Separation anxiety disorder in OCD

Towards a definitive symptom structure of obsessive-compulsive disorder: a factor and network analysis of 87 distinct symptoms in 1366 individuals

BACKGROUND

The symptoms of obsessive-compulsive disorder (OCD) are highly heterogeneous and it is unclear what is the optimal way to conceptualize this heterogeneity. This study aimed to establish a comprehensive symptom structure model of OCD across the lifespan using factor and network analytic techniques.

METHODS

A large multinational cohort of well-characterized children, adolescents, and adults diagnosed with OCD (N = 1366) participated in the study. All completed the Dimensional Yale-Brown Obsessive-Compulsive Scale, which contains an expanded checklist of 87 distinct OCD symptoms. Exploratory and confirmatory factor analysis were used to outline empirically supported symptom dimensions, and interconnections among the resulting dimensions were established using network analysis. Associations between dimensions and sociodemographic and clinical variables were explored using structural equation modeling (SEM).

RESULTS

Thirteen first-order symptom dimensions emerged that could be parsimoniously reduced to eight broad dimensions, which were valid across the lifespan: Disturbing Thoughts, Incompleteness, Contamination, Hoarding, Transformation, Body Focus, Superstition, and Loss/Separation. A general OCD factor could be included in the final factor model without a significant decline in model fit according to most fit indices. Network analysis showed that Incompleteness and Disturbing Thoughts were most central (i.e. had most unique interconnections with other dimensions). SEM showed that the eight broad dimensions were differentially related to sociodemographic and clinical variables.

CONCLUSIONS

Future research will need to establish if this expanded hierarchical and multidimensional model can help improve our understanding of the etiology, neurobiology and treatment of OCD.

Are anxiety disorders a pathway to obsessive-compulsive disorder? Different trajectories of OCD and the role of death anxiety

OBJECTIVES

A body of research has demonstrated high rates of comorbidity among individuals with obsessive-compulsive disorder (OCD). Further, recent empirical evidence has demonstrated the relevance of death anxiety in OCD. Given that the trajectory towards OCD remains unclear, the current study aimed to examine which disorders individuals typically experience prior to the onset of this disorder. Further, the study aimed to explore the role of death anxiety in the developmental pathways to the disorder.

METHODS

The present study involved administering a measure of death anxiety and conducting structured diagnostic interviews among a treatment-seeking sample of 98 individuals with OCD.

RESULTS

First, the findings revealed a number of anxiety-related disorders commonly experienced prior to the development of OCD, the most frequent of which were separation anxiety disorder, specific phobias, and generalised anxiety disorder. Second, consistent with hypotheses, individuals with higher death anxiety experienced more disorders prior to the onset of OCD. Conversely, those with lower fears of death were significantly more likely to develop OCD as their first disorder.

CONCLUSIONS

These findings support the argument that death anxiety may influence the trajectory towards OCD, and the comorbidity among anxiety-related disorders. However, further research is needed to clarify whether death anxiety plays a causal role in this trajectory.

The separation of adult separation anxiety disorder

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) categorization of mental disorders places "separation anxiety disorder" within the broad group of anxiety disorders, and its diagnosis no longer rests on establishing an onset during childhood or adolescence. In previous editions of DSM, it was included within the disorders usually first diagnosed in infancy, childhood, or adolescence, with the requirement for an onset of symptoms before the age of 18 years: symptomatic adults could only receive a retrospective diagnosis, based on establishing this early onset. The new position of separation anxiety disorder is based upon the findings of epidemiological studies that revealed the unexpectedly high prevalence of the condition in adults, often in individuals with an onset of symptoms after the teenage years; its prominent place within the DSM-5 group of anxiety disorders should encourage further research into its epidemiology, etiology, and treatment. This review examines the clinical features and boundaries of the condition, and offers guidance on how it can be distinguished from other anxiety disorders and other mental disorders in which "separation anxiety" may be apparent.

Dependent personality, separation anxiety disorder and other anxiety disorders in OCD

BACKGROUND

The purpose of this study was to investigate whether dependent personality and/or general personality dimensions might explain the strong relationships between separation anxiety disorder (Sep-AD) and three other anxiety disorders (agoraphobia, panic disorder and social anxiety disorder) in individuals with obsessive compulsive disorder (OCD).

METHODS

Using data from 509 adult participants collected during the OCD Collaborative Genetic Study, we used logistic regression models to evaluate the relationships between Sep-AD, dependent personality score, general personality dimensions and three additional anxiety disorders.

