Age of onset in obsessive-compulsive disorder: admixture analysis with a large sample

Structural neuroimaging of skin-picking disorder

BACKGROUND

Skin-picking disorder (SPD) is conceptualized as an obsessive-compulsive and related disorder (OCRD). Patients with SPD excessively manipulate their skin, which leads to skin lesions, psychological distress, and functional impairment. The neuroanatomical facets of this disorder are still poorly understood.

METHODS

A total of 220 participants (123 patients with a primary diagnosis of SPD and 97 healthy controls; mean age = 30 years, 80% female) were recruited for a voxel-based morphometry (VBM) study. VBM data were compared between patients and controls, and between three SPD subgroups, each characterized by a distinct age of symptom onset (before puberty, during puberty, adulthood).

RESULTS

Relative to the healthy comparison group, patients with SPD had significantly less grey matter volume (GMV) in regions of interest (ROIs: insula, orbitofrontal cortex, pallidum, cerebellum, supramarginal gyrus) and in the frontal pole and occipital regions (whole-brain findings). Early onset of symptoms (before puberty) was associated with elevated levels of focused skin-picking, in addition to less GMV in specific ROIs (insula, orbitofrontal cortex) as well as in paracingulate/ superior temporal regions (whole-brain findings).

CONCLUSIONS

SPD-related reductions in GMV were identified in brain regions involved in interoception, emotion regulation, and motor control. This partially aligns with findings for OCD. The detection of different age-of-onset groups based on clinical as well as morphometric data points to the heterogeneity of the disorder and warrants further investigation.

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.

Long-term remission rates and trajectory predictors in obsessive-compulsive disorder: Findings from a six-year naturalistic longitudinal cohort study

BACKGROUND

This naturalistic study, utilizing data from the Netherlands Obsessive-Compulsive Disorder Association (NOCDA) cohort, investigated the long-term remission rates and predictors of different trajectories of obsessive-compulsive disorder (OCD) within a clinical population.

METHODS

A sample of 213 participants was classified into three illness trajectories: "Chronic," "Episodic, "and "Remitted-OCD." Long-term remission rates were calculated based on three follow-up measurements over a 6-year period. A multinomial logistic regression model, incorporating five selected predictors with high explanatory power and one covariate, was employed to analyze OCD trajectory outcomes.

RESULTS

The long-term full remission rates, calculated from all the measurements combined (14%), were significantly lower than what was observed in earlier studies and when compared to assessments at each individual follow-up (∼30%). Moreover, high baseline symptom severity and early age of onset were identified as significant risk factors for a chronic course of OCD, while male sex and younger age predicted a more favorable trajectory. Notably, the likelihood of an episodic course remained high even without identified risk factors.

LIMITATIONS

The bi-annual data collection process is unable to capture participants' clinical conditions between assessments. Additionally, no data was collected regarding the specific type and duration of psychological treatment received. Regarding the type of treatment participants received.

CONCLUSIONS

Results suggest that long-term remission rates may be lower than previously reported. Consequently, employing multiple assessment points in longitudinal studies is necessary for valid estimation of long-term full remission rates. The results emphasize the importance of personalized clinical care and ongoing monitoring and maintenance for most OCD cases.

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.

Epidemiology of Body Dysmorphic Disorder and Appearance Preoccupation in Youth: Prevalence, Comorbidity and Psychosocial Impairment

OBJECTIVE

Little is known about how common and impairing body dysmorphic disorder (BDD) is in the general population of youth. We evaluated the prevalence, comorbidity, and psychosocial impairment associated with BDD and more broadly defined appearance preoccupation in young people.

METHOD

Data were drawn from the 2017 Mental Health of Children and Young People in England survey. BDD and psychiatric comorbidity were assessed in individuals 5 to 19 years of age (N = 7,654) according to DSM-5 criteria, using a clinician-rated standardized diagnostic assessment. Psychosocial impairment was measured with a quantitative scale and was indexed by reported self-harm and suicide attempts, as well as service use, assessed using structured interviews.

RESULTS

The point prevalence of BDD was 1.0% (95% CI = 0.8%-1.3%). BDD was significantly more common among adolescents than children (1.9 vs 0.1%; OR = 22.5, p < .001), and among female than male participants (1.8% vs 0.3%; OR = 7.3, p < .001). Approximately 70% of young people with BDD had psychiatric comorbidity, most commonly internalizing disorders. BDD was associated with self- and parent-reported psychosocial impairment, self-harm and suicide attempts, and service utilization. Appearance preoccupation was more common than full-syndrome BDD, but showed similar age and sex effects, patterns of comorbidity, and associated impairment.

CONCLUSION

BDD and appearance preoccupation are relatively common, especially among adolescent girls, and are associated with substantial co-occurring psychopathology, impairment, and risk. Improved screening is needed to increase detection and diagnosis of BDD, and to facilitate access to evidence-based treatment.

STUDY PREREGISTRATION INFORMATION

The epidemiology of body dysmorphic disorder the youth: prevalence, comorbidity and psychosocial impact; https://osf.io/g83jy.

The effectiveness and acceptability of the Bergen 4-day treatment for adolescents with OCD: a replication and extension

BACKGROUND

B4DT is a concentrated treatment format with prolonged sessions of exposure and ritual prevention (ERP) delivered over four consecutive days. Two previous open trials demonstrated promising results of the Bergen 4-day treatment (B4DT) for adolescents with obsessive-compulsive disorder (OCD). The aim of the current study was to replicate the initial results with a new sample of adolescents and different therapists at different sites across Norway.

METHODS

Forty-three youths participated in treatment program. At pretreatment, posttreatment, and the three-month follow-up, OCD symptoms were assessed using the CY-BOCS interview, while the GAD-7 and PHQ-9 were administered to rate general anxiety symptoms and depressive symptoms. Acceptability and patient satisfaction with the treatment were rated with the CSQ-8.

RESULTS

All symptoms were significantly reduced at posttreatment and follow-up. At posttreatment, 36 patients (85.71%) were defined as responders, while 29 patients (69.05%) achieved remission. At the three-month follow-up, 36 patients (92.3%) were defined as responders, while 33 patients (84.62%) were in remission. CSQ-8 scores indicated that the patients were highly satisfied with the treatment.

CONCLUSIONS

The B4DT was successfully replicated in a new sample at different sites across Norway, which indicates that this treatment is generalizable, effective and acceptable to adolescents with OCD.

Obsessive-Compulsive Disorder as an Epiphenomenon of Comorbid Bipolar Disorder? An Updated Systematic Review

BACKGROUND

Bipolar disorder (BD) and obsessive-compulsive disorder (OCD) comorbidity is an emerging condition in psychiatry, with relevant nosological, clinical, and therapeutic implications.

METHODS

We updated our previous systematic review on epidemiology and standard diagnostic validators (including phenomenology, course of illness, heredity, biological markers, and treatment response) of BD-OCD. Relevant papers published until (and including) 15 October 2023 were identified by searching the electronic databases MEDLINE, Embase, PsychINFO, and Cochrane Library, according to the PRISMA statement (PROSPERO registration number, CRD42021267685).

