Obsessions and compulsions in the community: prevalence, interference, help-seeking, developmental stability, and co-occurring psychiatric conditions

Relationship of obsessive-compulsive symptoms to clinical variables and cognitive functions in individuals at ultra high risk for psychosis

Few studies have investigated the relationship between obsessive-compulsive symptoms (OCS) and clinical variables, and cognition in individuals at ultra high-risk (UHR) for psychosis. The aim of this study was to evaluate the frequency of OCS and their relationship with clinical variables and cognitive functions in individuals at UHR. Eighty-four individuals at UHR for psychosis were administered the Brief Psychiatric Rating Scale, the Yale-Brown Obsession Compulsion Symptom Check List and, the Calgary Depression Scale for Schizophrenia. A cognitive test battery was also applied. We compared the clinical, functional, and cognitive parameters of individuals at UHR with and without OCS and healthy controls. Thirty-five percent of the UHR sample had at least two obsessions/compulsions. The duration of subthreshold psychotic symptoms was longer in individuals with OCS. Those who can work/study before first presentation were more frequent in OCS-positive group. CDSS scores were higher in those with OCS. Compared to controls, OCS-negative group's performance was worse in 8 cognitive test items, while OCS-positive group performed worse in only one cognitive test item. Our findings suggest that OCS are common in the UHR group. OCS might be related to higher level of depression, but better work/study performance, and less cognitive deficits in UHR group.

Symptom dimensions in obsessive-compulsive disorder as predictors of neurobiology and treatment response

Purpose of review

Specific symptom dimensions of obsessive-compulsive disorder (OCD) have been suggested as an approach to reduce the heterogeneity of obsessive-compulsive disorder, predict treatment outcome, and relate to brain structure and function. Here, we review studies addressing these issues.

Recent findings

The contamination and symmetry/ordering dimensions have not been reliably associated with treatment outcome. Some studies found that greater severity of sexual/aggressive/religious symptoms predicted a worse outcome after cognitive behavioral therapy (CBT) and a better outcome after serotonin reuptake inhibitors (SRIs). Contamination symptoms have been related to increased amygdala and insula activation in a few studies, while sexual/aggressive/religious symptoms have also been related to more pronounced alterations in the function and structure of the amygdala. Increased pre-treatment limbic responsiveness has been related to better outcomes of CBT, but most imaging studies show important limitations and replication in large-scale studies is needed. We review possible reasons for the strong limbic involvement of the amygdala in patients with more sexual/aggressive/religious symptoms, in relation to their sensitivity to CBT.

Summary

Symptom dimensions may predict treatment outcome, and patients with sexual/religious/aggressive symptoms are at a greater risk of not starting or delaying treatment. This is likely partly due to more shame and perceived immorality which is also related to stronger amygdala response. Competently delivered CBT is likely to help these patients improve to the same degree as patients with other symptoms.

Presence and Predictive Value of Obsessive-Compulsive Symptoms in Anxiety and Depressive Disorders

OBJECTIVE

Obsessive-compulsive symptoms (OCS) co-occur frequently with anxiety and depressive disorders, but the nature of their relationship and their impact on severity of anxiety and depressive disorders is poorly understood. In a large sample of patients with anxiety and depressive disorders, we assessed the frequency of OCS, defined as a Young Adult Self-Report Scale-obsessive-compulsive symptoms score >7. The associations between OCS and severity of anxiety and/or depressive disorders were examined, and it was investigated whether OCS predict onset, relapse, and persistence of anxiety and depressive disorders.

METHODS

Data were obtained from the third (at 2-year follow-up) and fourth wave (at 4-year follow-up) of data collection in the Netherlands Study of Anxiety and Depression cohort, including 469 healthy controls, 909 participants with a remitted disorder, and 747 participants with a current anxiety and/or depressive disorder.

RESULTS

OCS were present in 23.6% of the total sample, most notably in those with current combined anxiety and depressive disorders. In patients with a current disorder, OCS were associated with severity of this disorder. Moreover, OCS predicted (1) first onset of anxiety and/or depressive disorders in healthy controls (odds ratio [OR], 5.79; 95% confidence interval [CI], 1.15 to 29.14), (2) relapse in those with remitted anxiety and/or depressive disorders (OR, 2.31; 95% CI, 1.55 to 3.46), and (3) persistence in patients with the combination of current anxiety and depressive disorders (OR, 4.42; 95% CI, 2.54 to 7.70) within the 2-year follow-up period Conclusions: OCS are closely related to both the presence and severity of anxiety and depressive disorders and affect their course trajectories. Hence, OCS might be regarded as a course specifier signaling unfavorable outcomes. This specifier may be useful in clinical care to adapt and intensify treatment in individual patients.

Brain Structural Correlates of Subclinical Obsessive-Compulsive Symptoms in Healthy Children

OBJECTIVE

Subclinical obsessive-compulsive (OC) symptoms are frequently observed in children and have been reported to predict a subsequent diagnosis of OC disorder (OCD). Therefore, identifying the putative neurobiological signatures of such risk is crucial, because it would allow for the characterization of the underpinnings of OCD without the interfering effects of chronicity, medication, or comorbidities, especially when interpreted within the context of OCD clinical heterogeneity and taking into account normal neurodevelopmental changes. The present study aimed to identify the brain volumetric features associated with subclinical OC symptoms and the potential modulatory effects of sex and age in a large sample of healthy children.

METHOD

Two hundred fifty-five healthy children were assessed using the Obsessive-Compulsive Inventory-Child Version and underwent a brain structural magnetic resonance examination. The relation between total and symptom-specific scores and regional gray and white matter (GM and WM) volumes was evaluated. Participants were grouped according to sex and age (younger versus older) to assess the effect of these factors on symptom-brain morphometry associations.

RESULTS

Ordering symptoms were negatively related to GM volumes in the ventral caudate. Hoarding symptoms were positively associated with GM and WM volumes in the left inferior frontal gyrus, and obsessing symptoms correlated negatively with GM and WM volumes in the right temporal pole. Doubt-checking symptoms correlated positively with WM volumes in the right inferior fronto-occipital fasciculus and the corpus callosum. Sex and age modulated some of these associations.

CONCLUSION

Subclinical OC symptoms are associated with specific brain volumetric features, which could be considered potential neural signatures of increased risk for OCD.

Low frequency fluctuation of brain spontaneous activity and obsessive-compulsive symptoms in a large school-age sample

BACKGROUND

The present study was designed to explore alterations in brain dynamics at rest that are associated with Obsessive Compulsive Symptoms (OCS) in childhood by measuring low frequency fluctuation of spontaneous brain activity in a large school community sample from a developing country.

METHOD

Resting state functional magnetic resonance imaging data were collected in a sample of 655 children and adolescents (6-15 years old) from the brazilian 'High Risk Cohort Study for Psychiatric Disorders (HRC)'. OCS were assessed using items from the Compulsion and Obsessions section of the Development and Well-Being Assessment (DAWBA). The correlation between the fractional amplitude of low frequency fluctuations (fALFF) and the number of OCS were explored by using a general linear model, considering fALFF as response variable, OCS score as regressor and age, gender and site as nuisance variables.