RESULTS

The dependent personality score was strongly associated with Sep-AD and the other anxiety disorders in models adjusted for age at interview, age at onset of OC symptoms and worst ever OCD severity score. Several general personality dimensions, especially neuroticism, extraversion and conscientiousness, were also related to Sep-AD and the other anxiety disorders. Sep-AD was not independently related to these anxiety disorders, in multivariate models including general personality and dependent personality disorder scores.

CONCLUSIONS

The results suggest that Sep-AD in childhood and these other anxiety disorders in adulthood are consequences of dependent personality disorder (for agoraphobia and panic disorder) or introversion (for social phobia). It is unknown whether these results would be similar in a non-OCD sample.

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.

A prospective study of paediatric obsessive-compulsive symptomatology in a Spanish community sample

The obsessive-compulsive manifestations course was assessed with the Leyton obsessional inventory-child version survey (LOI-CV) in a 3-year prospective study, using a non-clinical sample. From an initial sample of 1,514 school-age children who underwent symptoms screening for obsessive-compulsive, anxiety and depression, 562 subjects (risk group/without risk group) were re-assessed in the 2nd phase and 242 subjects were monitored after 3 years. LOI-CV scores significantly decreased over time independently of age and gender. The prevalence, persistence and incidence for two levels of severity of obsessive–compulsive manifestations ranged between 4.8-30.4%, 9.3-28.4% and 1.1-14.4%, respectively. 34.6-64.5% of obsessive-compulsive symptomatology was predicted by anxiety, depressive and obsessive-compulsive symptoms. For the obsessiveness (less severe form of obsessive-compulsive manifestations), the depressive symptoms were not predictors. Gender and socioeconomic status were not related with obsessive-compulsive manifestations. These data support a substantial continuity of the obsessive-compulsive manifestations and the existence of different levels of severity within the obsessive-compulsive spectrum.

Separation anxiety disorder in adult patients with obsessive-compulsive disorder: prevalence and clinical correlates

OBJECTIVE

Individuals with obsessive-compulsive disorder (OCD) and separation anxiety disorder (SAD) tend to present higher morbidity than do those with OCD alone. However, the relationship between OCD and SAD has yet to be fully explored.

METHOD

This was a cross-sectional study using multiple logistic regression to identify differences between OCD patients with SAD (OCD+SAD, n=260) and without SAD (OCD, n=695), in terms of clinical and socio-demographic variables. Data were extracted from those collected between 2005 and 2009 via the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders project.

RESULTS

SAD was currently present in only 42 (4.4%) of the patients, although 260 (27.2%) had a lifetime diagnosis of the disorder. In comparison with the OCD group patients, patients with SAD+OCD showed higher chance to present sensory phenomena, to undergo psychotherapy, and to have more psychiatric comorbidities, mainly bulimia.

CONCLUSION

In patients with primary OCD, comorbid SAD might be related to greater personal dysfunction and a poorer response to treatment, since sensory phenomena may be a confounding aspect on diagnosis and therapeutics. Patients with OCD+SAD might be more prone to developing specific psychiatric comorbidities, especially bulimia. Our results suggest that SAD symptom assessment should be included in the management and prognostic evaluation of OCD, although the psychobiological role that such symptoms play in OCD merits further investigation.

Analysis of the interplay between depression, anxiety, and psychological resources in adolescence using self-report measures

OBJECTIVE

Following recent literature which stresses the importance of broadening the conceptualization of mental functioning in youth, this paper aims to investigate structural relations between indicators of anxiety, depressive symptoms, and psychological resources in non-referred Italian adolescents, as captured by the Strengths and Difficulties Questionnaire (SDQ; Goodman 2001 ), the Spence Children's Anxiety Scale (SCAS; Spence 1998 ) and the Children Depression Inventory (CDI; Kovacs 1992 ).

METHODS

A hierarchical model which considers both the interplays and overlaps between these instruments is tested by means of Confirmatory Factor Analysis, in order to explore the possibility to use the three tools within a meaningful screening battery. First, validity and reliability of SDQ, SCAS, and CDI is successfully controlled thanks to three appropriate preliminary studies, an evidence not already acquired in the Italian context for the adolescent population. Then, the focal study devises and tests a model that merges indicators of the SDQ, SCAS, and CDI scales into four correlated factors, that is, Psychological Resources, Externalized behavior problems, Internalized Fear and Internalized Anxious Misery.

CONCLUSIONS

Overall, findings corroborate the combined use of SDQ, SCAS, and CDI as a screening battery for the assessment of mental functioning in youth adopting a dimensional rather than a categorical approach.

Panic Disorder and Agoraphobia in OCD patients: clinical profile and possible treatment implications

OBJECTIVE

Panic Disorder (PD) and agoraphobia (AG) are frequently comorbid with obsessive-compulsive disorder (OCD), but the correlates of these comorbidities in OCD are fairly unknown. The study aims were to: 1) estimate the prevalence of PD with or without AG (PD), AG without panic (AG) and PD and/or AG (PD/AG) in a large clinical sample of OCD patients and 2) compare the characteristics of individuals with and without these comorbid conditions.