RESULTS

We identified 38 new articles, which added to the previous 64 and raised the total to 102. The lifetime comorbidity prevalence ranged from 0.26 to 27.8% for BD and from 0.3 to 53.3% for OCD. The onset of the two disorders appears to be often overlapping, although the appearance of the primary disorder may influence the outcome. Compared to a single diagnosis, BD-OCD exhibited a distinct pattern of OC symptoms typically following an episodic course, occurring in up to 75% of cases (vs. 3%). Notably, these OC symptoms tended to worsen during depressive episodes (78%) and improve during manic or hypomanic episodes (64%). Similarly, a BD course appears to be chronic in individuals with BD-OCD in comparison to patients without. Additionally, individuals with BD-OCD comorbidity experienced more depressive episodes (mean of 8.9 ± 4.2) compared to those without comorbidity (mean of 4.1 ± 2.7).

CONCLUSIONS

We found a greater likelihood of antidepressant-induced manic/hypomanic episodes (60% vs. 4.1%), and mood stabilizers with antipsychotic add-ons emerging as a preferred treatment. In line with our previous work, BD-OCD comorbidity encompasses a condition of greater nosological and clinical complexity than individual disorders.

A clinical investigation of psychotic vulnerability in early-onset Obsessive-Compulsive Disorder through Cognitive-Perceptive basic symptoms

Childhood-onset Obsessive-Compulsive Disorder (OCD) shows distinct comorbidity patterns and developmental pathways, as well as an increased risk of psychosis with respect to adult-onset forms. Nevertheless, little is known about the prodromal symptoms of psychosis in children and adolescents with a primary diagnosis of OCD. The present study was aimed at evaluating the occurrence of Cognitive-Perceptual basic symptoms (COPER) and high- risk criterion Cognitive Disturbances (COGDIS) in pediatric and adults OCD patients, verifying if they might vary according to the age of onset of OCD. The study included 90 outpatients with a primary diagnosis of obsessive-compulsive disorder. The study sample was collapsed into three groups according to the age at onset: 1) very early onset group (< 10 years); 2) early onset group (11-18 years); 3) adult-onset group (> 18 years). All patients were administered the Yale-Brown Obsessive- Compulsive Scale (Y-BOCS) and its Child version (CY-BOCS), the Schizophrenia Proneness Instrument-Adult (SPIA) and its Child and Adolescent version (SPI-CY) and the Social and Occupational Functioning Assessment Scale (SOFAS). COPER and COGDIS symptoms were positively associated with OCD severity and detectable, respectively, in 28.9 and 26.7% of our study sample. The very early onset group significantly had higher COPER and COGDIS symptoms than the adult-onset group. Our data suggest that COPER and COGDIS symptoms are frequent in obsessive patients, in particular in those with earlier onset; therefore, their detection in childhood-onset OCD may represent an early and specific indicator of psychotic vulnerability.

Microbiome analysis of circulating bacterial extracellular vesicles in obsessive-compulsive disorder

AIM

The present study examined the microbiome abundance and composition of drug-naive or drug-free patients with obsessive-compulsive disorder (OCD) compared with healthy controls. In addition, in the OCD group, the microbiome composition was compared between early-onset and late-onset OCD.

METHODS

Serum samples were collected from 89 patients with OCD and 107 age- and sex-matched healthy controls. Bacterial DNA was isolated from bacteria-derived extracellular vesicles in serum and then amplified and quantified using primers specific to the V3-V4 hypervariable region of the 16S ribosomal RNA gene. The 16S ribosomal DNA gene amplicon sequencing was performed.

RESULTS

The pooled estimate showed that α-diversity was significantly reduced in patients with OCD compared with that in healthy controls (PShannon  = 0.00015). In addition, a statistically significant difference was observed in β-diversity between patients with OCD and healthy controls at the order (P = 0.012), family (P = 0.003), genus (P < 0.001), and species (P = 0.005) levels. In the microbiome composition, Pseudomonas, Caulobacteraceae (f), Streptococcus, Novosphingobium, and Enhydrobacter at the genus level were significantly less prevalent in patients with OCD than in controls. In addition, among patients with OCD, the microbial composition in the early-onset versus late-onset types was significantly different with respect to the genera Corynebacterium and Pelomonas.

CONCLUSION

The present study showed an aberrant microbiome in patients with OCD, suggesting a role of the microbiota-brain interaction in the pathophysiology of OCD. Further longitudinal studies with larger sample sizes adjusting for various confounders are warranted.

Insight in obsessive-compulsive disorder: conception, clinical characteristics, neuroimaging, and treatment

Obsessive-compulsive disorder (OCD) is a chronic disabling disease with often unsatisfactory therapeutic outcomes. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has broadened the diagnostic criteria for OCD, acknowledging that some OCD patients may lack insight into their symptoms. Previous studies have demonstrated that insight can impact therapeutic efficacy and prognosis, underscoring its importance in the treatment of mental disorders, including OCD. In recent years, there has been a growing interest in understanding the influence of insight on mental disorders, leading to advancements in related research. However, to the best of our knowledge, there is dearth of comprehensive reviews on the topic of insight in OCD. In this review article, we aim to fill this gap by providing a concise overview of the concept of insight and its multifaceted role in clinical characteristics, neuroimaging mechanisms, and treatment for OCD.

Predictors of the 6-year outcome of obsessive-compulsive disorder: Findings from the Netherlands Obsessive-Compulsive Disorder Association study

OBJECTIVE

Obsessive-compulsive disorder is characterized by a chronic course that can vary between patients. The knowledge on the naturalistic long-term outcome of obsessive-compulsive disorder and its predictors is surprisingly limited. The present research was designed to identify clinical and psychosocial predictors of the long-term outcome of obsessive-compulsive disorder.

METHODS

We included 377 individuals with a current diagnosis of obsessive-compulsive disorder, who participated in the Netherlands Obsessive Compulsive Disorder Association study, a multicenter naturalistic cohort study. Predictors were measured at baseline using self-report questionnaires and clinical interviews. Outcome was assessed using the Yale-Brown Obsessive Compulsive Scale at 2-, 4- and 6-year follow-up.

RESULTS

The overall course of obsessive-compulsive disorder was characterized by two prominent trends: the first reflected an improvement in symptom severity, which was mitigated by the second, worsening trend in the long term. Several determinants affected the course variations of obsessive-compulsive disorder, namely, increased baseline symptom severity, late age of onset, history of childhood trauma and autism traits.

CONCLUSION

The long-term outcome of obsessive-compulsive disorder in naturalistic settings was characterized by an overall improvement in symptom severity, which was gradually halted to the point of increased worsening. However, after 6 years, the severity of symptoms remained below the baseline level. While certain determinants predicted a more favorable course, their effect diminished over time in correspondence to the general worsening trend. The results highlight the importance of a regular and continuous monitoring for symptom exacerbations as part of the management of the obsessive-compulsive disorder, regardless of the presence of putative predictors.

Intraoperative valence testing to adjudicate between ventral capsule/ventral striatum and bed nucleus of the stria terminalis target selection in deep brain stimulation for obsessive-compulsive disorder

OBJECTIVE

Deep brain stimulation (DBS) is an accepted therapy for severe, treatment-refractory obsessive-compulsive disorder (trOCD). The optimal DBS target location within the anterior limb of the internal capsule, particularly along the anterior-posterior axis, remains elusive. Empirical evidence from several studies in the past decade has suggested that the ideal target lies in the vicinity of the anterior commissure (AC), either just anterior to the AC, above the ventral striatum (VS), or just posterior to the AC, above the bed nucleus of the stria terminalis (BNST). Various methods have been utilized to optimize target selection for trOCD DBS. The authors describe their practice of planning trajectories to both the VS and BNST and adjudicating between them with awake intraoperative valence testing to individualize permanent target selection.