RESULTS

The number of OCS was positively correlated with the fALFF coefficients at the right sensorimotor cortex (pre-motor, primary motor cortex and post-central gyrus) and negatively correlated with the fALFF coefficients at the insula/superior temporal gyrus of both hemispheres. Our results were specific to OCS and not due to associations with overall psychopathology.

CONCLUSIONS

Our results suggest that brain spontaneous activity at rest in the sensorimotor and insular/superior-temporal cortices may be involved in OCS in children. These findings need independent replication and future studies should determine whether brain spontaneous activity changes within these regions might be predictors of risk for obsessive-compulsive disorder latter in life.

A multilevel longitudinal study of obsessive compulsive symptoms in adolescence: male gender and emotional stability as protective factors

The severity of obsessive compulsive symptoms (OCS) is suggested to be normally distributed in the general population, and they appear to have an impact on a range of aspects of adolescent development. Importantly, there are individual differences regarding susceptibility to OCS. In the present repeated measures study, OCS were studied in relation to gender and emotional stability (as a personality trait) using a normative sample of 515 adolescents at ages 16 and 18 years. OCS were assessed with the relevant subscale of the SCL-90-R and emotional stability with the Five Factor Questionnaire. A three-level hierarchical linear model was calculated to longitudinally assess the over time variations of OCS and their over time links to gender and emotional stability, while controlling for random effects due to the nesting of the data. Experiencing OCS increased with age (between 16 and 18 years). Additionally, male gender and higher emotional stability were associated with lower OCS at 16 years and these remained stable over time. Results indicate age-related and between individual differences on reported OCS that need to be considered for prevention and intervention planning.

Children with Obsessive-Compulsive Symptomology in the General Population: Different Subtypes?

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a moderately prevalent neurodevelopmental disorder, and many children suffer from subclinical obsessive-compulsive (OC) symptoms. The disorder is heterogeneous and has high comorbidity rates. In early disease stages of psychiatric disorders, symptoms are typically hard to attribute exclusively to specific disorders. The authors investigated whether profiles of neuropsychiatric symptoms can be distinguished within a large population-based study of school-aged children (7-10 years) scoring high on OC symptoms.

METHODS

OC symptoms and comorbid symptoms common in pediatric OCD were assessed: symptoms of attention-deficit hyperactivity disorder, oppositional defiant disorder, autism, and anxiety. Latent profile analysis was performed on the subgroup of children scoring high on OC symptoms (high-OC sample, n = 209, i.e., 4.5% of total sample, n = 4632) using the z scores of the measures of comorbid symptoms as indicators.

RESULTS

Three distinguishable profiles were found within the high-OC sample. The first subgroup ("OC-specific"; 81.3%, 3.7% of total sample) had only OC-specific problems, the second subgroup ("Comorbid OC"; 11.0%, 0.5% of total sample) had high scores on all measures of comorbid symptomology, and the third subgroup ("Autistic OC"; 7.7%, 0.3%, of total sample) scored especially high on autism.

CONCLUSION

The findings show that profiles based on neuropsychiatric symptoms can be distinguished within a population-based sample of school-aged children scoring high on obsessive-compulsive symptoms. These profiles may be useful in establishing patterns of symptom course during development. Longitudinal follow-up is necessary to ascertain whether at a later age these subgroups still differ in their symptom profile and neuropsychiatric trajectory.

Relationship between symptom dimensions and white matter alterations in obsessive-compulsive disorder

OBJECTIVE

To investigate the relationship between the severities of symptom dimensions in obsessive-compulsive disorder (OCD) and white matter alterations.

METHODS

We applied tract-based spatial statistics for diffusion tensor imaging (DTI) acquired by 3T magnetic resonance imaging. First, we compared fractional anisotropy (FA) between 20 OCD patients and 30 healthy controls (HC). Then, applying whole brain analysis, we searched the brain regions showing correlations between the severities of symptom dimensions assessed by Obsessive-Compulsive Inventory-Revised and FA in all participants. Finally, we calculated the correlations between the six symptom dimensions and multiple DTI measures [FA, axial diffusivity (AD), radial diffusivity (RD), mean diffusivity (MD)] in a region-of-interest (ROI) analysis and explored the differences between OCD patients and HC.

RESULTS

There were no between-group differences in FA or brain region correlations between the severities of symptom dimensions and FA in any of the participants. ROI analysis revealed negative correlations between checking severity and left inferior frontal gyrus white matter and left middle temporal gyrus white matter and a positive correlation between ordering severity and right precuneus in FA in OCD compared with HC. We also found negative correlations between ordering severity and right precuneus in RD, between obsessing severities and right supramarginal gyrus in AD and MD, and between hoarding severity and right insular gyrus in AD.

CONCLUSION

Our study supported the hypothesis that the severities of respective symptom dimensions are associated with different patterns of white matter alterations.

The Child Behavior Checklist-Obsessive-Compulsive Subscale Detects Severe Psychopathology and Behavioral Problems Among School-Aged Children

OBJECTIVE

The aims of this study were (1) to assess obsessive-compulsive symptoms (OCS) dimensionally in a school-aged community sample and to correlate them with clinical and demographical variables; (2) to determine a subgroup with significant OCS ("at-risk for OCD") using the Child Behavior Checklist (CBCL-OCS) and (3) to compare it with the rest of the sample; (4) To review the CBCL-OCS subscale properties as a screening tool for pediatric OCD.

METHODS

Data from the Brazilian High Risk Cohort were analyzed. The presence and severity of OCS were assessed through the CBCL-OCS subscale. DSM-IV psychiatric diagnoses were obtained by the Developmental and Well-Being Assessment. Behavioral problems were assessed using the Strengths and Difficulties Questionnaire, the Youth Strengths Inventory, and the CBCL internalizing and externalizing behavior subscales.

RESULTS

A total of 2512 (mean age: 8.86 ± 1.84 years; 55.0% male) children were included. Moderate correlations were found between OCS severity and functional impairment (r = 0.36, p < 0.001). Children with higher levels of OCS had higher rates of psychiatric comorbidity and behavioral problems (p < 0.001). A score of 5 or higher in the CBCL-OCS scale determined an "at-risk for OCD" subgroup, comprising 9.7% of the sample (n = 244), with behavioral patterns and psychiatric comorbidities (e.g., tics [odds ratios, OR = 6.41, p < 0.001]), anxiety disorders grouped [OR = 3.68, p < 0.001] and depressive disorders [OR = 3.0, p < 0.001] very similar to those described in OCD. Sensitivity, specificity, positive predictive value, and negative predictive value of the CBCL-OCS for OCD diagnosis were, respectively, 48%, 91.5%; 15.1%, and 98.2%.

CONCLUSIONS

The dimensional approach suggests that the presence of OCS in children is associated with higher rates of comorbidity, behavioral problems, and impairment. The "at-risk for OCD" group defined by the CBCL revealed a group of patients phenotypically similar to full blown OCD.

Checking behavior in rhesus monkeys is related to anxiety and frontal activity

When facing doubt, humans can go back over a performed action in order to optimize subsequent performance. The present study aimed to establish and characterize physiological doubt and checking behavior in non-human primates (NHP). We trained two rhesus monkeys (Macaca mulatta) in a newly designed “Check-or-Go” task that allows the animal to repeatedly check and change the availability of a reward before making the final decision towards obtaining that reward. By manipulating the ambiguity of a visual cue in which the reward status is embedded, we successfully modulated animal certainty and created doubt that led the animals to check. This voluntary checking behavior was further characterized by making EEG recordings and measuring correlated changes in salivary cortisol. Our data show that monkeys have the metacognitive ability to express voluntary checking behavior similar to that observed in humans, which depends on uncertainty monitoring, relates to anxiety and involves brain frontal areas.

