Obsessive-compulsive disorder: subclassification based on co-morbidity

Exploring latent clusters in pediatric OCD based on symptoms, severity, age, gender, and comorbidity

Given diverse symptom expression and high rates of comorbid conditions, the present study explored underlying commonalities among OCD-affected children and adolescents to better conceptualize disorder presentation and associated features. Data from 830 OCD-affected participants presenting to OCD specialty centers was aggregated. Dependent mixture modeling was used to examine latent clusters based on their age- and gender adjusted symptom severity (as measured by the Children's Yale-Brown Obsessive-Compulsive Scale; CY-BOCS), symptom type (as measured by factor scores calculated from the CY-BOCS symptom checklist), and comorbid diagnoses (as assessed via diagnostic interviews). Fit statistics favored a four-cluster model with groups distinguished primarily by symptom expression and comorbidity type. Fit indices for 3-7 cluster models were only marginally different and characteristics of the clusters remained largely stable between solutions with small clusters of distinct presentations added in more complex models. Rather than identifying a single classification system, the findings support the utility of integrating dimensional, developmental, and transdiagnostic information in the conceptualization of OCD-affected children and adolescents. Identified clusters point to the centrality of contamination concerns to OCD, relationships between broader symptom expression and higher levels of comorbidity, and the potential for complex/neurodevelopmental presentations.

Early-onset obsessive-compulsive disorder: Sociodemographic and clinical characterization of a large outpatient cohort

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a prevalent and disabling condition characterized by a wide variety of phenotypic expressions. Several studies have reinforced the hypothesis of OCD heterogeneity by proposing subtypes based on predominant symptomatology, course, and comorbidities. Early-onset OCD (EO) could be considered a neurodevelopmental subtype of OCD, with evidence of distinct neurocircuits supporting disease progression. To deepen the heterogeneous nature of the disorder, we analyzed sociodemographic and clinical differences between the EO and late-onset (LO) subtypes in a large outpatient cohort.

METHODS

Two hundred and eighty-four patients diagnosed with OCD were consecutively recruited from the OCD Tertiary Clinic at Luigi Sacco University Hospital in Milan. Sociodemographic and clinical variables were analyzed for the entire sample and compared between the two subgroups (EO, age <18 years [n = 117,41.2 %]; LO: late-onset, age ≥18 years [n = 167, 58.8 %]).

RESULTS

The EO group showed a higher frequency of male gender (65 % vs 42.5 %, p < .001), and a higher prevalence of Tic and Tourette disorders (9.4 % vs 0 %, p < .001) compared to the LO group. Additionally, in the EO subgroup, a longer duration of untreated illness was observed (9.01 ± 9.88 vs 4.81 ± 7.12; p < .001), along with a lower presence of insight (13.8 % vs. 7.5 %, p < .05).

CONCLUSIONS

The early-onset OCD subtype highlights a more severe clinical profile compared to the LO group. Exploring distinct manifestations and developmental trajectories of OCD can contribute to a better definition of homogeneous subtypes, useful for defining targeted therapeutic strategies for treatment.

The natural history of lifetime psychiatric disorders in patients with obsessive-compulsive disorder followed over half a century

OBJECTIVE

Few long-term studies have examined the life-time prevalence of comorbid psychiatric conditions in patients with obsessive-compulsive disorder (OCD). We therefore studied the frequency of comorbid psychiatric disorders, and their relation to onset and prognosis, in patients with OCD who were followed for almost half a century.

METHODS

During 1947-1953, 285 OCD patients were admitted as inpatients to a university hospital in Gothenburg, Sweden. Among those, 251 (88%) accepted a structured comprehensive psychiatric examination in 1954-1956. In 1989-1993, 176 survivors were eligible and 144 (response rate 82%) were re-examined. The same psychiatrist performed both examinations. OCD was diagnosed according to the Schneider criteria, and other mental disorders according to DSM-IV. Mean follow-up since onset was 47 years.

RESULTS

The lifetime frequency of depressive disorders was 84.7% (major depression 43.8%), generalized anxiety disorder (GAD) 71.5%, panic anxiety disorder 47.9%, agoraphobia 52.1%, specific phobias 64.6%, social phobia 47.9%, paranoid conditions 40.3% (29.1% paranoid ideation), psychotic disorders 15.3%, alcohol abuse 13.2% (men 39%, women 3%) and substance abuse 17.4%. Specific phobia most often started before OCD, while depression had a varied onset in relation to OCD. Social phobia, agoraphobia, GAD, alcohol and substance abuse, psychotic disorders and paranoid conditions most often started after OCD. Presence of GAD, psychotic disorder and substance abuse worsened prognosis of OCD.

CONCLUSION

Comorbid psychiatric conditions are common in OCD patients, and have onset throughout the course. OCD signals vulnerability for other psychiatric conditions, which are important to detect in clinical practice as they negatively affect the outcome.

Development and validation of a federated learning framework for detection of subphenotypes of multisystem inflammatory syndrome in children

Background

Multisystem inflammatory syndrome in children (MIS-C) is a severe post-acute sequela of SARS-CoV-2 infection. The highly diverse clinical features of MIS-C necessities characterizing its features by subphenotypes for improved recognition and treatment. However, jointly identifying subphenotypes in multi-site settings can be challenging. We propose a distributed multi-site latent class analysis (dMLCA) approach to jointly learn MIS-C subphenotypes using data across multiple institutions.

Methods

We used data from the electronic health records (EHR) systems across nine U.S. children's hospitals. Among the 3,549,894 patients, we extracted 864 patients < 21 years of age who had received a diagnosis of MIS-C during an inpatient stay or up to one day before admission. Using MIS-C conditions, laboratory results, and procedure information as input features for the patients, we applied our dMLCA algorithm and identified three MIS-C subphenotypes. As validation, we characterized and compared more granular features across subphenotypes. To evaluate the specificity of the identified subphenotypes, we further compared them with the general subphenotypes identified in the COVID-19 infected patients.

Findings

Subphenotype 1 (46.1%) represents patients with a mild manifestation of MIS-C not requiring intensive care, with minimal cardiac involvement. Subphenotype 2 (25.3%) is associated with a high risk of shock, cardiac and renal involvement, and an intermediate risk of respiratory symptoms. Subphenotype 3 (28.6%) represents patients requiring intensive care, with a high risk of shock and cardiac involvement, accompanied by a high risk of >4 organ system being impacted. Importantly, for hospital-specific clinical decision-making, our algorithm also revealed a substantial heterogeneity in relative proportions of these three subtypes across hospitals. Properly accounting for such heterogeneity can lead to accurate characterization of the subphenotypes at the patient-level.

Interpretation

Our identified three MIS-C subphenotypes have profound implications for personalized treatment strategies, potentially influencing clinical outcomes. Further, the proposed algorithm facilitates federated subphenotyping while accounting for the heterogeneity across hospitals.

Trait somatic anxiety is associated with reduced directed exploration and underestimation of uncertainty

Anxiety has been related to decreased physical exploration, but past findings on the interaction between anxiety and exploration during decision making were inconclusive. Here we examined how latent factors of trait anxiety relate to different exploration strategies when facing volatility-induced uncertainty. Across two studies (total N = 985), we demonstrated that people used a hybrid of directed, random and undirected exploration strategies, which were respectively sensitive to relative uncertainty, total uncertainty and value difference. Trait somatic anxiety, that is, the propensity to experience physical symptoms of anxiety, was inversely correlated with directed exploration and undirected exploration, manifesting as a lesser likelihood for choosing the uncertain option and reducing choice stochasticity regardless of uncertainty. Somatic anxiety is also associated with underestimation of relative uncertainty. Together, these results reveal the selective role of trait somatic anxiety in modulating both uncertainty-driven and value-driven exploration strategies.