METHODS

Eight patients with trOCD underwent awake DBS with trajectories planned for both VS and BNST targets bilaterally. The authors intraoperatively assessed the acute effects of stimulation on mood, energy, and anxiety and implanted the trajectory with the most reliable positive valence responses and least stimulation-induced side effects. The method of intraoperative target adjudication is described, and the OCD outcome at last follow-up is reported.

RESULTS

The mean patient age at surgery was 41.25 ± 15.1 years, and the mean disease duration was 22.75 ± 10.2 years. The median preoperative Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 39 (range 34-40). Two patients had previously undergone capsulotomy, with insufficient response. Seven (44%) of 16 leads were moved to the second target based on intraoperative stimulation findings, 4 of them to avoid strong negative valence effects. Three patients had an asymmetric implant (1 lead in each target). All 8 patients (100%) met full response criteria, and the mean Y-BOCS score reduction across the full cohort was 51.2% ± 12.8%.

CONCLUSIONS

Planning and intraoperatively testing trajectories flanking the AC-superjacent to the VS anteriorly and to the BNST posteriorly-allowed identification of positive valence responses and acute adverse effects. Awake testing helped to select between possible trajectories and identify individually optimized targets in DBS for trOCD.

Autoantibodies in patients with obsessive-compulsive disorder: a systematic review

Obsessive-compulsive disorder (OCD) is a frequent and debilitating mental illness. Although efficacious treatment options are available, treatment resistance rates are high. Emerging evidence suggests that biological components, especially autoimmune processes, may be associated with some cases of OCD and treatment resistance. Therefore, this systematic literature review summarizing all case reports/case series as well as uncontrolled and controlled cross-sectional studies investigating autoantibodies in patients with OCD and obsessive-compulsive symptoms (OCS) was performed. The following search strategy was used to search PubMed: "(OCD OR obsessive-compulsive OR obsessive OR compulsive) AND (antib* OR autoantib* OR auto-antib* OR immunoglob* OR IgG OR IgM OR IgA)". Nine case reports with autoantibody-associated OCD/OCS were identified: five patients with anti-neuronal autoantibodies (against N-methyl-D-aspartate-receptor [NMDA-R], collapsin response mediator protein [CV2], paraneoplastic antigen Ma2 [Ma2], voltage gated potassium channel complex [VGKC], and "anti-brain" structures) and four with autoantibodies associated with systemic autoimmune diseases (two with Sjögren syndrome, one with neuropsychiatric lupus, and one with anti-phospholipid autoantibodies). Six patients (67%) benefited from immunotherapy. In addition, eleven cross-sectional studies (six with healthy controls, three with neurological/psychiatric patient controls, and two uncontrolled) were identified with inconsistent results, but in six studies an association between autoantibodies and OCD was suggested. In summary, the available case reports suggest an association between OCD and autoantibodies in rare cases, which has been supported by initial cross-sectional studies. However, scientific data is still very limited. Thus, further studies on autoantibodies investigated in patients with OCD compared with healthy controls are needed.

Epigenetic modifications and obsessive-compulsive disorder: what do we know?

Obsessive-Compulsive Disorder (OCD) is a chronic, severe disabling neuropsychiatric disorder whose pathophysiology is not yet well defined. Generally, the symptom onset occurs during pre-adult life and affects subjects in different life aspects, including professional and social relationships. Although robust evidence indicates the presence of genetic factors in the etiopathology of OCD, the entirely mechanisms are not totally clarified. Thus, the possible interactions between genes and environmental risk factors mediated by epigenetic mechanisms should be sought. Therefore, we provide a review of genetic and epigenetic mechanisms related to OCD with a deep focus on the regulation of critical genes of the central nervous system seeking possible potential biomarkers.

Mapping the neuroanatomical heterogeneity of OCD using a framework integrating normative model and non-negative matrix factorization

Obsessive-compulsive disorder (OCD) is a spectrum disorder with high interindividual heterogeneity. We propose a comprehensible framework integrating normative model and non-negative matrix factorization (NMF) to quantitatively estimate the neuroanatomical heterogeneity of OCD from a dimensional perspective. T1-weighted magnetic resonance images of 98 first-episode untreated patients with OCD and matched healthy controls (HCs, n = 130) were acquired. We derived individualized differences in gray matter morphometry using normative model and parsed them into latent disease factors using NMF. Four robust disease factors were identified. Each patient expressed multiple factors and exhibited a unique factor composition. Factor compositions of patients were significantly correlated with severity of symptom, age of onset, illness duration, and exhibited sex differences, capturing sources of clinical heterogeneity. In addition, the group-level morphological differences obtained with two-sample t test could be quantitatively derived from the identified disease factors, reconciling the group-level and subject-level findings in neuroimaging studies. Finally, we uncovered two distinct subtypes with opposite morphological differences compared with HCs from factor compositions. Our findings suggest that morphological differences of individuals with OCD are the unique combination of distinct neuroanatomical patterns. The proposed framework quantitatively estimating neuroanatomical heterogeneity paves the way for precision medicine in OCD.

Validation of a French version of the Vancouver Obsessional Compulsive Inventory-Mental Contamination scale (VOCI-MC) and the Contamination Thought-Action Fusion scale (CTAF) in non-clinical and clinical samples

The Vancouver Obsessional Compulsive Inventory-Mental Contamination scale (VOCI-MC) and the Contamination Thought-Action Fusion scale (CTAF) are two self-report instruments that assess symptoms of mental contamination and fusion between thoughts, and feelings and behaviours associated with contamination, respectively. The aim of this study was to investigate the psychometric properties of the French version of these two scales in non-clinical and clinical samples. We included 79 participants diagnosed with obsessive-compulsive disorder (OCD), 31 diagnosed with anxiety disorders, who were recruited from the University Department of Adult Psychiatry in Montpellier, and 320 non-clinical participants recruited from the general population. Psychometric properties of the French VOCI-MC and CTAF were investigated. Results showed that the French versions of the VOCI-MC and the CTAF had high internal consistency, good convergent and divergent validity, as well as good temporal stability. Exploratory and confirmatory factor analyses showed a one-factor structure for the two scales in both non-clinical and OCD samples. Adequate discriminative validity was established by comparing OCD patients with contamination-related symptoms and OCD patients who did not report contamination-related symptoms. The French VOCI-MC and CTAF are valid and appropriate tools for measuring mental contamination in both clinical and research contexts.

The role of nitric oxide (NO) modulators in obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder (OCD) is as serious devastating anxiety disorder. Selective serotonin reuptake inhibitors (SSRIs) are largely used for the treatment of this mental disease. This pharmacological approach presents consistent limitations including modest efficacy and important side effects. There is pressing need, therefore, to develop new molecules with higher efficacy and safety. Nitric oxide (NO) is an intra-and inter-cellular messenger in the brain. Its involvement in the pathogenesis of OCD has been proposed. In a series of preclinical studies, the anxiolytic profile of NO modulators has been emerged. In the present review I intended to critically evaluate advances in research of these molecules as potential novel agents for the treatment of OCD, comment their advantages over currently used pharmacological therapy as well remaining challenges. Up to now, few preclinical studies have been carried out to this end. Nonetheless, experimental evidence proposes a role for NO and its modulators in OCD. Additional research is mandatory aiming to definitively determine a role for NO modulators for the treatment of OCD. A note of caution, however, is needed on account of potential neurotoxicity and narrow therapeutic window of NO compounds.