Age-Specific Prevalence of Hoarding and Obsessive Compulsive Disorder: A Population-Based Study

OBJECTIVE

Little is known about the age-specific prevalence of hoarding and obsessive compulsive symptoms (OCS), particularly in older age groups. The objectives of this study were to estimate the age-specific prevalence, severity, and relationships between hoarding and OCS in males and females using a large population-based sample.

METHODS

We assessed the age-specific prevalence rates of hoarding disorder (HD) and OC disorder (OCD) in males and females (at various age ranges between 15 and 97 years) from the Netherlands Twins Register (N = 15,194). Provisional HD and OCD diagnoses were made according to Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, criteria using self-report measures. We also assessed hoarding and OCS severity in the various age groups and explored specific hoarding and OCS patterns (e.g., difficulty discarding, excessive acquisition, clutter, checking, washing, perfectionism, and obsessions) with age.

RESULTS

Prevalence of provisional HD diagnoses (2.12%) increased linearly by 20% with every 5 years of age (z = 13.8, p < 0.0001) and did not differ between males and females. Provisional OCD diagnoses were most common in younger individuals and in individuals over age 65. Co-occurring OCD increased hoarding symptom severity (coefficient: 4.5; SE: 0.2; 95% CI: 4.1-4.9; t = 22.0, p < 0.0001). Difficulty discarding for HD and checking behaviors for OCD appeared to drive most increases in these diagnoses in older ages.

CONCLUSION

Increased prevalence and severity of HD with age appears to be primarily driven by difficulties with discarding. Increases in OCD prevalence with older age were unexpected and of potential clinical relevance.

Factor Structure and Measurement Invariance of the Obsessive-Compulsive Inventory – Child Version (OCI-CV) in General Population

Abstract. Evidence-based assessment is necessary as a first step for developing psychopathological studies and assessing the effectiveness of empirically validated treatments. There are several measures of obsessive-compulsive disorder (OCD) and/or symptomatology in children and adolescents, but all of them present some limitations. The Obsessive-Compulsive Inventory-Revised (OCI-R) by Foa and her colleagues has showed to be a good self-report measure to capture the dimensionality of OCD in adults and adolescents. The child version of the OCI (OCI-CV) was validated for clinical children and adolescents in 2010, showing excellent psychometric properties. The objective of this study was to examine the factor structure and invariance of the OCI-CV in the general population. Results showed a six-factor structure with one second-order factor, good consistency values, and invariance across region, age, and sex. The OCI-CV is an excellent inventory for assessing the dimensions of OCD symptomatology in general populations of children and adolescents. The invariance across sex and age warrants its utilization for research purposes.

Persistence of impulsivity in pediatric and adolescent patients with obsessive-compulsive disorder

AIM

Increasing clinical evidence points to impulsivity as a symptom of obsessive-compulsive disorder (OCD). However, little is known about its persistence over time.

METHODS

In this study, we evaluated the performance of 12 pediatric patients with OCD on the Stroop color-word task, which assesses impulsivity, and compared this with age- and sex-matched controls. In parallel, we measured changes in hemodynamic responses during the task, using near-infrared spectroscopy. As patients in the OCD group were naïve to treatment, we compared results before and after 3-year medication with serotonin reuptake inhibitors.

RESULTS

We report that, compared with controls, the OCD group had significantly poorer performance and less activation in the prefrontal cortex during the Stroop color-word task. Surprisingly, while serotonin-reuptake-inhibitors treatment reduced OCD symptomology, it did not improve the diminished hemodynamic responses or task performance of these patients.

CONCLUSION

Our findings suggest that a persistent deficit exists in the inhibitory control of pediatric patients with OCD; they also provide insight into the pathophysiology of OCD.

"On My Own, but Not Alone" - Adolescents' Experiences of Internet-Delivered Cognitive Behavior Therapy for Obsessive-Compulsive Disorder

INTRODUCTION

Childhood Obsessive-Compulsive Disorder (OCD) is a prevalent and impairing condition that can be effectively treated with Cognitive Behavior Therapy (CBT). However, a majority of children and adolescents do not have access to CBT. Internet-delivered CBT (ICBT) has been suggested as a way to increase availability to effective psychological treatments. Yet, the research on ICBT in children and adolescents has been lagging behind significantly both when it comes to quantitative as well as qualitative studies. The aim of the current study was to describe the experience of ICBT in adolescents with OCD.

METHOD

Eight adolescents with OCD that had received ICBT were interviewed with qualitative methodology regarding their experiences of the intervention. Data was summarized into thematic categories.

RESULTS

Two overarching themes were identified, autonomy and support, each consisting of three primary themes (self-efficacy, flexibility, secure self-disclosure and clinician support, parental support, identification/normalization, respectively).

CONCLUSIONS

The experiential hierarchical model that was identified in this study is, in part, transferrable to previous research. In addition, it highlights the need of further study of important process variables of ICBT in young patient populations.

Violent obsessions are associated with suicidality in an OCD analog sample of college students

The picture of suicide in obsessive-compulsive disorder (OCD) is unclear because previous research did not uniformly control for depressive symptoms when examining the relationship between OCD and suicidality. Specific links between OC symptom dimensions and suicidality were also not adequately studied. As such, we investigated specific associations between OC symptom dimensions and suicidality, beyond the contribution of depressive symptoms, in an OCD analog sample of college students, a group traditionally at risk for suicide. One hundred and forty-six college students (103 females; 43 males) who exceeded the clinical cut-off for OC symptoms on the Obsessive-Compulsive Inventory, Revised (OCI-R) were recruited. Participants completed an online questionnaire containing measures that assessed suicidality and OC and depressive symptom severity. Total OC symptom severity, unacceptable thoughts, and especially violent obsessions exhibited significant positive zero-order correlations with suicidality. However, analyses of part correlations indicated that only violent obsessions had a significant unique association with suicidality after controlling for depressive symptoms. Our findings support the hypothesis that violent obsessions have a specific role in suicidality beyond the influence of depressive symptoms in an OCD analog sample of college students. A strong clinical focus on suicide risk assessment and safety planning in college students reporting violent obsessions is therefore warranted. Future related research should employ longitudinal or prospective designs and control for other possible comorbid symptoms in larger and more representative samples of participants formally diagnosed with OCD in order to verify the generalizability of our findings to these groups.

The Toronto Obsessive-Compulsive Scale: Psychometrics of a Dimensional Measure of Obsessive-Compulsive Traits

OBJECTIVE

To describe the Toronto Obsessive-Compulsive Scale (TOCS), a novel 21-item parent- or self-report questionnaire that covers wide variation in obsessive-compulsive (OC) traits, and to evaluate its psychometric properties in a community-based pediatric sample.

METHOD

The TOCS was completed for 16,718 children and adolescents between the ages of 6 and 17 years in a community setting. Internal consistency, convergent validity with the Obsessive-Compulsive Scale of the Child Behaviour Checklist (CBCL-OCS), divergent validity with the Strengths and Weaknesses of ADHD (Attention-Deficit/Hyperactivity Disorder) Symptoms and Normal Behaviour Rating Scale (SWAN), interrater reliability, as well as sensitivity and specificity of the TOCS were assessed.