Anxiety-related activity of ventral hippocampal interneurons

Anxiety is an aversive mood reflecting the anticipation of potential threats. The ventral hippocampus (vH) is a key brain region involved in the genesis of anxiety responses. Recent studies have shown that anxiety is mediated by the activation of vH pyramidal neurons targeting various limbic structures. Throughout the cortex, the activity of pyramidal neurons is controlled by GABA-releasing inhibitory interneurons and the GABAergic system represents an important target of anxiolytic drugs. However, how the activity of vH inhibitory interneurons is related to different anxiety behaviours has not been investigated so far. Here, we integrated in vivo electrophysiology with behavioural phenotyping of distinct anxiety exploration behaviours in rats. We showed that pyramidal neurons and interneurons of the vH are selectively active when animals explore specific compartments of the elevated-plus-maze (EPM), an anxiety task for rodents. Moreover, rats with prior goal-related experience exhibited low-anxiety exploratory behaviour and showed a larger trajectory-related activity of vH interneurons during EPM exploration compared to high anxiety rats. Finally, in low anxiety rats, trajectory-related vH interneurons exhibited opposite activity to pyramidal neurons specifically in the open arms (i.e. more anxiogenic) of the EPM. Our results suggest that vH inhibitory micro-circuits could act as critical elements underlying different anxiety states.

Phenotypic Impact of Rare Potentially Damaging Copy Number Variation in Obsessive-Compulsive Disorder and Chronic Tic Disorders

BACKGROUND

Recent studies report an important-and previously underestimated-role of rare variation in risk of obsessive-compulsive disorder (OCD) and chronic tic disorders (CTD). Using data from a large epidemiological study, we evaluate the distribution of potentially damaging copy number variation (pdCNV) in OCD and CTD, examining associations between pdCNV and the phenotypes of probands, including a consideration of early- vs. late-diagnoses.

METHOD

The Obsessive-Compulsive Inventory-Revised (OCI-R) questionnaire was used to ascertain psychometric profiles of OCD probands. CNV were identified genome-wide using chromosomal microarray data.

RESULTS

For 993 OCD cases, 86 (9%) were identified as pdCNV carriers. The most frequent pdCNV found was at the 16p13.11 region. There was no significant association between pdCNV and the OCI-R total score. However, pdCNV was associated with Obsessing and Checking subscores. There was no significant difference in pdCNV frequency between early- vs. late-diagnosed OCD probands. Of the 217 CTD cases, 18 (8%) were identified as pdCNV carriers. CTD probands with pdCNV were significantly more likely to have co-occurring autism spectrum disorder (ASD).

CONCLUSIONS

pdCNV represents part of the risk architecture for OCD and CTD. If replicated, our findings suggest pdCNV impact some OCD symptoms. Genes within the 16p13.11 region are potential OCD risk genes.

Prevalence and risk factors of suicidal ideations among patients with obsessive-compulsive disorder in Egypt

Background

Suicidal ideations were reported in many studies among patient with obsessive-compulsive disorder (OCD); this study aimed to evaluate the prevalence and factors associated with current suicidal ideations among Egyptian patients with obsessive-compulsive disorder (OCD). A consecutive sample of 120 Egyptian OCD patients was included in the study. OCD was diagnosed using the structured clinical interview for DSM-V axis Ι disorders, clinical version (SCID-I-CV). Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was also applied to the patients. Presence of current suicidal ideations was assessed using Scale for Suicidal Ideation (SSI).

Results

Twenty eight (23.3%) of the OCD patients reported presence of current suicidal ideations, religious obsessions OR = 3.53, P = 0.009, and presence of comorbid major depressive disorder OR = 1.77, P = 0.04.

Conclusion

Religious obsessions and comorbid major depressive disorder were found to be significant predictors for the current suicidal ideations in patients with OCD; however, religious obsessions were the strongest predictor. Religious obsessions should be evaluated and treated to decrease the risk of suicidal thoughts in Egyptian OCD patients.

Polygenic Heterogeneity Across Obsessive-Compulsive Disorder Subgroups Defined by a Comorbid Diagnosis

Among patients with obsessive-compulsive disorder (OCD), 65-85% manifest another psychiatric disorder concomitantly or at some other time point during their life. OCD is highly heritable, as are many of its comorbidities. A possible genetic heterogeneity of OCD in relation to its comorbid conditions, however, has not yet been exhaustively explored. We used a framework of different approaches to study the genetic relationship of OCD with three commonly observed comorbidities, namely major depressive disorder (MDD), attention-deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD). First, using publicly available summary statistics from large-scale genome-wide association studies, we compared genetic correlation patterns for OCD, MDD, ADHD, and ASD with 861 somatic and mental health phenotypes. Secondly, we examined how polygenic risk scores (PRS) of eight traits that showed heterogeneous correlation patterns with OCD, MDD, ADHD, and ASD partitioned across comorbid subgroups in OCD using independent unpublished data from the Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH). The comorbid subgroups comprised of patients with only OCD (N = 366), OCD and MDD (N = 1,052), OCD and ADHD (N = 443), OCD and ASD (N = 388), and OCD with more than 1 comorbidity (N = 429). We found that PRS of all traits but BMI were significantly associated with OCD across all subgroups (neuroticism: p = 1.19 × 10-32, bipolar disorder: p = 7.51 × 10-8, anorexia nervosa: p = 3.52 × 10-20, age at first birth: p = 9.38 × 10-5, educational attainment: p = 1.56 × 10-4, OCD: p = 1.87 × 10-6, insomnia: p = 2.61 × 10-5, BMI: p = 0.15). For age at first birth, educational attainment, and insomnia PRS estimates significantly differed across comorbid subgroups (p = 2.29 × 10-4, p = 1.63 × 10-4, and p = 0.045, respectively). Especially for anorexia nervosa, age at first birth, educational attainment, insomnia, and neuroticism the correlation patterns that emerged from genetic correlation analysis of OCD, MDD, ADHD, and ASD were mirrored in the PRS associations with the respective comorbid OCD groups. Dissecting the polygenic architecture, we found both quantitative and qualitative polygenic heterogeneity across OCD comorbid subgroups.

Exome sequencing in obsessive-compulsive disorder reveals a burden of rare damaging coding variants

Obsessive-compulsive disorder (OCD) affects 1-2% of the population, and, as with other complex neuropsychiatric disorders, it is thought that rare variation contributes to its genetic risk. In this study, we performed exome sequencing in the largest OCD cohort to date (1,313 total cases, consisting of 587 trios, 41 quartets and 644 singletons of affected individuals) and describe contributions to disease risk from rare damaging coding variants. In case-control analyses (n = 1,263/11,580), the most significant single-gene result was observed in SLITRK5 (odds ratio (OR) = 8.8, 95% confidence interval 3.4-22.5, P = 2.3 × 10-6). Across the exome, there was an excess of loss of function (LoF) variation specifically within genes that are LoF-intolerant (OR = 1.33, P = 0.01). In an analysis of trios, we observed an excess of de novo missense predicted damaging variants relative to controls (OR = 1.22, P = 0.02), alongside an excess of de novo LoF mutations in LoF-intolerant genes (OR = 2.55, P = 7.33 × 10-3). These data support a contribution of rare coding variants to OCD genetic risk.

