimate was reported. Out of the 11,490 references located, 144 studies met the selection criteria. For the total scale, the mean reliability was 0.866 for coefficients alpha, 0.848 for test–retest correlations, and 0.922 for intraclass correlations. The moderator analyses led to a predictive model where the standard deviation of the total test and the target population (clinical vs. nonclinical) explained 38.6% of the total variability among coefficients alpha. Finally, clinical implications of the results are discussed.

Genetics of obsessive-compulsive disorder and related disorders

Twin and family studies support a significant genetic contribution to obsessive-compulsive disorder (OCD) and related disorders, such as chronic tic disorders, trichotillomania, skin-picking disorder, body dysmorphic disorder, and hoarding disorder. Recently, population-based studies and novel laboratory-based methods have confirmed substantial heritability in OCD. Genome-wide association studies and candidate gene association studies have provided information on specific gene variations that may be involved in the pathobiology of OCD, though a substantial portion of the genetic risk architecture remains unknown.