RESULTS

The internal consistency of the 21 TOCS items was excellent (Cronbach's α = 0.94). TOCS was moderately correlated with the CBCL-OCS (Spearman correlation = 0.51) and poorly correlated with the SWAN (Pearson correlation = 0.02). Sensitivity and specificity analyses indicated that a TOCS total score of greater than 0 successfully discriminated community-reported obsessive-compulsive disorder (OCD) cases from noncases. OC traits were continuously distributed both at the total score and dimensional level in our pediatric community sample.

CONCLUSION

TOCS is a multidimensional measure of OC traits in children and adolescents with sound psychometric properties. TOCS reveals that OC traits are common and continuously distributed in a community sample. TOCS may be a useful measure for studies of the characteristics and etiology of OC traits.

Putamen volume correlates with obsessive compulsive characteristics in healthy population

Obsessions and compulsions (OCs) are frequent in healthy subjects; however neural backgrounds of the subclinical OCs were largely unknown. Results from recent studies suggested involvement of the putamen in the OC traits. To investigate this issue, 49 healthy subjects were assessed using structural magnetic resonance imaging (MRI) and the Maudsley Obsessive Compulsive Inventory (MOCI). Anatomical delineation on MRI yielded the global volume and local shape of the putamen. Other striatal structures (the caudate nucleus and globus pallidus) were also examined for exploratory purpose. The relationship between volume/shape of each structures and MOCI measure was analyzed, with sex, age, state anxiety, trait anxiety, and full-scale Intelligence Quotient regressed out. The volume analysis revealed a positive relationship between the MOCI total score and the bilateral putamen volumes. The shape analysis demonstrated associations between the higher MOCI total score and hypertrophy of the anterior putamen in both hemispheres. The present study firstly revealed that the volume changes of the putamen correlated with the manifestation of subclinical OC traits. The dysfunctional cortico-anterior striatum networks seemed to be one of the neuronal subsystems underlying the subclinical OC traits.

Obsessive-compulsive symptoms are associated with psychiatric comorbidities, behavioral and clinical problems: a population-based study of Brazilian school children

Pediatric-onset obsessive-compulsive disorder (OCD) is underdiagnosed, and many affected children are untreated. The present study seeks to evaluate the presence and the clinical impact of OCD and obsessive-compulsive symptoms (OCS) in a large sample of school-age children. In Phase I, we performed an initial screening using the Family History Screen (FHS). In Phase II, we identified an "at-risk" sample, as well as a randomly selected group of children. A total of 2,512 children (6-12 years old) were assessed using the FHS, the Development and Well-Being Assessment (DAWBA), the Strengths and Difficulties Questionnaire (SDQ), and the Child Behavior Checklist (CBCL). Data analyses included descriptive and multivariate analytical techniques. 2,512 children (mean age: 8.86 ± 1.84 years; 55.0% male) were categorized into one of the three diagnostic groups: OCD (n = 77), OCS (n = 488), and unaffected controls (n = 1,947). There were no significant socio-demographic differences (age, gender, socioeconomic status) across groups. The OCS group resembled the OCD on overall impairment, including school problems and delinquent behaviors. However, the OCD group did have significantly higher rates of several comorbid psychiatric disorders, including separation anxiety, generalized anxiety, and major depressive disorder, than OCS or unaffected controls. Moreover, the OCD group also scored higher than the SDQ, as well as on each of CBCL items rated by the parent. Our findings suggest that there is a psychopathological continuum between OCS and OCD in school-aged children. The presence of OCS is associated with functional impairment, which needs further investigation in longitudinal studies.

Obsessive-Compulsive Symptoms in Medical Students: Prevalence, Severity, and Correlates

OBJECTIVES

The study aims were to estimate the prevalence and correlates of symptoms suggestive of obsessive-compulsive disorder (OCD) among medical students and investigate the severity and correlates of specific obsessive-compulsive symptom (OCS) dimensions in this population.

METHODS

A cross-sectional study with 471 Brazilian medical students, who were assessed using the Obsessive-Compulsive Inventory-Revised (OCI-R). The main outcomes were "probable OCD" (OCI-R score >27) and overall/dimensional OCI-R scores. Sociodemographic data, depressive symptoms, and several aspects of academic life were also investigated. Bivariate analyses were followed by regression models.

RESULTS

Eighteen (3.8%) participants presented probable OCD, which was associated with depression. The mean OCI-R score was 8.9, and greater overall severity was independently associated with being a freshman, difficulty in adaptation, and depressive symptoms. Higher scores in the "checking" and "washing" dimensions were associated with being a freshman, in the "neutralization" and "ordering" dimensions with adaptation difficulties, and in the "hoarding" dimension with adaptation difficulties and depressive symptoms. The "obsession" dimension was associated with being a freshman, difficulty making friends, depressive symptoms, and psychological/psychiatric treatment.

CONCLUSIONS

Probable OCD is more frequent in medical students than in the general population and is associated with depressive symptoms. Efforts are required to identify OCS in this population, particularly among first-year students and to provide treatment, when necessary. Institutional programs that properly receive freshmen, enhancing their integration with other colleagues and their adaptation to the city, may decrease the level of stress and, consequently, OCS severity.

Comorbidity variation in patients with obsessive-compulsive disorder according to symptom dimensions: Results from a large multicentre clinical sample

BACKGROUND

Obsessive-compulsive disorder (OCD) has a heterogeneous and complex phenomenological picture, characterized by different symptom dimensions and comorbid psychiatric disorders, which frequently co-occur or are replaced by others over the illness course. To date, very few studies have investigated the associations between specific OCD symptom dimensions and comorbid disorders.

METHODS

Cross-sectional, multicenter clinical study with 1001 well-characterized OCD patients recruited within the Brazilian Research Consortium on Obsessive-Compulsive and Related Disorders. The primary instruments were the Dimensional Yale-Brown Obsessive Compulsive Scale (DY-BOCS) and the Structured Clinical Interview for DSM-IV Axis I Disorders. Bivariate analyses between symptom dimensions and comorbidities were followed by logistic regression.

RESULTS

The most common comorbidities among participants (56.8% females) were major depression (56.4%), social phobia (34.6%), generalized anxiety disorder (34.3%), and specific phobia (31.4%). The aggressive dimension was independently associated with posttraumatic stress disorder (PTSD), separation anxiety disorder, any impulse-control disorder and skin picking; the sexual-religious dimension was associated with mood disorders, panic disorder/agoraphobia, social phobia, separation anxiety disorder, non-paraphilic sexual disorder, any somatoform disorder, body dysmorphic disorder and tic disorders; the contamination-cleaning dimension was related to hypochondriasis; and the hoarding dimension was associated with depressive disorders, specific phobia, PTSD, impulse control disorders (compulsive buying, skin picking, internet use), ADHD and tic disorders. The symmetry-ordering dimension was not independently associated with any comorbidity.

LIMITATIONS

Cross-sectional design; participants from only tertiary mental health services; personality disorders not investigated.

CONCLUSIONS

Different OCD dimensions presented some specific associations with comorbid disorders, which may influence treatment seeking behaviors and response, and be suggestive of different underlying pathogenic mechanisms.