Experimentally induced and real-world anxiety have no demonstrable effect on goal-directed behaviour

BACKGROUND

Goal-directed control guides optimal decision-making and it is an important cognitive faculty that protects against developing habits. Previous studies have found some evidence of goal-directed deficits when healthy individuals are stressed, and in psychiatric conditions characterised by compulsive behaviours and anxiety. Here, we tested if goal-directed control is affected by state anxiety, which might explain the former results.

METHODS

We carried out a causal test of this hypothesis in two experiments (between-subject N = 88; within-subject N = 50) that used the inhalation of hypercapnic gas (7.5% CO2) to induce an acute state of anxiety in healthy volunteers. In a third experiment (N = 1413), we used a correlational design to test if real-life anxiety-provoking events (panic attacks, stressful events) are associated with impaired goal-directed control.

RESULTS

In the former two causal experiments, we induced a profoundly anxious state, both physiologically and psychologically, but this did not affect goal-directed performance. In the third, correlational, study, we found no evidence for an association between goal-directed control, panic attacks or stressful life eventsover and above variance accounted for by trait differences in compulsivity.

CONCLUSIONS

In sum, three complementary experiments found no evidence that anxiety impairs goal-directed control in human subjects.

Specialty knowledge and competency standards for pharmacotherapy for pediatric obsessive-compulsive disorder

Evidence based treatments for pediatric Obsessive-Compulsive Disorder (OCD) are delivered with varying levels of expertise. This paper is part of the phase two series by the International OCD Accreditation Task Force (ATF) to advance a standardized high level of care globally. This paper presents specific knowledge and competencies recommended for specialized practice for pediatric psychopharmacologists working with OCD, developed by an international group of clinicians with extensive expertise in assessment and treatment of OCD. Tabulated knowledge and competency standards are operationalized as clinician abilities with specification of evidence for each standard. The distinction between current practice guidelines and ATF standards is discussed. Drug treatment has a solid evidence base. However, it should not be applied isolated, but informed by broad competence in general child and adolescent psychiatry and pediatrics. Other treatment relevant areas such as specialty CBT, family functioning, developmental issues, and neurobiology require consideration. Drug treatment includes several phases with varying degrees of evidence: Starting up medication, titration to maximum tolerated dose, maintenance, termination, and relapse prevention. In complex cases, pharmacotherapy with weak evidence may be needed to target symptoms and/or co-morbidity. The ATF knowledge and competency standards presented will be reviewed and updated commensurate with research.

Obsessive-Compulsive Personality Disorder Co-occurring in Individuals with Obsessive-Compulsive Disorder: A Systematic Review and Meta-analysis

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Assess the rates of co-occurring obsessive-compulsive personality disorder (OCPD) in patients with obsessive-compulsive disorder (OCD)• Identify characteristics related to OCD with co-occurring OCPD.

ABSTRACT

The current literature discloses discrepant findings regarding the rates of co-occurring obsessive-compulsive personality disorder (OCPD) in patients with obsessive-compulsive disorder (OCD). In addition, it is not clear which characteristics are related specifically to OCD with co-occurring OCPD. We conducted the first systematic review and meta-analysis of the studies of the prevalence of OCPD in patients with OCD. We also investigated potential moderators of the prevalence, including OCD severity, age of onset of OCD, sex, current age, methodological quality, and publication date of the studies. Electronic databases and gray literature were searched by two independent reviewers. A PRISMA systematic review with a random-effect meta-analysis was conducted. Thirty-four studies were included. A significant mean effect size of 0.25 without publication bias indicated that OCPD was present in 25% of patients with OCD, suggesting that the two conditions are distinct clinical entities. This prevalence was higher than the rates found in the literature for any other personality disorders among OCD patients. OCPD that occurs in the context of OCD was more likely to be present in males and to be characterized by a later age of onset of OCD, older age at assessment, and less severe OCD symptoms. Clinicians should consider these findings when assessing and planning treatment of OCD with co-occurring OCPD.

Early onset obsessive-compulsive disorder: the biological and clinical phenotype

Moving from a behavioral-based to a biological-based classification of mental disorders is a crucial step toward a precision-medicine approach in psychiatry. In the last decade, a big effort has been made in order to stratify genetic, immunological, neurobiological, cognitive, and clinical profiles of patients. Making the case of obsessive-compulsive disorder (OCD), a lot have been made in this direction. Indeed, while the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of OCD aimed to delineate a homogeneous group of patients, it is now clear that OCD is instead an heterogeneous disorders both in terms of neural networks, immunological, genetic, and clinical profiles. In this view, a convergent amount of literature, in the last years, indicated that OCD patients with an early age at onset seem to have a specific clinical and biological profile, suggesting it as a neurodevelopmental disorder. Also, these patients tend to have a worse outcome respect to adult-onset patients and there is growing evidence that early-interventions could potentially improve their prognosis. Therefore, the aim of the present paper is to review the current available genetic, immunological, neurobiological, cognitive, and clinical data in favor of a more biologically precise subtype of OCD: the early-onset subtype. We also briefly resume current available recommendations for the clinical management of this specific population.

A systematic review and realist synthesis on toilet paper hoarding: COVID or not COVID, that is the question

OBJECTIVE

To explore whether the coronavirus disease 2019 (COVID-19) pandemic is associated with toilet paper hoarding and to assess which risk factors are associated with the risk of toilet paper hoarding.

DESIGN

A systematic review and realist review were conducted.

DATA SOURCES

PubMed, Web of Science, Scopus and PsycINFO were searched (systematic review). PubMed, pre-prints and grey literature were also searched (realist review). The databases were searched from inception until October 2020.

STUDY SELECTION

There were no restrictions on the study design.

OUTCOMES AND MEASURES

For the systematic review, toilet paper hoarding was the main outcome, and pathological use of toilet paper was the secondary outcome. For the realist review, the context-mechanisms-outcome (CMO) scheme included the COVID-19 pandemic (context), four proposed mechanisms, and one outcome (toilet paper hoarding). The four potential mechanisms were (1) gastrointestinal mechanisms of COVID-19 (e.g. diarrhoea), (2) social cognitive biases, (3) stress-related factors (mental illnesses, personality traits) and (4) cultural aspects (e.g. differences between countries).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

All studies of human populations were considered (including general population studies and clinical studies of patients suffering from mental health problems).

RESULTS

The systematic review identified 14 studies (eight studies for the main outcome, six studies for the secondary outcome). Three surveys identified the role of the COVID-19 threat in toilet paper hoarding in the general population. One study pointed to an association between a personality trait (conscientiousness) and toilet paper buying and stockpiling as well as an additional significant indirect effect of emotionality through the perceived threat of COVID-19 on toilet paper buying and stockpiling. Six case reports of pathological use of toilet paper were also identified, although none of them were associated with the COVID-19 pandemic. The realist review suggested that of all the mechanisms, social cognitive biases and a bandwagon effect were potential contributors to toilet paper hoarding in the general population. The stressful situation (COVID-19 pandemic) and some personality traits (conscientiousness) were found to be associated with toilet paper hoarding. Cultural differences were also identified, with relatively substantial effects of toilet paper hoarding in several Asian regions (Australia, Japan, Taiwan and Singapore).

CONCLUSIONS

The COVID-19 pandemic has been associated with a worldwide increase in toilet paper hoarding. Social media and social cognitive biases are major contributors and might explain some differences in toilet paper hoarding between countries. Other mental health-related factors, such as the stressful situation of the COVID-19 pandemic, fear of contagion, or particular personality traits (conscientiousness), are likely to be involved.