METHOD

A cross-sectional study with 1001 patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders using several assessment instruments, including the Dimensional Yale-Brown Obsessive-Compulsive Scale and the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. Bivariate analyses were followed by logistic regression models.

RESULTS

The lifetime prevalence of PD was 15.3% (N=153), of AG 4.9% (N=49), and of PD/AG 20.2% (N=202). After logistic regression, hypochondriasis and specific phobia were common correlates of the three study groups. PD comorbidity was also associated with higher levels of anxiety, having children, major depression, bipolar I, generalized anxiety and posttraumatic stress disorders. Other independent correlates of AG were: dysthymia, bipolar II disorder, social phobia, impulsive-compulsive internet use, bulimia nervosa and binge eating disorder. Patients with PD/AG were also more likely to be married and to present high anxiety, separation anxiety disorder, major depression, impulsive-compulsive internet use, generalized anxiety, posttraumatic stress and binge eating disorders.

CONCLUSIONS

Some distinct correlates were obtained for PD and AG in OCD patients, indicating the need for more specific and tailored treatment strategies for individuals with each of these clinical profiles.

Trajectory in obsessive-compulsive disorder comorbidities

The main goal of this study is to contribute to the understanding of the trajectory of comorbid disorders associated with obsessive-compulsive disorder (OCD) according to the first manifested psychiatric disorder and its impact in the clinical course of OCD and subsequent psychiatric comorbidities. One thousand and one OCD patients were evaluated at a single time point. Standardized instruments were used to determine the current and lifetime psychiatric diagnoses (Structured Clinical Interview for DSM-IV Axis I and for impulse-control disorders) as well as to establish current obsessive-compulsive, depressive and anxiety symptom severity (Yale-Brown Obsessive-Compulsive Scale; Dimensional Yale-Brown Obsessive-Compulsive Scale, Beck Depression and Anxiety Inventories and the OCD Natural History Questionnaire). To analyze the distribution of comorbidities according to age at onset Bayesian approach was used. Five hundred eight patients had the first OC symptom onset till the age of 10 years old. The first comorbidity to appear in the majority of the sample was separation anxiety disorder (17.5%, n=175), followed by ADHD (5.0%, n=50) and tic disorders (4.4%, n=44). OCD patients that presented with separation anxiety disorder as first diagnosis had higher lifetime frequency of post-traumatic stress disorder (p=0.003), higher scores in the Sexual/Religious dimension (p=0.04), Beck Anxiety (p<0.001) and Depression (p=0.005) Inventories. OCD patients that initially presented with ADHD had higher lifetime frequencies of substance abuse and dependence (p<0.001) and worsening OCD course (p=0.03). OCD patients that presented with tic disorders as first diagnosis had higher lifetime frequencies of OC spectrum disorders (p=0.03). OCD is a heterogeneous disorder and that the presence of specific comorbid diagnoses that predate the onset of OCD may influence its clinical presentation and course over the lifetime.

The parametric, psychological, neuropsychological, and neuroanatomical properties of self and world evaluation

BACKGROUND

As an individual moves from adolescence to adulthood, they need to form a new sense of self as their environment changes from a limited to a more expansive structure. During this critical stage in development the last dramatic steps of neural development occur and numerous psychiatric conditions begin to manifest. Currently, there is no measure that aids in the quantification of how the individual is adapting to, and conceptualizing their role in, these new structures. To fill this gap we created the Self and World Evaluation Expressions Test(SWEET).

METHOD

Sixty-five young adults (20.6 years-old), 36 with a history of drug use, completed the SWEET. A factor analysis was performed on the SWEET and the resultant factors were correlated with psychological, neuropsychological, and neuroanatomical battery that included both T1-wieghted and diffusion tensor magnetic resonance imaging scans.

RESULTS

WE DERIVED FOUR FACTORS: Self, Social-Emotional, Financial-Intellectual, and Spirituality. While showing limited relationships to psychological and neuropsychological measures, both white matter integrity and gray matter density showed significant relationships with SWEET factors.

CONCLUSIONS

These findings suggest that while individual responses may not be indicative of psychological or cognitive processes they may relate to changes in brain structure. Several of these structures, such as the negative correlation of the affective impact of world with the dorsal anterior corpus callosum white matter integrity have been observed in psychiatric conditions (e.g., obsessive-compulsive disorder). Further longitudinal research using the SWEET may help understand the impact of dramatic shifts in self/world conceptualization and potentially link these shifts to underlying changes in brain structure.