Treatment Efficacy of Combined Sertraline and Guanfacine in Comorbid Obsessive-Compulsive Disorder and Attention Deficit/Hyperactivity Disorder: Two Case Studies

OBJECTIVE

Treatment of obsessive-compulsive disorder (OCD) is complicated by comorbid psychiatric disorders. Successful treatment of 2 pediatric patients with severe OCD and comorbid attention deficit/hyperactivity disorder (ADHD) is described.

METHOD

A report on 2 pediatric clinical cases (Ages 9 and 10) with comorbid OCD and ADHD was used to describe response to medication management through the serotonin transporter inhibitor, sertraline, and the noradrenergic α2A receptor agonist, guanfacine, along with cognitive behavioral therapy.

RESULTS

Cognitive behavioral therapy combined with titrated doses of the serotonin transporter inhibitor, sertraline, and the noradrenergic α2A receptor agonist, guanfacine resolved OCD symptoms and the underlying ADHD.

CONCLUSION

The novel observations support a focused psychological and pharmacological approach to successful treatment of complex symptoms in patients with comorbid OCD and ADHD. Limitations to generalizability are discussed.

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.

Cortico-Basal Ganglia Circuit Function in Psychiatric Disease

Circuit dysfunction models of psychiatric disease posit that pathological behavior results from abnormal patterns of electrical activity in specific cells and circuits in the brain. Many psychiatric disorders are associated with abnormal activity in the prefrontal cortex and in the basal ganglia, a set of subcortical nuclei implicated in cognitive and motor control. Here we discuss the role of the basal ganglia and connected prefrontal regions in the etiology and treatment of obsessive-compulsive disorder, anxiety, and depression, emphasizing mechanistic work in rodent behavioral models to dissect causal cortico-basal ganglia circuits underlying discrete behavioral symptom domains relevant to these complex disorders.

From Thought to Action: How the Interplay Between Neuroscience and Phenomenology Changed Our Understanding of Obsessive-Compulsive Disorder

The understanding of obsessive-compulsive disorder (OCD) has evolved with the knowledge of behavior, the brain, and their relationship. Modern views of OCD as a neuropsychiatric disorder originated from early lesion studies, with more recent models incorporating detailed neuropsychological findings, such as perseveration in set-shifting tasks, and findings of altered brain structure and function, namely of orbitofrontal corticostriatal circuits and their limbic connections. Interestingly, as neurobiological models of OCD evolved from cortical and cognitive to sub-cortical and behavioral, the focus of OCD phenomenology also moved from thought control and contents to new concepts rooted in animal models of action control. Most recently, the proposed analogy between habitual action control and compulsive behavior has led to the hypothesis that individuals suffering from OCD may be predisposed to rely excessively on habitual rather than on goal-directed behavioral strategies. Alternatively, compulsions have been proposed to result either from hyper-valuation of certain actions and/or their outcomes, or from excessive uncertainty in the monitoring of action performance, both leading to perseveration in prepotent actions such as washing or checking. In short, the last decades have witnessed a formidable renovation in the pathophysiology, phenomenology, and even semantics, of OCD. Nevertheless, such progress is challenged by several caveats, not least psychopathological oversimplification and overgeneralization of animal to human extrapolations. Here we present an historical overview of the understanding of OCD, highlighting converging studies and trends in neuroscience, psychiatry and neuropsychology, and how they influenced current perspectives on the nosology and phenomenology of this disorder.

Psychiatric disorders, myoclonus dystonia and SGCE: an international study

Objective

Myoclonus‐dystonia (M‐D) is a hyperkinetic movement disorder, typically alcohol‐responsive upper body myoclonus and dystonia. The majority of autosomal dominant familial cases are caused by epsilon‐sarcoglycan gene (SGCE) mutations. Previous publications have observed increased rates of psychiatric disorders amongst SGCE mutation‐positive populations. We analyzed the psychiatric data from four international centers, forming the largest cohort to date, to further determine the extent and type of psychiatric disorders in M‐D.

Methods

Psychiatric data from SGCE mutation‐positive M‐D cohorts, collected by movement disorder specialists in the Netherlands, United Kingdom, United States, and Germany, were analyzed. These data were collected using standardized, systematic questionnaires allowing classification of symptoms according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM‐IV) criteria. Based on motor findings and SGCE mutation analysis, participants were classified into one of three groups: manifesting carriers, nonmanifesting carriers and noncarriers.

Results

Data from 307 participants were evaluated (140 males, 167 females, mean age at examination: 42.5 years). Two‐thirds of motor affected mutation carriers (n = 132) had ≥1 psychiatric diagnosis, specific, and social phobias being most common followed by alcohol dependence and obsessive‐compulsive disorder (OCD). Compared to familial controls, affected mutation carriers had significantly elevated overall rates of psychiatric disorders (P < 0.001). The most significant differences were observed with alcohol dependence (P < 0.001), OCD (P < 0.001), social and specific phobias (P < 0.001).

Interpretation

M‐D due to SGCE mutations is associated with specific psychiatric disorders, most commonly OCD, anxiety‐related disorders, and alcohol dependence. These suggest either a potential pleiotropic function for SGCE within the central nervous system or a secondary effect of the motor disorder.

A study of diagnostic accuracy of the Florida Obsessive-Compulsive Inventory--Thai Version (FOCI-T)

BACKGROUND

The Florida Obsessive-Compulsive Inventory (FOCI) is a self-reported measure to assess the symptoms and severity of obsessive-compulsive disorder (OCD), which can be completed in five minutes. Although preliminary studies have shown its good psychometric properties, the study of receiver operating characteristics (ROC) to use it as a screening tool has never been reported elsewhere. This study aimed to use the ROC analysis to determine the optimal cut-off score of the Thai version of the FOCI (FOCI-T).

METHODS

A total of 197 participants completed the FOCI-T, the Patient Health Questionnaire (PHQ-9), and the Pictorial Thai Quality of Life (PTQL), and they were also interviewed with the Mini International Neuropsychiatric Interview (MINI) for their diagnosis. The ROC analyses of the FOCI-T Severity Scores were computed to determine the best cut-off score.

RESULTS

When the Thai version of the MINI was used in the interview, it was found that 38 participants were diagnosed with OCD, 43 participants were non-OCD, and 116 participants were healthy adults. The ROC analyses indicated that the FOCI-T Severity Scale could significantly distinguish OCD patients from non-OCD patients and healthy adults. The area under curve was estimated to be 0.945 (95%CI = 0.903-0.972). A cut-off score of ≥ 5 provided the best sensitivity (0.92) and specificity (0.82).

CONCLUSION

The Thai version of the Florida Obsessive-Compulsive Inventory has demonstrated its good predictive abilities, so it could be used as a brief screening tool to detect obsessive-compulsive disorder patients with high sensitivity and specificity.

Differences in duration of untreated illness, duration, and severity of illness among clinical phenotypes of obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a prevalent, disabling, and comorbid condition that is frequently under-recognized and poorly treated. OCD phenotypes may differ in terms of clinical presentation and severity. However, few studies have investigated whether clinical phenotypes differ in terms of latency to treatment (ie, duration of untreated illness[DUI]), duration, and severity of illness. The present study was aimed to quantify the aforementioned variables in a sample of OCD patients.