REGISTRATION

PROSPERO CRD42020182308.

Overlapping features between social anxiety and obsessive-compulsive spectrum in a clinical sample and in healthy controls: toward an integrative model

BACKGROUND

While the literature frequently highlighted an association between social anxiety disorder (SAD) and obsessive-compulsive disorder (OCD), few studies investigated the overlapping features of these conditions. The presented work evaluated the relationship between SAD and OCD spectrum in a clinical population and in healthy controls (HC).

METHODS

Fifty-six patients with OCD, 51 with SAD, 43 with major depressive disorder (MDD), and 59 HC (N = 209) were assessed using the Mini International Neuropsychiatric Interview, the Social Phobia Spectrum (SCI-SHY), and the Obsessive-Compulsive Spectrum (SCI-OBS).

RESULTS

SAD patients scored significantly higher than other groups on all SCI-SHY domains and total score; OCD patients scored significantly higher than HC. MDD patients scored significantly higher than HC on the SCI-SHY total, Behavioral inhibition, and Interpersonal sensitivity domains. OCD patients scored significantly higher than other groups on all SCI-OBS domains except Doubt, for which OCD and SAD scored equally high. SAD patients scored significantly higher than HC on the SCI-OBS total, Childhood/adolescence, Doubt, and Hypercontrol domains. MDD patients scored significantly higher than HC on the Hypercontrol domain. SCI-OBS and SCI-SHY were widely correlated among groups, although lower correlations were found among OCD patients. Stronger correlations were observed between SCI-SHY Interpersonal sensitivity and SCI-OBS Doubt, Obsessive-compulsive themes, and Hypercontrol; between SCI-SHY Specific anxieties/phobic features and SCI-OBS Obsessive-compulsive themes; and between SCI-SHY Behavioral inhibition and SCI-OBS Doubt, with slightly different patterns among groups.

CONCLUSION

OCD and SAD spectrums widely overlap in clinical samples and in the general population. Interpersonal sensitivity and obsessive doubts might represent a common cognitive core for these conditions.

Classification of comorbidity in obsessive-compulsive disorder: A latent class analysis

OBJECTIVE

Patients with OCD differ markedly from one another in both number and kind of comorbid disorders. In this study, we set out to identify and characterize homogeneous subgroups of OCD patients based on their comorbidity profile.

METHODS

In a cohort of 419 adult subjects with OCD, the lifetime presence of fifteen comorbid disorders was assessed. Latent class analysis was used to identify comorbidity-based subgroups. Groups were compared with regard to core clinical characteristics: familiality, childhood trauma, age at onset, illness severity, OCD symptom dimensions, personality characteristics, and course of illness.

RESULTS

The study sample could be divided in a large group (n = 311) with a low amount of comorbidity that could be further subdivided into two subgroups: OCD simplex (n = 147) and OCD with lifetime major depressive disorder (n = 186), and a group (n = 108) with a high amount of comorbidity that could be further subdivided into a general anxiety-related subgroup (n = 49), an autism/social phobia-related subgroup (n = 27), and a psychosis/bipolar-related subgroup (n = 10). Membership of the high-comorbid subgroup was associated with higher scores on childhood trauma, illness severity, and the aggression/checking symptom dimension and lower scores on several personality characteristics.

CONCLUSION

Grouping OCD patients based on their comorbidity profile might provide more homogeneous, and therefore, more suitable categories for future studies aimed at unraveling the etiological mechanisms underlying this debilitating disorder.

Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder

OBJECTIVE

Trichotillomania (TTM) is characterized by the pulling out of one's hair. TTM was classified as an impulse control disorder in DSM-IV, but is now classified in the obsessive-compulsive related disorders section of DSM-5. Classification for TTM remains an open question, especially considering its impact on treatment of the disorder. In this review, we questioned the relation of TTM to tic disorder and obsessive-compulsive disorder (OCD).

METHOD

We reviewed relevant MEDLINE-indexed articles on clinical, neuropsychological, neurobiological, and therapeutic aspects of trichotillomania, OCD, and tic disorders.

RESULTS

Our review found a closer relationship between TTM and tic disorder from neurobiological (especially imaging) and therapeutic standpoints.

CONCLUSION

We sought to challenge the DSM-5 classification of TTM and to compare TTM with both OCD and tic disorder. Some discrepancies between TTM and tic disorders notwithstanding, several arguments are in favor of a closer relationship between these two disorders than between TTM and OCD, especially when considering implications for therapy. This consideration is essential for patients.

A Developmental Psychopathology Perspective of Obsessive-Compulsive Disorder

Objective:

This integrative review explores Obsessive-Compulsive Disorder (OCD) from the perspective of developmental psychopathology, in terms of its multifaceted etiology and course.

Background:

Individuals affected by OCD experience intrusive and undesired thoughts accompanied by behaviors used to mitigate the unwanted images. Accordingly, there are several sub-types and personality dispositions reflective of the overall continuum of OCD, spanning normality and psychopathology. The etiology is complex, with generalized psychological and biological vulnerabilities, as well as contributors from life stress. Moreover, OCD is a disorder with a highly comorbid and overlapping presence; therefore, difficulties may arise when differentiating between OCD and other problems.

Conclusion:

Treatment non-responsiveness is a pervasive trend in persons afflicted with OCD, but the most effective approach likely involves a stepped-care model incorporating cognitive-behavioral psychotherapy and psychotropic medications. Other considerations will also be discussed.

Reduced focal fiber collinearity in the cingulum bundle in adults with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a disabling condition, often associated with a chronic course. Given its role in attentional control, decision-making, and emotional regulation, the anterior cingulate cortex is considered to have a key role in the pathophysiology of the disorder. Notably, the cingulum bundle, being the major white matter tract connecting to this region, has been historically a target for the surgical treatment of intractable OCD. In this study, we aimed to identify the extent to which focal-more than diffuse-abnormalities in fiber collinearity of the cingulum bundle could distinguish 48 adults with OCD (mean age [SD] = 23.3 [4.5] years; F/M = 30/18) from 45 age- and sex-matched healthy control adults (CONT; mean age [SD] = 23.2 [3.8] years; F/M = 28/17) and further examine if these abnormalities correlated with symptom severity. Use of tract-profiles rather than a conventional diffusion imaging approach allowed us to characterize white matter microstructural properties along (100 segments), as opposed to averaging these measures across, the entire tract. To account for these 100 different segments of the cingulum bundle, a repeated measures analysis of variance revealed a main effect of group (OCD < CONT; F_[1,87] = 5.3; P = 0.024) upon fractional anisotropy (FA, a measure of fiber collinearity and/or white matter integrity), in the cingulum bundle, bilaterally. Further analyses revealed that these abnormalities were focal (middle portion) within the left and right cingulum bundle, although did not correlate with symptom severity in OCD. Findings indicate that focal abnormalities in connectivity between the anterior cingulate cortex and other prefrontal cortical regions may represent neural mechanisms of OCD.