Deep brain stimulation of the subthalamic nucleus to improve symptoms and cognitive functions in patients with refractory obsessive-compulsive disorder: a longitudinal study

There are conflicting results regarding the effect of deep brain stimulation (DBS) of different regions on the cognitive functions of patients with severe refractory obsessive-compulsive disorder (OCD). Moreover, it is not yet clear whether the rate of improvement in obsession-compulsion symptoms and cognitive functions following DBS is interrelated. We investigated the effect of the subthalamic nucleus (STN)-DBS on both the severity of symptoms and cognitive functions of patients and also investigated the possible interrelationship between the two. Twelve patients (10 males and two females; 56.17 ± 4.52 years old) were assessed before and 1 month and 3 months after the DBS surgery using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the N-Back, the selective and divided attention (SDA), the Tower of London (TOL), and the Wisconsin Card Sorting (WCS) tests. We found that the severity of symptoms and cognitive functions improved significantly after DBS and this effect lasted at least up to 3 months. Furthermore, it was revealed that the severity of symptoms and cognitive profiles of patients were significantly correlated. Compulsion severity had the highest correlation with perseveration errors, while obsession severity was most correlated with the number of n-back errors. Based on our findings, it seems that the STN acts at least to some extent as a common functional/anatomical ground for the severity of symptoms and cognitive functions of patients with severe refractory OCD, and it can probably be considered as the region of interest for DBS in this group of patients.

Early Identification and Intervention in Pediatric Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by persistent thoughts with subsequent repetitive behaviors. Interventions that are effective for adult OCD cannot simply be generalized to pediatric OCD, since OCD in children and adolescents usually has a different clinical presentation, etiology and course from adult OCD. Delayed and inadequate treatment is associated with a worse prognosis, making the need for early identification and intervention in pediatric OCD very urgent. In this paper, we reflected on the current constraints that make early interventions for pediatric OCD unpromoted and reviewed the approaches with potential application for early identification and early intervention in pediatric OCD, categorized by three-level prevention stages corresponding to a clinical staging model. Since the etiology of pediatric OCD is still unclear, primary prevention is most lacking, and early interventions for pediatric OCD are currently focused on the secondary prevention stage, which aims to prevent the conversion of obsessive-compulsive symptoms into full-blown OCD; tertiary prevention mostly focuses on the alleviation of mild to moderate OCD, while interventions for co-morbidities are still in their infancy. We closed by considering the important research questions on this topic.

Misdiagnosis of Psychosis and Obsessive-Compulsive Disorder in a Young Patient with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social interaction and the presence of restricted and repetitive patterns of behavior. Making a first diagnosis of ASD in adults has certain difficulties, including inaccurate recall of developmental history and overlapping behaviors with other psychiatric conditions. This case study presents a young man who was assessed to have no major mental illness during his first visit to emergency services in a psychiatric hospital. During his second visit, he was initially assessed to have first episode psychosis, due to his possible delusional beliefs related to the insurance payout, social withdrawal, and strange behaviors, and then later he was assessed to have obsessive-compulsive disorder (OCD) instead of psychosis, because of his recurrent and intrusive thoughts. Eventually, his diagnosis was revised to ASD during outpatient follow-up after more comprehensive assessment. It is not easy to differentiate ASD from psychosis among some adult patients, even for expert psychiatrists. Cognitive rigidity in ASD may be similar to delusions in psychosis. Unusual behaviors in ASD can be confused with disorganized behaviors in psychosis. Differentiating ASD from OCD can be a complicated task as well, due to similarities between ASD and OCD. Restricted interests and repetitive behaviors in ASD may be perceived as obsessions and compulsions in OCD. Overall, diagnosis of ASD in adults requires comprehensive evaluation. Distinguishing symptoms of OCD and psychosis from autistic traits is critical for accurate diagnosis and optimal treatment. Although research in adult ASD has expanded alongside increased prevalence statistics over the past few years, more efforts to enhance the diagnostic processes in adult ASD are needed to reduce the challenges in this field.

Assessing response, remission, and treatment resistance in patients with obsessive-compulsive disorder with and without tic disorders: results from a multicenter study

BACKGROUND

Highlighting the relationship between obsessive-compulsive disorder (OCD) and tic disorder (TD), two highly disabling, comorbid, and difficult-to-treat conditions, Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) acknowledged a new "tic-related" specifier for OCD, ie, obsessive-compulsive tic-related disorder (OCTD). As patients with OCTD may frequently show poor treatment response, the aim of this multicenter study was to investigate rates and clinical correlates of response, remission, and treatment resistance in a large multicenter sample of OCD patients with versus without tics.

METHODS

A sample of 398 patients with a DSM-5 diagnosis of OCD with and without comorbid TD was assessed from 10 different psychiatric departments across Italy. For the purpose of the study, treatment response profiles in the whole sample were analyzed comparing the rates of response, remission, and treatment-resistance as well as related clinical features. Multivariate logistic regressions were performed to identify possible factors associated with treatment response.

RESULTS

The remission group was associated with later ages of onset of TD and OCD. Moreover, significantly higher rates of psychiatric comorbidities, TD, and lifetime suicidal ideation and attempts emerged in the treatment-resistant group, with larger degrees of perceived worsened quality of life and family involvement.

CONCLUSIONS

Although remission was associated with later ages of OCD and TD onset, specific clinical factors, such as early onset and presence of psychiatric comorbidities and concomitant TD, predicted a worse treatment response with a significant impairment in quality of life for both patients and their caregivers, suggesting a worse profile of treatment response for patients with OCTD.

Early intervention in obsessive-compulsive disorder: From theory to practice

Obsessive-compulsive disorder (OCD) is frequent and often disabling. Yet, correct diagnosis and appropriate treatment implementation are usually delayed, with undesirable consequences. In this paper we review the rationale for early intervention in OCD and provide recommendations for early intervention services. Two scenarios are discussed, i.e., subclinical (prodromal) obsessive-compulsive symptoms (OCS) and full-blown OCD. Although the typical patient with OCD reports a long history of subclinical OCS, longitudinal studies suggest most individuals with OCS in the community do not convert to full-blown OCD. Thus, research on "at risk" phenotypes for OCD and how they should incorporate different risk factors (e.g., polygenic risk scores) are badly needed. For this specific scenario, preventative treatments that are cheap, well tolerated and highly scalable (e.g., lifestyle interventions) are of major interest. On the other hand, increasing evidence suggests OCD to be a progressive disorder and the severity and duration of illness to be associated with both biological changes and increased clinical complexity, including greater number of physical and psychiatric comorbidities, increased family accommodation and worse treatment response. Therefore, prompt identification and early treatment implementation for full-blown OCD are also critical for ethical, clinical and therapeutic reasons. Based on the existing findings, we argue that, regardless of focusing on subclinical OCS or clinical OCD, early intervention services need to target a childhood age group. In addition to delivering well established treatments to people with full-blown OCD early on their illness, early intervention services also need to provide psychoeducation for patients, families and teachers.