METHODS

One hundred fourteen outpatients with a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) diagnosis of OCD were recruited, and their main clinical features were collected. Severity of illness was assessed through the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and the main phenotypes were identified through the Y-BOCS Symptom Checklist. A one-way analysis of variance (ANOVA) test, followed by a Bonferroni post-hoc test, were performed to compare DUI, duration, and severity of illness across subgroups.

RESULTS

In the whole sample, the mean DUI exceeded 7 years (87.35±11.75 months), accounting for approximately half of the mean duration of illness (172.2±13.36 months). When subjects were categorized into 4 main clinical phenotypes, respectively, aggressive/checking (n=31), contamination/cleaning (n=37), symmetry/ordering (n=32), and multiple phenotypes (n=14), DUI, duration, and severity of illness resulted significantly higher in the aggressive/checking subgroup, compared to other subgroups (F=3.58, p<0.01; F=3.07, p<0.01; F=4.390, p<0.01).

DISCUSSION

In a sample of OCD patients, along with a mean latency to treatment of approximately 7 years, regardless of the phenotype, patients had spent half of their duration of illness (DI) without being treated. DUI, duration, and severity of illness resulted significantly higher in the aggressive/checking subgroup.

Obsessive-compulsive symptoms among alcoholics in outpatient treatment: Prevalence, severity and correlates

The literature on symptoms of obsessive-compulsive disorder (OCD) in alcoholic patients is scarce and such symptoms can go unnoticed, worsening the prognosis of alcoholism. The objectives were to estimate the prevalence and severity of obsessive-compulsive symptoms in alcoholics undergoing outpatient treatment and to assess sociodemographic and clinical correlates, including suicidal behaviors. The instruments used in this cross-sectional study were the Obsessive-Compulsive Inventory - Revised (OCI-R), the Short Alcohol Dependence Data and the Beck Depression Inventory. After descriptive analyses, bivariate analyses between the categorical ("probable OCD": OCI-R≥27) and dimensional (OCI-R total and subscales scores) outcomes and all explanatory variables were conducted. Eleven (20.4%) of the 54 alcoholic patients (37 men and 17 women) presented "probable OCD", which was associated with lower income, more severe dependence, depression, lifetime suicidal thoughts and plans and suicide attempts. OCI-R severity (mean 16.0) was associated with the same predictors and with psychiatric hospitalization. Suicidal behaviors were mainly associated with the Obsession, Hoarding and Washing subscales. It is essential to investigate and treat OCD symptoms in alcoholics, as they are associated with greater severity of dependence, depression and suicidal behaviors. Longitudinal studies are required to assess the impact of OCD treatment on the clinical course of alcoholism.

External Criticism by Parents and Obsessive Beliefs in Adolescents: Mediating Role of Beliefs associated with Inflated Responsibility

BACKGROUND & OBJECTIVES

Obsessive-compulsive disorder (OCD) is considered as a rare disorder in children. According to cognitive theories, criticism triggers responsibility behavior and thus causes obsessive behaviors. The purpose of the present study was to investigate the mediating role of beliefs associated with responsibility in the relationship between external criticism of parents and obsessive beliefs in adolescents.

MATERIALS & METHODS

In this study, 547 high school students aged from 15 to18 years were selected using multi-stage cluster random sampling from four regions of the education office in Shiraz. Obsessive Beliefs Questionnaire-child version (OBQ-CV), Pathway to Inflated Responsibility beliefs Scale (PIRBS), and perceived criticism questionnaire were used to collect data. Pearson's correlation was used to investigate the relationship between the study variables. For analysis of mediation model, multiple mediators analysis using Macro Software was used.

RESULTS

External criticism only indirectly and through beliefs associated with inflated responsibility accounts for 6% of the variance of responsibility, 14% of the variance of threat estimation and 10% of the variance of perfectionism of obsessive beliefs (P<0.05). However, external criticism, both directly and indirectly and through beliefs associated with inflated responsibility accounts for 7% of the variance of the importance of obsessive beliefs.

CONCLUSION

This study showed that the beliefs associated with inflated responsibility can mediate the relationship between external criticism and obsessive beliefs. According to the cognitive model of Salkovskis, criticism by parents, as a violation to and an influence on children, by affecting the subscales of inflated responsibility, can increase the symptoms of obsessive-compulsive disorder. In order to identify potential affecting mechanisms of criticism on obsessive-compulsive disorder, further experimental research is required.

Obsessive-compulsive disorder (OCD): Practical strategies for pharmacological and somatic treatment in adults

This narrative review gathers together a range of international experts to critically appraise the existing trial-based evidence relating to the efficacy and tolerability of pharmacotherapy for obsessive compulsive disorder in adults. We discuss the diagnostic evaluation and clinical characteristics followed by treatment options suitable for the clinician working from primary through to specialist psychiatric care. Robust data supports the effectiveness of treatment with selective serotonin reuptake inhibitors (SSRIs) and clomipramine in the short-term and the longer-term treatment and for relapse prevention. Owing to better tolerability, SSRIs are acknowledged as the first-line pharmacological treatment of choice. For those patients for whom first line treatments have been ineffective, evidence supports the use of adjunctive antipsychotic medication, and some evidence supports the use of high-dose SSRIs. Novel compounds are also the subject of active investigation. Neurosurgical treatments, including ablative lesion neurosurgery and deep brain stimulation, are reserved for severely symptomatic individuals who have not experienced sustained response to both pharmacological and cognitive behavior therapies.

Obsessive-compulsive symptom dimensions in a population-based, cross-sectional sample of school-aged children

BACKGROUND

Obsessive-compulsive disorder can be expressed as four potentially overlapping obsessive-compulsive symptom (OCS) dimensions (OCSD) ("symmetry/ordering", "contamination/cleaning", "aggressive/sexual/religious" and "collecting/hoarding"). In clinical samples, some dimensions are more familial and associated with increased psychiatric comorbidity and malfunctioning. However, data concerning OCS and OCSD are scarce in non-clinical samples, particularly among children. The present study aims to estimate: (1) the prevalence and sex/age distribution of OCS/OCSD in a community-based sample of schoolchildren; (2) the association between OCS and additional clinical factors; and (3) the degree of familial aggregation of OCS/OCSD.

METHODS

OCS and OCSD were evaluated in 9937 Brazilian school-children (6-12 years-old) and their biological relatives using the Family History Screen. Data analyses included gradient estimated equations and post-hoc tests.

RESULTS

We included data on 9937 index-children, 3305 siblings (13-18 years-old), and 16,218 parents. Biological mothers were the informants in 87.6% of the interviews. OCS were present in 14.7% of the index-children; 15.6% of their siblings; 34.6% of their mothers and 12.1% of their fathers. The prevalence of OCS and each of the OCSD gradually increased from ages 6 to 12 years. Overall, OCS in children were associated with the presence of other psychiatric symptoms, as well as behavioral/school impairment. OCS and each of the four OCSD aggregated significantly within families.

CONCLUSIONS

OCS are prevalent and associated with psychiatric symptoms and clinical impairment among school-aged children. OCSD aggregate within families in a dimension-specific fashion. These findings suggest a natural continuum between OCS and OCD with regard to their dimensional character.