Corticostriatal-limbic correlates of sub-clinical obsessive-compulsive traits

Obsessive-compulsive (OC) traits such as intrusive worrisome ideas or excessive concerns for threats are frequent in general population (5%-13%). However, the structural neural correlates of the sub-clinical OC traits remain largely unknown. Based on the data of obsessive-compulsive disorder (OCD), we hypothesized that the subcortical and cortical structures, constituting the cortico-striatal-thalamo-cortical circuit (CSTC) and the limbic system, could be associated with OC traits. Here we conducted voxel-based morphometry (VBM) in order to investigate fine grained volume changes of these structures in 49 non-clinical subjects. Analysis of structural covariances of these structures was also conducted. We identified volume changes associated with OC traits in the left putamen and the left amygdala. The results of structural covariance analysis revealed increased covariances in relation to the heightened OC traits between the left putamen to bilateral medial prefrontal cortex and to the left cerebellum, and between the left globus pallidus to the bilateral anterior cingulate cortices. The present finding of volume changes of the corticostriatal-limbic structures may reflect neuroplasticity associated with OC traits. Since the abnormality of these structures were also observed in the clinical OCD, the subclinical subjects with OC traits shared "neuronal obsessive traits" that might precondition OCD at the network level.

Obsessive-compulsive symptom dimensions: Association with comorbidity profiles and cognitive-behavioral therapy outcome in pediatric obsessive-compulsive disorder

Our aims were to examine: (1) classes of comorbid disorders in a sample of children and adolescents with Obsessive-Compulsive Disorder (OCD), (2) how these classes relate to obsessive-compulsive symptom dimensions, and (3) the extent to which obsessive-compulsive symptom dimensions predict Cognitive-Behavioral Therapy (CBT) outcome. Participants (N = 269) were assessed with the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS-PL) and the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Latent Class Analysis (LCA) was used to identify comorbidity classes. Regression analyses were used to evaluate symptom dimensions as predictors of treatment outcome and their relation to comorbidity classes. Comorbidity was included in the treatment outcome analyses as it can affect outcome. Comorbidity was best categorized by a three-class model and each class was distinctively correlated with the OCD symptom dimensions. Higher scores on the symmetry/hoarding factor increased the chance of responding to CBT by an odds ratio of 1.56 (p = 0.020) when controlled for age, gender, and comorbidity class. The harm/sexual factor (p = 0.675) and contamination/cleaning factor (p = 0.122) did not predict CBT outcome. Three clinically relevant comorbidity subgroups in pediatric OCD were identified. Patients who exhibited higher levels of symmetry/hoarding dimension were more prone to respond to CBT.

Current and up-and-coming pharmacotherapy for obsessive-compulsive disorder in adults

INTRODUCTION

Only 40-60% of obsessive-compulsive patients respond to first line treatments, such as selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy. Several second-line treatments have been investigated in the last two decades, and most of them seem to work, at least in a subset of patients. However, since there is still a lack of treatment predictors, the treatment of obsessive-compulsive disorder (OCD) is still empirical and non-evidence based.

AREAS COVERED

In this paper, we review current and up-and-coming pharmacotherapy for OCD in adults, focusing on two emerging fields of research, inflammation and glutamate systems, since they have attracted the greatest attention in recent years in OCD pharmacological research.

EXPERT OPINION

Most of the investigated second-line agents seem to work at least in a subset of patients with OCD. These results raise an open question: what works for who? In our opinion, this question should be answered in a precision medicine perspective or, in other words, individualizing diagnostic processes and treatment approaches. In a precision medicine approach, OCD treatment should be sub-type specific, phase specific, multimodal and sequential, and, more importantly, dimensional.

Obsessive-Compulsive and Depressive Symptoms: The Role of Depressive Cognitive Styles

Obsessive-compulsive disorder (OCD) commonly co-occurs with depression, resulting in heightened severity and poorer treatment response. Research on the associations between specific obsessive-compulsive symptoms (OCS) and depressive symptoms has utilized measures that have not fully considered the relationship across OCS dimensions. Little is known about which factors explain the overlap between OCS and depressive symptoms. OCS and depressive symptoms may be related via depressive cognitive styles, such as rumination or dampening (i.e., down-regulating positive emotions). We evaluated the associations of OCS dimensions with depressive symptoms and cognitive styles. We also examined the indirect effects of rumination and dampening in the relationship between OCS and depressive symptoms. Participants (N = 250) completed questionnaires online. Greater depressive symptoms, rumination, and dampening were associated with greater levels of all OCS dimensions. Path analysis was utilized to examine a model including the direct effect of depressive symptoms on overall OCS and two indirect effects (through rumination and dampening). There was a significant indirect effect of depressive cognitive styles on the relationship between OCS and depressive symptoms, through rumination and dampening. Replication in a clinical sample and experimental manipulations may bear important implications for targeting depressive cognitive styles in treatments for OCD and depression.

A critical appraisal of heterogeneity in Obsessive-Compulsive Disorder using symptom-based clustering analysis

Obsessive-compulsive disorder (OCD) encompasses a broad range of symptoms and is commonly considered a heterogeneous condition. Attempts were made to define discrete OCD subtypes using a range of symptom-based methods including factor and cluster analyses. The present study aims to find the most appropriate clustering model based on Yale-Brown obsessive-compulsive scale (YBOCS) checklist explaining OCD heterogeneity. Five different clustering algorithms (FCM, K-means, Ward, Ward+K-means and Complete) applied on YBOCS symptoms of 216 patients with OCD. Data studied as four different sets including item-level raw data, item-based factor scores, category-level raw data and category-based factor scores and clustering results for 2 to 6 cluster solutions evaluated by four clustering indices (Davies-Bouldin, Calinski-Harabasz, Silhouettes and Dunn indices). Two-cluster solution was detected as the most appropriate model for item and category-based clustering analyses of YBOCS checklist symptoms. Patients in each cluster were characterized based on their clinical and demographic properties and results showed that they had similar patterns of symptoms but in different severities. Heterogenity of OCD based on the YBOCS-symptoms has been challenged as OCD patients were classified based on their symptom severity not their symptom patterns. More investigations need to find appropriate measures explaining OCD heterogeneity with clinical importance.

A trans-diagnostic perspective on obsessive-compulsive disorder

Progress in understanding the underlying neurobiology of obsessive-compulsive disorder (OCD) has stalled in part because of the considerable problem of heterogeneity within this diagnostic category, and homogeneity across other putatively discrete, diagnostic categories. As psychiatry begins to recognize the shortcomings of a purely symptom-based psychiatric nosology, new data-driven approaches have begun to be utilized with the goal of solving these problems: specifically, identifying trans-diagnostic aspects of clinical phenomenology based on their association with neurobiological processes. In this review, we describe key methodological approaches to understanding OCD from this perspective and highlight the candidate traits that have already been identified as a result of these early endeavours. We discuss how important inferences can be made from pre-existing case-control studies as well as showcasing newer methods that rely on large general population datasets to refine and validate psychiatric phenotypes. As exemplars, we take 'compulsivity' and 'anxiety', putatively trans-diagnostic symptom dimensions that are linked to well-defined neurobiological mechanisms, goal-directed learning and error-related negativity, respectively. We argue that the identification of biologically valid, more homogeneous, dimensions such as these provides renewed optimism for identifying reliable genetic contributions to OCD and other disorders, improving animal models and critically, provides a path towards a future of more targeted psychiatric treatments.