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.

An ultra-brief screening scale for pediatric obsessive-compulsive disorder: The OCI-CV-5

BACKGROUND

Obsessive-compulsive disorder (OCD) is an often disabling and chronic condition that is normally assessed using diagnostic interviews or lengthy self-report questionnaires. This makes routine screening in general health settings impractical, and as a result OCD is often under-(or mis-)recognized. The present study reports on the development of an ultra-brief version of the Obsessive-Compulsive Inventory-Child Version (OCI-CV) which may be administered routinely as a screener for pediatric OCD.

METHOD

A total of 489 youth diagnosed with OCD, 259 non-clinical controls, and 299 youth with other disorders completed the OCI-CV and other indices of psychopathology. Using item analyses, we extracted five items and examined the measure's factor structure, sensitivity and specificity, and convergent and discriminant validity.

RESULTS

We extracted five items that assess different dimensions of OCD (washing, checking, ordering, obsessing, neutralizing/counting), termed the OCI-CV-5. Results revealed that the measure possesses good to excellent psychometric properties, and a cutoff off (≥2) yielded optimal sensitivity and specificity.

LIMITATIONS

Participants were predominantly White. In addition, more research is needed to examine the OCI-CV-5's test-retest reliability and sensitivity to treatment.

CONCLUSIONS

The OCI-CV-5 shows promise as an ultra-brief self-report screener for identifying OCD in youth when in-depth assessment is unfeasible.

Age of onset of social anxiety disorder and psychiatric and mental health outcomes: Results from a nationally representative study

OBJECTIVE

Prior studies support that younger age of onset would be associated with poorer psychiatric and mental health outcomes for many psychiatric disorders. However, such relationship has never been examined for social anxiety disorder (SAD) in a nationally representative sample.

METHODS

Using data from the second Wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), we have identified four groups of participants with a lifetime DSM-IV diagnosis of SAD based on the self-reported age of onset (childhood onset (<12 years, N = 658), adolescence onset (12-17 years, N = 663), early-adulthood onset (18-39 years, N = 663), and late-adulthood onset (>39 years, N = 415)), and a control group without a lifetime history of SAD (N = 32,205). We performed multinomial logistic regression models to compare lifetime DSM-IV psychiatric disorders and current mental health-related quality of life (assessed with the mental component summary score (MSC) of the SF-12) across these groups.

RESULTS

The lifetime prevalence rates of panic disorder, agoraphobia and post-traumatic stress disorder were significantly higher in the adulthood onset groups than in groups with an onset during childhood or adolescence (p < 0.01 for most models). MCS score was significantly higher in the childhood (46.0 (SE = 0.5)) or adolescence (46.5 (SE = 0.5)) onset groups than in the groups with an onset during adulthood (early-adulthood onset: 43.5 (SE = 0.6), and late-adulthood onset: 43.0 (SE = 0.8)).

LIMITATIONS

Our results relied on retrospective self-reported data.

CONCLUSION

Among individuals with SAD, a later age of onset was significantly associated with greater lifetime rates of psychiatric disorders and diminished quality of life.

The OCI-CV-R: A Revision of the Obsessive-Compulsive Inventory - Child Version

BACKGROUND

The Obsessive-Compulsive Inventory-Children's Version (OCI-CV) was developed to assess obsessive-compulsive symptoms in youth. Recent changes in the Diagnostic and Statistical Manual (DSM-5) exclude hoarding from inclusion in the diagnosis of obsessive-compulsive disorder (OCD). Accordingly, the present study examined the reliability, validity, factorial structure, and diagnostic sensitivity of a revised version of the scale - the OCI-CV-R- that excludes items assessing hoarding.

METHODS

Participant were 1047 youth, including 489 meeting DSM criteria for primary OCD, 298 clinical controls, and 260 nonclinical controls, who completed the OCI-CV and measures of obsessive-compulsive symptom severity, depression, and anxiety at various treatment and research centers.

RESULTS

Findings support a five-factor structure (doubting/checking, obsessing, washing, ordering, and neutralizing), with a higher order factor. Factorial invariance was found for older (12-17 years) and younger (7-11 years) children. Internal consistency of the OCI-CV-R was acceptable, and discriminant and convergent validity were adequate and akin to that of its progenitor. Diagnostic sensitivity and specificity were found for a total score of 8 and higher.

CONCLUSION

It is recommended that the OCI-CV-R replace the former version, and that this measure serve as part of a comprehensive clinical assessment of youth with OCD. Recommendations for further research with ethnically and racially diverse samples, as well as the need to establish benchmark scores are discussed.

Mental Health Literacy and Stigma Among Salvadorian Youth: Anxiety, Depression and Obsessive-Compulsive Related Disorders

This study examined (1) adolescent mental health literacy (MHL) and stigma for depression, anxiety and obsessive-compulsive and related disorders (OCRDs), and (2) demographic moderators. Participants were 383 high school students (50.9% boys) aged 11-18 years (M = 14.12, SD = 1.91) in El Salvador. Participants read vignettes of adolescents with mental health problems and reported on their beliefs about (1) what was wrong with the young person, (2) expected recovery time, (3) help-seeking beliefs and recommendations, and (4) stigma and preferred social distance associated with each condition. Results suggested that recognition of mental health conditions, especially anxiety disorders and OCRDs, was limited, although one third could recognize depression in a peer. Help-seeking attitudes were favorable. Adolescents were only somewhat willing to be affiliated with someone experiencing a mental health problem. Girls showed better MHL and lower stigma than boys. Stigma was lower among those with exposure to mental health problems.

Immunological causes of obsessive-compulsive disorder: is it time for the concept of an "autoimmune OCD" subtype?

Obsessive-compulsive disorder (OCD) is a highly disabling mental illness that can be divided into frequent primary and rarer organic secondary forms. Its association with secondary autoimmune triggers was introduced through the discovery of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection (PANDAS) and Pediatric Acute onset Neuropsychiatric Syndrome (PANS). Autoimmune encephalitis and systemic autoimmune diseases or other autoimmune brain diseases, such as multiple sclerosis, have also been reported to sometimes present with obsessive-compulsive symptoms (OCS). Subgroups of patients with OCD show elevated proinflammatory cytokines and autoantibodies against targets that include the basal ganglia. In this conceptual review paper, the clinical manifestations, pathophysiological considerations, diagnostic investigations, and treatment approaches of immune-related secondary OCD are summarized. The novel concept of "autoimmune OCD" is proposed for a small subgroup of OCD patients, and clinical signs based on the PANDAS/PANS criteria and from recent experience with autoimmune encephalitis and autoimmune psychosis are suggested. Red flag signs for "autoimmune OCD" could include (sub)acute onset, unusual age of onset, atypical presentation of OCS with neuropsychiatric features (e.g., disproportionate cognitive deficits) or accompanying neurological symptoms (e.g., movement disorders), autonomic dysfunction, treatment resistance, associations of symptom onset with infections such as group A streptococcus, comorbid autoimmune diseases or malignancies. Clinical investigations may also reveal alterations such as increased levels of anti-basal ganglia or dopamine receptor antibodies or inflammatory changes in the basal ganglia in neuroimaging. Based on these red flag signs, the criteria for a possible, probable, and definite autoimmune OCD subtype are proposed.