Emotional perception and theory of mind in first episode psychosis: the role of obsessive-compulsive symptomatology

The aim of the present study was to investigate the effects of comorbid obsessive-compulsive symptoms on emotional perception and theory of mind (ToM) in patients with first-episode psychosis. Participants were 65 patients with non-affective first episode psychosis (FEP) and 47 healthy controls. The patient group was divided into two subgroups, those with (FEP+; n=38) and those without obsessive-compulsive symptomatology (FEP-; n=27). Emotion perception and ToM were assessed with the Perception of Social Inference Test. Severity of psychotic and obsessive-compulsive symptoms was assessed with the Positive and Negative Syndrome Scale (PANSS) and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), respectively. Deficits in emotion recognition and theory of mind were confirmed in patients with non-affective first-episode psychosis compared to healthy controls. In patients, comorbidity with obsessive-compulsive symptoms was associated with worse performance on certain aspects of social cognition (ToM 2nd order) compared to FEP- patients. Our findings of impaired emotion perception and ToM in patients with first-episode psychosis support the hypothesis that deficits are already present at illness onset. Presence of OCS appears to have further deleterious effects on social cognition, suggesting that these patients may belong to a schizo-obsessive subtype of schizophrenia characterized by more extensive neurobiological impairment.

Repetitive transcranial magnetic stimulation (rTMS) augmentation of selective serotonin reuptake inhibitors (SSRIs) for SSRI-resistant obsessive-compulsive disorder (OCD): a meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Randomized controlled trials (RCTs) on repetitive transcranial magnetic stimulation (rTMS) as augmentation of selective serotonin reuptake inhibitors (SSRIs) for SSRI-resistant obsessive-compulsive disorder (OCD) have yielded conflicting results. Therefore, this meta-analysis was conducted to assess the efficacy of this strategy for SSRI-resistant OCD.

METHODS

Scientific and medical databases, including international databases (PubMed, MEDLINE, EMBASE, CCTR, Web of Science, PsycINFO), two Chinese databases (CBM-disc, CNKI), and relevant websites dated up to July 2014, were searched for RCTs on this strategy for treating OCD. Mantel-Haenszel random-effects model was used. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score, response rates and drop-out rates were evaluated.

RESULTS

Data were obtained from nine RCTs consisting of 290 subjects. Active rTMS was an effective augmentation strategy in treating SSRI-resistant OCD with a pooled WMD of 3.89 (95% CI = [1.27, 6.50]) for reducing Y-BOCS score and a pooled odds ratio (OR) of 2.65 (95% CI = [1.36, 5.17] for response rates. No significant differences in drop-out rates were found. No publication bias was detected.

CONCLUSION

The pooled examination demonstrated that this strategy seems to be efficacious and acceptable for treating SSRI-resistant OCD. As the number of RCTs included here was limited, further large-scale multi-center RCTs are required to validate our conclusions.

Impulsive and compulsive behaviors in Parkinson's disease

BACKGROUND

Impulsive and compulsive behaviors (ICBs) are a heterogeneous group of conditions that may be caused by long-term dopaminergic replacement therapy (DRT) of Parkinson's disease (PD). The spectrum of ICBs includes dopamine dysregulation syndrome (DDS), punding, and impulse control disorders (ICDs).

CONTENTS

We made a detailed review regarding the epidemiology, pathology, clinical characteristics, risk factors, diagnosis as well as treatment of ICBs.

RESULTS

The prevalence of ICBs in PD patients is approximately 3-4% for DDS, 0.34-4.2% for punding, and 6-14% for ICDs, with higher prevalence in Western populations than in Asian. Those who take high dose of levodopa are more prone to have DDS, whereas, ICDs are markedly associated with dopamine agonists. Different subtypes of ICBs share many risk factors such as male gender, higher levodopa equivalent daily dose, younger age at PD onset, history of alcoholism, impulsive, or novelty-seeking personality. The Questionnaire for Impulsive-Compulsive Disorder in Parkinson's Disease-Rating Scale seems to be a rather efficacious instrument to obtain relevant information from patients and caregivers. Treatment of ICBs is still a great challenge for clinicians. Readjustment of DRT remains the primary method. Atypical antipsychotics, antidepressants, amantadine, and psychosocial interventions are also prescribed in controlling episodes of psychosis caused by compulsive DRT, but attention should be drawn to balance ICBs symptoms and motor disorders. Moreover, deep brain stimulation of the subthalamic nucleus might be a potential method in controlling ICBs.

CONCLUSION

The exact pathophysiological mechanisms of ICBs in PD remains poorly understood. Further researches are needed not only to study the pathogenesis, prevalence, features, and risk factors of ICBs, but to find efficacious therapy for patients with these devastating consequences.

Declining transition rates to psychosis: the role of diagnostic spectra and symptom overlaps in individuals with attenuated psychosis syndrome

Transition to psychosis in at-risk individuals has markedly declined in recent years. So far it has never been discussed in detail that with the growing awareness and increasing availability of early psychosis services, a much broader diagnostic spectrum is now being seen in these services. Subsequently, subjects present with symptoms that meet psychosis risk on a purely psychometric basis but may be the phenotypical expression of another underlying mental disorder. Here we critically review four groups of symptoms and clinical features that are frequently reported by individuals with suspected psychosis risk states, yet share strong commonalities with other mental disorders and conditions: isolated hallucinations; unusual bodily perceptions, hypochondriatic fears and cenesthetic psychotic symptoms; depersonalization; obsessive-compulsive, overvalued and delusional ideas. Of the 616 individuals so far assessed in the Bruderholz Early Psychosis Outpatient Service for Adolescents and Young Adults, 218 (30.5%) met ultra-high risk (UHR) criteria, 188 (86.2%) of whom suffered from one of the four above-mentioned symptom groups. The appraisal of the diagnostic spectra and their overlapping symptoms constitute a tremendous challenge in the clinical assessment of each referred individual. The final conclusion of a clinical assessment should not end with the mere assignment - or non-assignment - to a presumed psychosis risk group, but needs to take into account the 'Gestalt' of these particular symptoms and clinical features and thus be based on many more facets than solely a psychometric or nosological approach. Such an approach may break down the heterogeneous psychosis risk group and enable appropriate treatment regimes.

Second generation antipsychotic-induced obsessive-compulsive symptoms in schizophrenia: a review of the experimental literature

Second generation antipsychotics (SGAs) have been implicated in the de novo emergence and exacerbation of obsessive-compulsive symptoms (OCS) in patients with schizophrenia. Among SGAs, clozapine, olanzapine, and risperidone are the most prominent agents associated with these sequelae, according to case reports. Comorbid OCS can impede recovery by compromising treatment benefits, medication compliance, and clinical prognoses. Previous reviews of SGA-induced OCS have predominantly focused on descriptive case reports, with limited attention paid toward experimental findings. To address this paucity of data, we sought to review the effects of SGAs on OCS in schizophrenia in the experimental literature, while addressing the role of different treatment (duration, dose, serum levels) and pharmacogenetic factors. Our findings suggest that clozapine confers the greatest risk of OCS in schizophrenia, with 20 to 28% of clozapine-treated patients experiencing de novo OCS, in addition to 10 to 18% incurring an exacerbation of pre-existing OCS. Clozapine can also yield full threshold obsessive-compulsive disorder (OCD), in some cases. Olanzapine is another high risk drug for secondary OCS which occurs in 11 to 20% of schizophrenic patients receiving olanzapine therapy. At this time, there is insufficient experimental evidence to characterize the effects of other SGAs on OCS. Despite some experimental support for the involvement of longer treatment duration and genetic factors in mediating drug-induced OCS, more research is needed to clearly elucidate these associations. Based on these results, schizophrenic patients should be routinely monitored for OCS throughout the course of SGA treatment, particularly when clozapine or olanzapine is administered.