Structure and clinical correlates of obsessive-compulsive symptoms in a large sample of children and adolescents: a factor analytic study across five nations

The underlying structure of obsessive-compulsive disorder (OCD) remains to be confirmed in child and adolescent populations. In this paper we report the first factor analytic study of individual OCD items from Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). OCD symptoms were assessed using the CY-BOCS symptom checklist in a sample of 854 patients with OCD (7-18 years of age) recruited from clinics in five countries. Pooled data were subjected to exploratory and confirmatory factor analysis (CFA) to identify the optimal factor structure. Various models were tested for age and gender subgroups. Also, the invariance of the solution across age and gender was tested and associations with demographic and clinical factors were explored. A three-factor model provided the best-fit solution. It consisted of the following factors: (1) harm/sexual, (2) symmetry/hoarding, (3) contamination/cleaning. The factor structure was invariant for age and gender across subgroups. Factor one was significantly correlated with anxiety, and factor two with depression and anxiety. Factor three was negatively correlated with tic disorder and attention-deficit/hyperactivity disorder (ADHD). Females had higher scores on factor two than males. The OCD symptom structure in children and adolescents is consistent across age and gender and similar to results from recent child and adolescents although hoarding may not be a separate factor. Our three-factor structure is almost identical to that seen in early studies on adults. Common mental disorders had specific patterns of associations with the different factors.

Distinguishing Fear Versus Distress Symptomatology in Pediatric OCD

Prior research has identified OCD subtypes or "clusters" of symptoms that differentially relate to clinical features of the disorder. Given the high comorbidity between OCD and anxiety, OCD symptom clusters may more broadly associate with fear and/or distress internalizing constructs. This study examines fear and distress dimensions, including physical concerns (fear), separation anxiety (fear), perfectionism (distress), and anxious coping (distress), as predictors of previously empirically-derived OCD symptom clusters in a sample of 215 youth diagnosed with primary OCD (ages 7-17, mean age = 12.25). Self-reported separation fears predicted membership in Cluster 1 (aggressive, sexual, religious, somatic obsessions, and checking compulsions) while somatic/autonomic fears predicted membership in Cluster 2 (symmetry obsessions and ordering, counting, repeating compulsions). Results highlight the diversity of pediatric OCD symptoms and their differential association with fear, suggesting the need to carefully assess both OCD and global fear constructs that might be directly targeted in treatment.

COMPULS: design of a multicenter phenotypic, cognitive, genetic, and magnetic resonance imaging study in children with compulsive syndromes

BACKGROUND

Compulsivity, the closely linked trait impulsivity and addictive behaviour are associated with several neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and obsessive compulsive disorder (OCD). All three disorders show impaired fronto-striatal functioning, which may be related to altered glutamatergic signalling. Genetic factors are also thought to play an important role in the aetiology of compulsivity-related disorders.

METHODS

The COMPULS study is a multi-center study designed to investigate the relationship between the traits compulsivity, impulsivity, and, to a lesser extent, addictive behaviour within and across the neurodevelopmental disorders ADHD, ASD, and OCD. This will be done at the phenotypic, cognitive, neural, and genetic level. In total, 240 participants will take part in COMPULS across four different sites in Europe. Data collection will include diagnostic interviews, behavioural questionnaires, cognitive measures, structural, functional and spectral neuroimaging, and genome-wide genetic information.

DISCUSSION

The COMPULS study will offer the unique opportunity to investigate several key aspects of compulsivity across a large cohort of ADHD, ASD and OCD patients.

Depression and risk of suicide in patients with obsessive-compulsive disorder: A hospital-based study

BACKGROUND

Obsessive Compulsive Disorder (OCD) is a chronic, distressing, anxiety disorder associated with significant functional impairment. Patient with OCD often suffer from one or more co-morbid disorders. Major depression has been the most common co-morbid syndrome. Comorbid Axis I disorders along with increased severity of comorbid depressive and anxiety symptoms, increased severity of obsessions, feelings of hopelessness and past history of suicide attempts have been associated with worsening levels of suicidality in OCD (Angelakis I, Gooding P., 2015). As per data Thirty-six percent of the patients of OCD report lifetime suicidal thoughts and 11% have a history of attempted suicide(Torres AR, Ramos-Cerqueira AT, et al, 2011). There is a reasonable probability that the patient of OCD have suicidal thoughts, plans or actually attempt suicide.

AIM

To assess depression and suicidality in OCD patients.

METHOD

This study was conducted on 50 patients diagnosed with OCD as per ICD 10 criteria, both outpatient & indoor, from department of psychiatry, Dayanand Medical College & Hospital, Ludhiana, Punjab, India. A socio-demographic proforma (containing demographic details), Hamilton Depression Rating & Scale, Columbia suicide severity rating scale (CSSRS) & Yale Brown Obsessive Compulsive Scale Symptom Checklist (YBOCS) were administered.

RESULTS

Mild depression was found out to be 40% whereas 16% were suffering from moderate depression and 10% and 14% had severe and very severe depression respectively. Suicidal ideation was found in 52 % of patients.16% of patients had history of actual attempt. Data showed that 70% of females had suicidal ideations. It was also found that in cases of severe and very severe depression associated with OCD all the patients had suicidal ideations as compared to 35% in mild and 87.5% in moderate depressive patients. It was found that 40% of severe depressive and 28.57% of very severe depressive patients had attempted suicide one or more times during the course of illness. Also suicidality was found to be maximum in those with symptoms of cleanliness and contamination (57%) followed by religious obsessions (45%), sexual obsessions (33%), repeated rituals (31%) and other obsessions like need to touch, ask (26%) respectively.

CONCLUSION

OCD is associated with high risk not only depression but also of suicidal behavior. It is vital that patients of OCD undergo detailed assessment for suicide risk and associated depression. Aggressive treatment of depression may be warranted to modify the risk of suicide. Behavioral and cognitive techniques along with pharmacotherapy should be used to target co-existing depressive symptoms so as to decrease morbidity and mortality.

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.

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.

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.

COMT and MAO-A polymorphisms and obsessive-compulsive disorder: a family-based association study

Objective

Obsessive-compulsive disorder (OCD) is a common and debilitating psychiatric illness. Although a genetic component contributes to its etiology, no single gene or mechanism has been identified to the OCD susceptibility. The catechol-O-methyltransferase (COMT) and monoamine oxidase A (MAO-A) genes have been investigated in previous OCD studies, but the results are still unclear. More recently, Taylor (2013) in a comprehensive meta-analysis of genetic association studies has identified COMT and MAO-A polymorphisms involved with OCD. In an effort to clarify the role of these two genes in OCD vulnerability, a family-based association investigation was performed as an alternative strategy to the classical case-control design.

Methods

Transmission disequilibrium analyses were performed after genotyping 13 single-nucleotide polymorphisms (eight in COMT and five in MAO-A) in 783 OCD trios (probands and their parents). Four different OCD phenotypes (from narrow to broad OCD definitions) and a SNP x SNP epistasis were also analyzed.

Results

OCD, broad and narrow phenotypes,were not associated with any of the investigated COMT and MAO-A polymorphisms. In addition, the analyses of gene-gene interaction did not show significant epistatic influences on phenotype between COMT and MAO-A.

Conclusions

The findings do not support an association between DSM-IV OCD and the variants of COMT or MAO-A. However, results from this study cannot exclude the contribution of these genes in the manifestation of OCD. The evaluation of broader spectrum phenotypes could help to understand the role of these and other genes in the pathophysiology of OCD and its spectrum disorders.

[Comorbidity of depression and nonaffective - schizophrenia spectrum disorders: the clinical-epidemiological study EDIP]

AIM

To explore the association between depression and heterogenic nonaffective symptom complexes in the study EDIP (Epidemiology of Depression and nonaffective Psychiatric disorders).

MATERIAL AND METHODS

The study consisted of two stages. The first stage (91 patients) aimed to resolve organizational and methodological issues, the second stage was performed in the epidemiological sample of 705 patients.