A Retrospective Evaluation on Demographic, Phenomenological, and Comorbidity Features of Pediatric Obsessive-Compulsive Disorder

ABSTRACT

The impacts of sex, age of onset, phenotype, and comorbidity on clinical features were explored in a large clinical sample with pediatric obsessive-compulsive disorder (p-OCD) (n = 457), along with concomitant specific features in the framework of different symptom dimensions/phenotypes, by a retrospective cross-sectional evaluation design. The most prevalent phenotype was obsession/checking (almost half), and the clinical features belonging to different phenotypes varied among sexes, age of onset, severity, and comorbidities. The contamination and aggressive obsessions, along with the compulsions such as cleaning and repeating routine activities, were the most prevalent symptoms, which were prevalently accompanied by generalized anxiety disorder, attention deficit hyperactivity disorder, and depression. Females with OCD were likely prone to exhibit comorbid internalizing disorders, whereas males were prone to externalizing. This recent study on a large Turkish clinical sample of p-OCD followed up within 5 years, highlighting separate evidence on subtyping of p-OCD in phenotype and comorbidity frame.

Genetics of obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a psychiatric disorder with multiple symptom dimensions (e.g. contamination, symmetry). OCD clusters in families and decades of twin studies clearly demonstrate an important role for genetics in the etiology of the disorder.

METHODS

In this review, we summarize the genetic epidemiology and molecular genetic studies of OCD and obsessive-compulsive symptoms.

RESULTS

OCD is a heritable, polygenic disorder with contributions from both common and rare variants, including de novo deleterious variations. Multiple studies have provided reliable support for a large additive genetic contribution to liability to OCD, with discrete OCD symptom dimensions having both shared and unique genetic risks. Genome-wide association studies have not produced significant results yet, likely because of small sample sizes, but larger meta-analyses are forthcoming. Both twin and genome-wide studies show that OCD shares genetic risk with its comorbid conditions (e.g. Tourette syndrome and anorexia nervosa).

CONCLUSIONS

Despite significant efforts to uncover the genetic basis of OCD, the mechanistic understanding of how genetic and environmental risk factors interact and converge at the molecular level to result in OCD's heterogeneous phenotype is still mostly unknown. Future investigations should increase ancestral genetic diversity, explore age and/or sex differences in genetic risk for OCD and expand the study of pharmacogenetics, gene expression, gene × environment interactions and epigenetic mechanisms for OCD.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

A dimensional perspective on the genetics of obsessive-compulsive disorder

This review covers recent findings in the genomics of obsessive-compulsive disorder (OCD), obsessive-compulsive symptoms, and related traits from a dimensional perspective. We focus on discoveries stemming from technical and methodological advances of the past five years and present a synthesis of human genomics research on OCD. On balance, reviewed studies demonstrate that OCD is a dimensional trait with a highly polygenic architecture and genetic correlations to multiple, often comorbid psychiatric phenotypes. We discuss the phenotypic and genetic findings of these studies in the context of the dimensional framework, relying on a continuous phenotype definition, and contrast these observations with discoveries based on a categorical diagnostic framework, relying on a dichotomous case/control definition. Finally, we highlight gaps in knowledge and new directions for OCD genetics research.

Developmental Trajectories of Pediatric Obsessive-Compulsive Symptoms

Children who experience obsessive-compulsive symptoms (OCS) may be at risk for developing Obsessive-Compulsive Disorder (OCD). The current study aimed to investigate developmental trajectories of OCS, as well as possible predictors, within a community-based sample of children. Children (N = 1147) from the longitudinal NICHD Study of Early Child Care and Youth Development (SECCYD) were assessed for OCS, via the Child Behavioral Checklist - Obsessive-Compulsive Scale (OCS-8), eight times between Pre-Kindergarten (54 months; Pre-K) and High School (15 years of age; HS.) Participants were recruited within the United States and included only maternal caregivers. Preliminary analyses indicated that approximately 3% of the sample was above the diagnostic cutoff score on the OCS-8 at the High School time-point. Latent growth models tested symptom trajectories. Findings demonstrated three groups of OCS trajectories. Most children fell within a low symptomatology group (the No Peak group) with low OCS across all time points. Two additional OCS trajectories were also demonstrated: Pre-K Peak (high to low OCS across time) and HS Peak (low to high OCS across time). Both higher attention problems and greater depression/anxiety symptoms at the Pre-K time point predicted children's membership in the Pre-K Peak or HS Peak groups compared to the No Peak group. Membership within the HS Peak group predicted a high likelihood of children's OCS being above previously established cutoff scores for an OCD diagnosis at age 15 years. Membership within either the Pre-K Peak or No Peak groups predicted a low likelihood. This study provides new evidence for the existence of different developmental trajectories for youth with OCS. From a clinical perspective, these results may have important implications when considering the identification and early intervention of childhood OCS and OCD within the community.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTITIONER POINTS

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

Clinical characteristics of moderate-severe obsessive-compulsive disorder in children and adolescents in China

Objective

This study reports clinical characteristic of moderate–severe obsessive–compulsive disorder (OCD) among school students in China.

Methods

We examined 153 patients for the distribution of OCD symptoms using the Yale-Brown Obsessive Compulsive Scale Symptoms Checklist, the severity of anxiety and depression symptoms using the Hamilton Anxiety Scale and the Hamilton Depression Scale-24, respectively, and impairment in learning, family and social functions using the Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire.

Results

The number of total OCD, obsession and compulsion symptoms was 6.71 (standard deviation [SD] = 2.25), 3.77 (SD = 1.32) and 2.94 (SD = 1.59), respectively. The incidence of moderate and severe depressive symptoms for junior high school students was significantly higher than for primary and high school students. The number of children and adolescents with OCD increased with age, reaching a peak in the senior high school stage.

Conclusion

The most common symptoms in children and adolescent OCD patients are miscellaneous obsessions, aggressiveness, religiousness, checking, miscellaneous compulsions, cleaning-washing and repeating. These patients show a relatively high co-occurrence rate of anxiety symptoms and depressive symptoms, which impairs their learning, as well as their family and social functions.

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.

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

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

Structural neuroimaging biomarkers for obsessive-compulsive disorder in the ENIGMA-OCD consortium: medication matters

No diagnostic biomarkers are available for obsessive-compulsive disorder (OCD). Here, we aimed to identify magnetic resonance imaging (MRI) biomarkers for OCD, using 46 data sets with 2304 OCD patients and 2068 healthy controls from the ENIGMA consortium. We performed machine learning analysis of regional measures of cortical thickness, surface area and subcortical volume and tested classification performance using cross-validation. Classification performance for OCD vs. controls using the complete sample with different classifiers and cross-validation strategies was poor. When models were validated on data from other sites, model performance did not exceed chance-level. In contrast, fair classification performance was achieved when patients were grouped according to their medication status. These results indicate that medication use is associated with substantial differences in brain anatomy that are widely distributed, and indicate that clinical heterogeneity contributes to the poor performance of structural MRI as a disease marker.