Internet-delivered cognitive behavior therapy for adolescents with obsessive-compulsive disorder: an open trial

BACKGROUND

International guidelines recommend Cognitive Behavior Therapy (CBT) as the first line treatment for pediatric obsessive-compulsive disorder (OCD). However, a substantial proportion of patients do not have access to such treatment. We developed and tested the feasibility, efficacy and acceptability of a novel therapist-guided, Internet-delivered CBT (ICBT) platform for adolescents with OCD.

METHODS

An interactive, age-appropriate ICBT platform ("BiP OCD") was developed. Twenty-one adolescents (12-17 years) with a DSM-IV diagnosis of OCD and their parents were enrolled in the study. All participants received 12 weeks of ICBT with therapist support. The primary outcome measure was the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Acceptability was assessed at post-treatment.

RESULTS

Participants completed on average 8.29 (SD = 3.0) of the 12 treatment chapters. Treatment yielded significant improvements on all clinician-, parent- and most self-administered outcome measures, with a large effect size of d = 2.29 (95% CI 1.5-3.07) on the CY-BOCS. Patients continued to improve at follow-up. At 6-month follow-up, 71% were classified as responders (≥35% decrease on the CY-BOCS) and 76% as being in remission (CY-BOCS score ≤12). Average clinician support time was less than 20 minutes per patient per week. The majority of participants felt that BiP OCD was age-appropriate and rated the treatment as good or very good.

CONCLUSIONS

ICBT could be efficacious, acceptable, and cost-effective for adolescents with OCD. More rigorously controlled studies are needed to further evaluate the treatment.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT01809990.

Excluding the typical patient: thirty years of pharmacotherapy efficacy trials for obsessive-compulsive disorder

BACKGROUND

Over the past 30 years, clinical trials have resulted in several successful pharmacotherapies for obsessive-compulsive disorder (OCD), yet patients in clinical settings often report inadequate response. This study compares clinical characteristics of treatment-seeking OCD patients to the inclusion/exclusion criteria used in pharmacotherapy trials.

METHODS

The sample consisted of 325 community members with a DSM-IV diagnosis of OCD who underwent systematic interviews with clinicians knowledgeable in the diagnosis and treatment of OCD. We compiled pharmacotherapy studies for OCD published between 1980 and 2010 using Medline, PubMed, and library resources, and estimated the proportion of patients in each decade satisfying the most common inclusion/exclusion criteria.

RESULTS

We included 39 clinical trials and found 72% of the 325 patients would have been excluded from trials conducted between 1980 and 2010. Exclusion was projected as dramatically lower for trials conducted between 1980 and 1989 (19.7%) compared with 74.8% for trials conducted between 1990 and 1999 and 76.9% for trials between 2000 and 2010.

CONCLUSIONS

The majority of treatment-seeking individuals with OCD would not qualify for OCD treatment studies due to comorbid psychiatric disorders, and failure to meet OCD severity threshold criteria. This illustrates the need to include a more community-representative sample of OCD patients in clinical trials examining pharmacotherapy efficacy.

Late-onset obsessive-compulsive disorder: risk factors and correlates

BACKGROUND

While a great amount of attention has been paid to early-onset obsessive-compulsive disorder (OCD), there is a dearth of studies on patients showing OCD for the first time at later stages of life. In this study, we aimed at determining possible risk factors/correlates for OCD onset at or after age 40, here termed late-onset OCD.

METHOD

A series of models including several potential variables associated with late onset OCD were tested using a monolayer neural network. To this regard, data from the Brazilian Research Consortium of Obsessive-Compulsive Spectrum Disorders (CTOC) (n = 1001) was employed. For the purposes of this study, we considered a diagnosis of late onset OCD to be present whenever distress and interference associated with OCD symptoms emerged at or after age 40. Different nested models were compared through the Akaike Criteria keeping the variables with p value ≤0.05.

RESULTS

Late-onset OCD occurred in 8.6% of the sample. A model including female sex, a history of chronic (>10 years) subclinical obsessive-compulsive symptoms, the co-occurrence of posttraumatic stress disorder (PTSD) after age 40, and a history of recent pregnancy in self or significant others was able to explain a sizeable proportion of late-onset OCD. The general performance of this model, represented by the Maximum Likelihood R2, was 29.4%.

CONCLUSION

Our results suggest that late-onset OCD is more likely to occur in females, in individuals with long periods of subclinical obsessive-compulsive symptoms, and in association with a major traumatic event occurring after age 40 and a history of recent pregnancy in self or in significant others.

Dissemination of Evidence-Based Treatment for Pediatric Obsessive-Compulsive Disorder in the Southern Region of Brazil: Challenges and Future Directions

Pediatric obsessive-compulsive disorder (OCD) is a prevalent condition that responds well to specialized treatment including cognitive behavioral therapy (CBT) or serotonin reuptake inhibitors or their combination. In Brazil, the dissemination of evidence-based treatment for pediatric OCD is hindered because of the peculiarities of the health system. The presence of a multitiered health system (public, insured, and private) with insufficient investment in public mental health and relative inaccessibility of insured/private care for most of the Brazilian population make the implementation of specialized OCD treatment centers largely unavailable in Brazil. Furthermore, lack of appropriate training in child mental health, CBT, and evidence-based approaches to OCD in current psychiatry and psychology training programs further impede improvement in diagnosis and treatment. The challenges faced in the current system in Brazil will be discussed and also strategies and programs that are currently being implemented in the south of Brazil to help address the gaps in treatment for pediatric patients with OCD.

Spanish version of the Dimensional Obsessive-Compulsive Scale (DOCS): psychometric properties and relation to obsessive beliefs

OBJECTIVES

Our main goal was to provide the psychometric properties of the Spanish version of the Dimensional Obsessive-Compulsive Scale (DOCS) in a non-clinical sample (n = 237) and in adult patients with Obsessive-Compulsive Disorder (OCD) (n = 110). We also examined the association between OC symptom dimensions and obsessive beliefs.

METHODS

The psychometric properties involved four steps: reliability, structural validity, convergent and discriminant validity and diagnostic sensitivity. Linear regression analyses were used to assess the associations between OC symptoms and obsessive beliefs.

RESULTS

Exploratory and confirmatory factor analyses replicated the original four-factor structure in both samples. The DOCS showed good performance in terms of internal consistency, test-retest reliability and convergent validity in both samples. The DOCS showed better diagnostic sensitivity than another self-report instrument of OC symptoms, the Obsessive-Compulsive Inventory Revised. Findings of the relationship between obsessive beliefs and OC symptoms revealed that certain obsessive beliefs predicted specific OC symptom dimensions.

CONCLUSIONS

The Spanish version of the DOCS has similar psychometric properties than the original English instrument, although its performance is somewhat better in OCD patients than in students. It will be important to ascertain its ability to discriminate OCD from other associated disorders.