RESULTS AND CONCLUSION

The heterogeneity (inequivalence and bidirectionality) of associations between depression and heteronomous nonaffective disorders have been identified. The associations are distinguished in three types: 1) affinity (agonism); 2) repulsion (antagonism); 3) lack of selective interaction (inertness) between depression and nonaffective disorders. The results obtained are discussed in a context of two conceptually polar psychopathological models of comorbidity between depression and nonaffective disorders: 1) based on a nosological dichotomy «affective disease - schizophrenia» and 2) denying the abovementioned dichotomy. The first model places depression among disorders of a mild psychiatric register. The second model supposes the integration of depression with syndromes typical for schizophrenia in a common "affect-symptoms" space and considers the increase of depression frequency proportionally to duration and severity of schizophrenia. Our own results have shown that depression is observed not only among disorders of mild psychiatric registers, but also in schizophrenia, though with a significantly lower frequency (as a nonobligatory compound of a syndrome). Thus, depression influence in comorbid delusional, schizophrenic and other severe nonaffective disorders is greatly diminished.

Comorbidity in obsessive-compulsive disorder (OCD): a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

BACKGROUND

Obsessive-compulsive disorder (OCD) is often associated with significant psychiatric comorbidity. Comorbid disorders include mood and anxiety disorders as well as obsessive-compulsive spectrum disorders (OCSDs). This paper aims to investigate comorbidity of DSM Axis I-disorders, including OCSDs, in patients with OCD from 10 centers affiliated with the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS).

METHODS

This is a cross-sectional study of comorbidity of Axis I disorders including OCSDs in 457 outpatients with primary OCD (37% male; 63% female), with ages ranging from 12 to 88years (mean: 39.8±13). Treating clinicians assessed Axis I disorders using the Mini International Neuropsychiatric Interview and assessed OCSDs using the Structured Clinical Interview for OCD related/spectrum disorders (SCID-OCSD).

RESULTS

In terms of the OCSDs, highest comorbidity rates were found for tic disorder (12.5%), BDD (8.71%) and self-injurious behavior (7.43%). In terms of the other Axis I-disorders, major depressive disorder (MDD; 15%), social anxiety disorder (SAD; 14%), generalized anxiety disorder (GAD; 13%) and dysthymic disorder (13%) were most prevalent.

DISCUSSION

High comorbidity of some OCSDs in OCD supports the formal recognition of these conditions in a separate chapter of the nosology. Rates of other Axis I disorders are high in both the general population and in OCSDs, indicating that these may often also need to be the focus of intervention in OCD.

DSM-5 obsessive-compulsive and related disorders: clinical implications of new criteria

For the publication of DSM-5, obsessive-compulsive disorder (OCD) was the subject of significant revisions to its classification and diagnostic criteria. One of these significant changes was the placement of OCD in a new category, "Obsessive-Compulsive and Related Disorders (OCRDs)," which also includes body dysmorphic disorder (BDD), trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, hoarding disorder, substance/medication-induced OCRD, OCRD due to another medical condition, and other specified OCRDs. Changes in the diagnostic criteria and grouping of these disorders may have significant clinical implications, and will be reviewed in this article.

Latent class analysis of obsessive-compulsive symptoms in a clinical sample

OBJECTIVE

Obsessive-compulsive disorder (OCD) is probably a heterogeneous condition. To date, research investigating the symptom structure of OCD has generally focused on variable-classification approaches, primarily factor analysis. Our aim was to use the latent class analysis, an advanced individual-classification method, in order to define homogeneous sub-groups based on the Yale-Brown Obsessive-Compulsive Scale Check List (Y-BOCS CL) assessments within 193 outpatients with OCD.

METHOD

Latent class analysis of 13 obsessive-compulsive symptom-clusters measured by the Yale-Brown Obsessive-Compulsive Scale Check List was performed. Associations of demographic and clinical features with latent class membership were tested by using logistic regression models. Differences in severity of obsessive-compulsive symptoms, obsessive beliefs, and depressive symptomotology between latent classes were evaluated with the chi-square likelihood test.

RESULTS

Latent class analysis models of best fit yielded 3 latent classes: "autogenous obsessions", "reactive obsessive-compulsive", and "reactive obsessions". Outpatients in reactive obsessive-compulsive group reported significantly higher scores on the Y-BOCS global, obsessions, and compulsions scales than outpatients in other two sub-groups. Participants in reactive obsessive-compulsive group were predominantly female, single, and had a history of family psychopathology; whereas autogenous and reactive obsessions groups were predominantly male. There were no differences in severity of depression and obsessive belief domains.

CONCLUSIONS

The results provide support for the validity of autogenous/reactive distinction for OCD. These three classes may have important implications for research and clinical purposes.

Unique relations among anxiety sensitivity factors and anxiety, depression, and suicidal ideation

Anxiety sensitivity (AS) is composed of three lower-order dimensions, cognitive concerns, physical concerns, and social concerns. We examined the relations between AS dimensions using a more adequate assessment of subscales (ASI-3) than has previously been used, and measures of anxiety and mood disorders as well as suicidal ideation in a sample of 256 (M age = 37.10 years, SD = 16.40) treatment-seeking individuals using structural equation modeling. AS cognitive concerns was uniquely associated with generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), major depressive disorder (MDD), post-traumatic stress disorder (PTSD), and suicidal ideation. AS physical concerns was uniquely associated with OCD, social anxiety disorder (SAD), panic disorder (PD), and specific phobia. AS social concerns was uniquely associated with SAD, GAD, OCD, and MDD. These results highlight the importance of considering the lower-order AS dimensions when examining the relations between AS and psychopathology.

Emerging drugs to treat obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a chronic and disabling neuropsychiatric disorder with a lifetime prevalence of approximately 1 - 2% and a rate of treatment resistance of 40%. Other disorders have been related to OCD and have been grouped together in a separate DSM-5 chapter, hypothesizing the existence of an 'OC spectrum', showing a paradigm shift in the conceptualization of the disorder.

AREAS COVERED

A review of the most important and recent neurobiological findings that sustain the hypothesis of a more sophisticated model of the disorder is provided, together with a brief overview of the most relevant pharmacological animal models of OCD and its first-line treatments. Current research goals, new compounds tested and the rationale behind the development of these new pharmacologic agents are then explained and reviewed.

EXPERT OPINION

In the past years, no effective novel compounds have emerged for the treatment of OCD, even if many efforts has been made in the study of its neurobiological underpinnings. Relevant changes in the conceptualization of the disorder, suggested by interesting new neurobiological evidences, may result helpful in the development of new treatments.

Clinical features of pure obsessive-compulsive disorder

OBJECTIVE

Psychiatric comorbidity is the rule in obsessive-compulsive disorder (OCD); however, very few studies have evaluated the clinical characteristics of patients with no co-occurring disorders (non-comorbid or "pure" OCD). The aim of this study was to estimate the prevalence of pure cases in a large multicenter sample of OCD patients and compare the sociodemographic and clinical characteristics of individuals with and without any lifetime axis I comorbidity.

METHOD

A cross-sectional study with 955 adult patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (C-TOC). Assessment instruments included the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, The USP-Sensory Phenomena Scale and the Brown Assessment of Beliefs Scale. Comorbidities were evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders. Bivariate analyses were followed by logistic regression.