COVID-19 Pandemic and Mental Health: Prevalence and Correlates of New-Onset Obsessive-Compulsive Symptoms in a Canadian Province

Background: This cross-sectional online survey investigates the prevalence of obsessive-compulsive disorder (OCD) symptoms at an early stage of the COVID-19 pandemic in Canada. Methods: OCD symptoms, moderate/high stress, likely generalized anxiety disorder (GAD) and likely major depressive disorder (MDD) were assessed with the Brief Obsessive-Compulsive Scale (BOCS), Perceived Stress Scale (PSS), Generalized Anxiety Disorder 7-item (GAD-7) scale, and Patient Health Questionnaire-9 (PHQ-9) scale, respectively. Results: Out of 32,805 individuals subscribed to Text4Hope, 6041 completed an online survey; the response rate was 18.4%. Overall, 60.3% of respondents reported onset of OCD symptoms and 53.8% had compulsions to wash hands during the COVID-19 pandemic. Respondents who showed OCD symptoms only since the start of COVID-19 were significantly more likely to have moderate/high stress (z = 6.4, p < 0.001), likely GAD (z = 6.0, p < 0.001), and likely MDD (z = 2.7, p < 0.01). Similarly, respondents who engaged in compulsive hand washing were significantly more likely to have moderate/high stress (z = 4.6, p < 0.001) and likely GAD (z = 4.6 p < 0.001), but not likely MDD (z = 1.4, p = 0.16). Conclusion: The prevalence of OCD symptoms increased during the COVID-19 pandemic, at a rate significantly higher than pre-pandemic rates reported for the sample population. Presenting with OCD symptoms increased the likelihood of presenting with elevated stress, likely GAD, and likely MDD.

Effect of D-Cycloserine on the Effect of Concentrated Exposure and Response Prevention in Difficult-to-Treat Obsessive-Compulsive Disorder: A Randomized Clinical Trial

IMPORTANCE

Evidence is lacking for viable treatment options for patients with difficult-to-treat obsessive-compulsive disorder (OCD). It has been suggested that D-cycloserine (DCS) could potentiate the effect of exposure and response prevention (ERP) treatment, but the hypothesis has not been tested among patients with difficult-to-treat OCD.

OBJECTIVE

To evaluate whether DCS potentiates the effect of concentrated ERP among patients with difficult-to-treat OCD.

DESIGN, SETTING, AND PARTICIPANTS

The study was a randomized placebo-controlled triple-masked study with a 12-month follow-up. Participants were adult outpatients with difficult-to-treat OCD. A total of 220 potential participants were referred, of whom 36 did not meet inclusion criteria and 21 declined to participate. Patients had either relapsed after (n = 100) or not responded to (n = 63) previous ERP treatment. A total of 9 specialized OCD teams within the public health care system in Norway participated, giving national coverage. An expert team of therapists from the coordinating site delivered treatment. Inclusion of patients started in January 2016 and ended in August 2017. Data analysis was conducted February to September 2019.

INTERVENTIONS

All patients received individual, concentrated ERP treatment delivered during 4 consecutive days in a group setting (the Bergen 4-day treatment format) combined with 100 mg DCS, 250 mg DCS, or placebo.

MAIN OUTCOMES AND MEASURES

Change in symptoms of OCD and change in diagnostic status. Secondary outcomes measures included self-reported symptoms of OCD, anxiety, depression, and quality of life.

RESULTS

The total sample of 163 patients had a mean (SD) age of 34.5 (10.9) years, and most were women (117 [71.8%]). They had experienced OCD for a mean (SD) of 16.2 (10.2) years. A total of 65 patients (39.9%) were randomized to receive 100 mg DCS, 67 (41.1%) to 250 mg of DCS, and 31 (19.0%) to placebo. Overall, 91 (56.5%) achieved remission at posttreatment, while 70 (47.9%) did so at the 12-month follow-up. There was no significant difference in remission rates among groups. There was a significant reduction in symptoms at 12 months, and within-group effect sizes ranged from 3.01 (95% CI, 2.38-3.63) for the group receiving 250 mg DCS to 3.49 (95% CI, 2.78-4.18) for the group receiving 100 mg DCS (all P < .001). However, there was no significant effect of treatment group compared with placebo in obsessive-compulsive symptoms (250 mg group at posttreatment: d = 0.33; 95% CI, -0.10 to 0.76; 100 mg group at posttreatment: d = 0.36; 95% CI, -0.08 to 0.79), symptoms of depression and anxiety (eg, Patient Health Questionnaire-9 score among 250 mg group at 12-month follow-up: d = 0.30; 95% CI, -0.17 to 0.76; Generalized Anxiety Disorder-7 score among 100 mg group at 12-month follow-up: d = 0.27; 95% CI, -0.19 to 0.73), and well-being (250 mg group: d = 0.10; 95% CI, -0.42 to 0.63; 100 mg group: d = 0.34; 95% CI, -0.19 to 0.86). No serious adverse effects were reported.

CONCLUSIONS AND RELEVANCE

In this study, DCS did not potentiate ERP treatment effect, but concentrated ERP treatment was associated with improvement.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02656342.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

An empirically derived recommendation for the classification of body dysmorphic disorder: Findings from structural equation modeling

Body dysmorphic disorder (BDD), together with its subtype muscle dysmorphia (MD), has been relocated from the Somatoform Disorders category in the DSM-IV to the newly created Obsessive-Compulsive and Related Disorders category in the DSM-5. Both categorizations have been criticized, and an empirically derived classification of BDD is lacking. A community sample of N = 736 participants completed an online survey assessing different psychopathologies. Using a structural equation modeling approach, six theoretically derived models, which differed in their allocation of BDD symptoms to various factors (i.e. general psychopathology, somatoform, obsessive-compulsive and related disorders, affective, body image, and BDD model) were tested in the full sample and in a restricted sample (n = 465) which indicated primary concerns other than shape and weight. Furthermore, measurement invariance across gender was examined. Of the six models, only the body image model showed a good fit (CFI = 0.972, RMSEA = 0.049, SRMR = 0.027, TLI = 0.959), and yielded better AIC and BIC indices than the competing models. Analyses in the restricted sample replicated these findings. Analyses of measurement invariance of the body image model showed partial metric invariance across gender. The findings suggest that a body image model provides the best fit for the classification of BDD and MD. This is in line with previous studies showing strong similarities between eating disorders and BDD, including MD. Measurement invariance across gender indicates a comparable presentation and comorbid structure of BDD in males and females, which also corresponds to the equal prevalence rates of BDD across gender.

Serum Lipids among Drug Naïve or Drug-Free Patients with Obsessive Compulsive Disorder and their Association with Impulsivity: A Comparative Study

BACKGROUND

The derangement of serum lipids is well documented in psychiatric disorders like schizophrenia, mania, and depression but not in obsessive compulsive disorder (OCD), where it has been inadequately examined. Also, serum lipid abnormalities are increasingly found in "impulsivity," an important sub-construct of OCD. Our study aimed to examine serum lipid profile among patients with OCD and its association with clinical profile and impulsivity among them.

METHODS

Forty drug naïve or drug-free (four weeks for oral and eight weeks for any depot psychotropics) patients with OCD according to International Classification of Disease -10th version (ICD-10): Diagnostic Criteria for Research (DCR) by the World Health Organization (WHO), from outpatient and inpatient departments of a tertiary care psychiatric hospital were recruited. Measures like Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Hamliton Rating Scale for Depression (HAM-D), Barratt's Impulsivity Scale (BIS-11), and Hamilton Rating Scale for Anxiety (HAM-A) were administered. Forty age and sex-matched healthy controls (HC) were recruited after screening with General Health Questionnaire 12 (GHQ-12). Serum lipids were assessed in both the groups.

RESULTS

Serum high density lipoproteins (HDL) (P < 0.001; partial η2 = 0.176) and apolipoprotein B (P < 0.001; partial η2 = 0.531) were significantly higher in OCD group than age- and sex-matched HC. A trend toward lower serum HDL (P = 0.06; partial η2 = 0.060) was observed among patients of OCD with high impulsivity. Serum HDL was negatively correlated with BIS attention (rs =-0.32; p = 0.03), BIS motor (rs = 0.40; P = 0.01), BIS non-planning (rs = - 0.36; P = 0.02), and BIS total (rs = - 0.36; P = 0.01) scores. Serum triglycerides (TG) (rs = 0.34; P = 0.03) and apolipoprotein B (rs = -0.32; P = 0.04) were negatively correlated with Y-BOCS compulsion score. Serum TG (rs = -0.45, P < 0.01) and serum very low density lipoprotein (VLDL) was negatively (rs = -0.39; P = 0.01) correlated with Y-BOCS total scores. Serum VLDL was positively (rs = 0.34; P = 0.03) correlated with BIS motor scores.

CONCLUSIONS

Serum lipid fractions are deranged among patients with OCD. Different lipid fractions have different associations with clinical profiles of OCD. Impulsivity among patients with OCD may have a specific association with serum lipids. A small sample size, use of self-report measure without adaptation for impulsivity, a lack of metabolic profile assessment among participants, and a lack of assessment of impulsivity among HC were the limitations of our tudy.

Childhood trauma and attachment style predict the four-year course of obsessive compulsive disorder: Findings from the Netherlands obsessive compulsive disorder study

INTRODUCTION

Obsessive compulsive disorder (OCD) is a chronic psychiatric disorder where most patients do not reach full symptomatic remission. Identifying predictors of course can improve patients' care by informing clinicians on prognosis and enhancing treatment strategies. Several predictors associated with improved outcome of OCD were identified. However, research focused mainly on clinical, illness-related predictors of the course of OCD. This study examined the contribution of environmental and interpersonal predictors on the long-term outcome of OCD, in addition to the previously identified clinical indicators.

METHODS

We used the baseline, two and four-year data of 382 adult OCD patients participating in the naturalistic cohort study of the Netherlands Obsessive Compulsive Disorder Association (NOCDA). Remission was assessed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Predictors of outcome were assessed at baseline, via clinician-rated and self-report instruments.

RESULTS

Remission at two and at four-year follow-up ranged from 11% to 26%. Early age of onset and the presence of childhood trauma predicted a worse four-year course. Secure attachment style emerged as a protective predictor of improved outcome.

LIMITATIONS

The naturalistic design of our study did not enable a systematic estimation the effect of treatments received during the follow-up period. Furthermore, age of onset and childhood trauma were assessed retrospectively, which may contribute to recall bias.

CONCLUSION

Results coincide with previous prediction research and stress the importance of adaptive interpersonal functioning in the course of OCD. Clinical implications and future research directions are discussed.

Psychopharmacological Treatment of Obsessive-Compulsive Disorder (OCD)

Background:

Obsessive-compulsive disorder (OCD) is associated with affective and cognitive symptoms causing personal distress and reduced global functioning. These have considerable societal costs due to healthcare service utilization.

Objective:

Our aim was to assess the efficacy of pharmacological interventions in OCD and clinical guidelines, providing a comprehensive overview of this field.

Methods:

We searched the PubMed database for papers dealing with drug treatment of OCD, with a specific focus on clinical guidelines, treatments with antidepressants, antipsychotics, mood stabilizers, off-label medications, and pharmacogenomics.

Results:

Prolonged administration of selective serotonin reuptake inhibitors (SSRIs) is most effective. Better results can be obtained with a SSRI combined with cognitive behavioral therapy (CBT) or the similarly oriented exposure and response prevention (ERP). Refractory OCD could be treated with different strategies, including a switch to another SSRI or clomipramine, or augmentation with an atypical antipsychotic. The addition of medications other than antipsychotics or intravenous antidepressant administration needs further investigation, as the evidence is inconsistent. Pharmacogenomics and personalization of therapy could reduce treatment resistance.

Conclusions:

SSRI/clomipramine in combination with CBT/ERP is associated with the optimal response compared to each treatment alone or to other treatments. New strategies for refractory OCD are needed. The role of pharmacogenomics could become preponderant in the coming years.

Combination therapy for rapid treatment of severe obsessive-compulsive disorder: a case report

Objective

A 29-year-old male from Guizhou, China, had been suffering from obsessive–compulsive disorder since graduation from junior high school at 14 years. He was afraid of putting glass substances in his mouth. His main symptoms were repetitive thoughts, inquiries and examinations for more than 6 hours a day. He dropped out of school and stayed at home. He had been taking 60 mg/day paroxetine for 7 consecutive years. Over the past 2 years, his obsessive–compulsive symptoms had increased and were present for 12 hours a day.

Methods

The patient was treated using a combination of drugs, transcutaneous electrical acupoint stimulation–exposure and response prevention therapy (TEAS–ERP) and parental involvement.

Results

After 28 days, his Yale–Brown Obsessive Compulsive Scale score dropped from 40 to 11 points. After 1 month, telephone follow-up showed that he was able to do housework and was ready to go to work. After 6 months, he was able to easily work, and his compulsive behaviour only occurred 1 to 2 times each day for about 0.5 minutes each time.

Conclusions

The combination of TEAS–ERP, sertraline and clomipramine had a rapid effect. There was no resumption of obsessive–compulsive symptoms during post-treatment follow-up.

Risk of schizophrenia among people with obsessive-compulsive disorder: A nationwide population-based cohort study

High comorbidity of obsessive-compulsive disorder (OCD) has been reported in patients with schizophrenia. The sequence of OCD and schizophrenia onset might clarify the underlying pathophysiological relationships between these two disorders, but available evidence is limited. In this study, we used a population-based cohort to investigate the risk of schizophrenia in people with newly diagnosed OCD. Patients who were first diagnosed with OCD from 2000 to 2013 were selected from the Longitudinal Health Insurance Research Database. The non-OCD group was randomly sampled, and matched with the OCD group by gender, age, urbanization level, and income. Cox regression analyses and competing risk model were used to estimate the risk of schizophrenia, adjusting for potential confounding factors. In total, 2009 patients with OCD and 8036 controls were identified. The crude incidences of schizophrenia in the OCD and non-OCD groups were 876.2 per 100,000 person-years and 28.7 per 100,000 person-years, respectively. After adjustment, a substantially higher risk of schizophrenia was observed in the OCD group (hazard ratio = 30.29, 95% confidence interval = 17.91-51.21). Male gender, age of OCD onset before 20 years, and antipsychotic prescription were associated with schizophrenia. Patients with comorbidity of autistic disorder have higher risk of schizophrenia (hazard ratio = 4.63, 95% confidence interval = 1.58-13.56). In conclusion, OCD diagnosis, male gender, age of OCD onset before 20 years, comorbidity of autistic disorder, and antipsychotic use were associated with higher risk of schizophrenia. It is essential for psychiatrists to note that OCD may be the initial presentation of schizophrenia.