RESULTS

Only 74 patients (7.7%) presented pure OCD. Compared with those presenting at least one lifetime comorbidity (881, 92.3%), non-comorbid patients were more likely to be female and to be working, reported less traumatic experiences and presented lower scores in the Y-BOCS obsession subscale and in total DY-BOCS scores. All symptom dimensions except contamination-cleaning and hoarding were less severe in non-comorbid patients. They also presented less severe depression and anxiety, lower suicidality and less previous treatments. In the logistic regression, the following variables predicted pure OCD: sex, severity of depressive and anxious symptoms, previous suicidal thoughts and psychotherapy.

CONCLUSIONS

Pure OCD patients were the minority in this large sample and were characterized by female sex, less severe depressive and anxious symptoms, less suicidal thoughts and less use of psychotherapy as a treatment modality. The implications of these findings for clinical practice are discussed.

Anxiety and affective disorder comorbidity related to serotonin and other neurotransmitter systems: obsessive-compulsive disorder as an example of overlapping clinical and genetic heterogeneity

Individuals with obsessive-compulsive disorder (OCD) have also been shown to have comorbid lifetime diagnoses of major depressive disorder (MDD; rates greater than 70%), bipolar disorder (rates greater than 10%) and other anxiety disorders (e.g. panic disorder, post-traumatic stress disorder (PTSD)). In addition, overlap exists in some common genetic variants (e.g. the serotonin transporter gene (SLC6A4), the brain-derived neurotrophic factor (BDNF) gene), and rare variants in genes/chromosomal abnormalities (e.g. the 22q11 microdeletion syndrome) found across the affective/anxiety disorder spectrums. OCD has been proposed as a possible independent entity for DSM-5, but by others thought best retained as an anxiety disorder subtype (its current designation in DSM-IV), and yet by others considered best in the affective disorder spectrum. This review focuses on OCD, a well-studied but still puzzling heterogeneous disorder, regarding alterations in serotonergic, dopaminergic and glutamatergic neurotransmission in addition to other systems involved, and how related genes may be involved in the comorbidity of anxiety and affective disorders. OCD resembles disorders such as depression, in which gene × gene interactions, gene × environment interactions and stress elements coalesce to yield OC symptoms and, in some individuals, full-blown OCD with multiple comorbid disorders.

The association of the metabolic profile in diabetes mellitus type 2 patients with obsessive-compulsive symptomatology and depressive symptomatology: new insights

OBJECTIVE

The aim of the present study was to explore the relationship between diabetes mellitus type 2, Obsessive- compulsive disorder (OCD) symptomatology and depressive symptomatology with the metabolic profile of diabetic patients.

METHODS

One hundred and thirty-one diabetic patients were randomly selected. In the first assessment all participants completed the Zung Self Rating Scale (ZUNG) and the Maudsley O-C Inventory Questionnaire (MOCI). After 1 year, diabetic patients that were initially uncontrolled (n = 31) (HbA1c > 7) were re-evaluated by the same psychometric tools. From those 31 patients, 10 had managed to control their metabolic profile.

RESULTS

In the first evaluation MOCI and the sub-scale of slowness were statistically related with the diabetic profile (controlled, HbA1c ≤ 7; uncontrolled, HbA1c > 7), with uncontrolled patients scoring significantly higher on the overall MOCI score and the factor of slowness of MOCI scale (P = 0.028). The analysis revealed a positive association between depressive symptomatology (P = 0.004) and obsessive-compulsive disorder symptomatology (P < 0.001) and the metabolic profile of the patients. In the second evaluation the patients that managed to control their metabolic profile scored lower in both ZDRS and MOCI, although these differences in scores failed to reach significance levels were indicative of a tendency.

CONCLUSIONS

The present results provide initial evidence that diabetes mellitus type 2 is associated with obsessive-compulsive disorder symptomatology and depressive symptomatology.

Social phobia in obsessive-compulsive disorder: prevalence and correlates

BACKGROUND

Social Phobia (SP) is an anxiety disorder that frequently co-occurs with obsessive-compulsive disorder (OCD); however, studies that evaluate clinical factors associated with this specific comorbidity are rare. The aim was to estimate the prevalence of SP in a large multicenter sample of OCD patients and compare the characteristics of individuals with and without SP.

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 Axis I Disorders. Univariate analyses were followed by logistic regression.

RESULTS

Lifetime prevalence of SP was 34.6% (N=346). The following variables remained associated with SP comorbidity after logistic regression: male sex, lower socioeconomic status, body dysmorphic disorder, specific phobia, dysthymia, generalized anxiety disorder, agoraphobia, Tourette syndrome and binge eating disorder.

LIMITATIONS

The cross-sectional design does not permit the inference of causal relationships; some retrospective information may have been subject to recall bias; all patients were being treated in tertiary services, therefore generalization of the results to other samples of OCD sufferers should be cautious. Despite the large sample size, some hypotheses may not have been confirmed due to the small number of cases with these characteristics (type 2 error).

CONCLUSION

SP is frequent among OCD patients and co-occurs with other disorders that have common phenomenological features. These findings have important implications for clinical practice, indicating the need for broader treatment approaches for individuals with this profile.

Skin picking and trichotillomania in adults with obsessive-compulsive disorder

The objective of this study was to compare patients with obsessive-compulsive disorder (OCD) associated with pathologic skin picking (PSP) and/or trichotillomania, and patients with OCD without such comorbidities, for demographic and clinical characteristics. We assessed 901 individuals with a primary diagnosis of OCD, using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I disorders. Diagnoses of PSP and trichotillomania were made in 16.3% and 4.9% of the sample, respectively. After the logistic regression analysis, the following factors retained an association with OCD-PSP/trichotillomania: younger (odds ratio [OR] = 0.979; P = .047), younger at the onset of compulsive symptoms (OR = 0.941; P = .007), woman (OR = 2.538; P < .001), with a higher level of education (OR = 1.055; P = .025), and with comorbid body dysmorphic disorder (OR = 2.363; P = .004). These findings support the idea that OCD accompanied by PSP/trichotillomania characterizes a specific subgroup.

Does anti-obsessional pharmacotherapy treat so-called comorbid depressive and anxiety states?

BACKGROUND

Obsessive-compulsive disorder (OCD) is a chronic condition that normally presents high rates of psychiatric comorbidity. Depression, tic disorders and other anxiety disorders are among the most common comorbidities in OCD adult patients. There is evidence that the higher the number of psychiatric comorbidities, the worse the OCD treatment response. However, little is known about the impact of OCD treatment on the outcome of the psychiatric comorbidities usually present in OCD patients. The aim of this study was to investigate the impact of exclusive, conventional treatments for OCD on the outcome of additional psychiatric disorders of OCD patients, detected at baseline.

METHODS

Seventy-six patients with primary OCD admitted to the treatment protocols of the Obsessive-Compulsive Spectrum Disorders Program between July 2007 and December 2009 were evaluated at pre-treatment and after 12 months. Data were analyzed to verify possible associations between OCD treatment response and the outcome of psychiatric comorbidities.

RESULTS

Results showed a significant association between OCD treatment response and improvement of major depression and dysthymia (p-value=0.002), other anxiety disorders (generalized anxiety disorder, social phobia, specific phobia, posttraumatic stress disorder, panic disorder, agoraphobia and anxiety disorder not otherwise specified) (p-value=0.054) and tic disorders (p-value=0.043).

LIMITATIONS

This is an open, non-blinded study, without rating scales for comorbid conditions. Further research is necessary focusing on the possible mechanisms by which OCD treatment could improve these specific disorders.

CONCLUSIONS

Our results suggest that certain comorbid disorders may benefit from OCD-targeted treatment.