What is the optimal way to subdivide obsessive-compulsive disorder?

A hypothesis on Cotard's syndrome as an evolution of obsessive-compulsive disorder

Cotard's syndrome usually presents as combined symptoms occurring in a broad series of neurological, psychiatric, and medical disorders, being severe depression the most frequent. The syndrome is not classified as a distinct clinical entity in the nosological systems but appears solely as a clinical condition in case reports. Thus, the diagnosis of Cotard's syndrome mainly centres on the psychiatric interview and the ability of the clinician to recognise specific symptoms due to the absence of both clinical instruments and diagnostic criteria. Cotard's syndrome has never been described to date in patients with a history of obsessive-compulsive disorder (OCD). We report a case of a 49-year-old woman presenting obsessive symptoms and related compulsions for more than 30 years. Cotard's syndrome appeared after 3 years from a tragic event that had caused a psychological trauma. Such an occurrence may have contributed to worsening OCD and leading to a second major depressive episode followed by a suicidal attempt. Since then, the subject of our patient's obsessive thoughts changed, and the belief of being dead appeared. The repetitive and stereotyped thoughts caused severe distress, and accompanied the compulsive nature of reassurance seeking, temporarily beneficial to the anxiety arousing. The transition from obsession to delusion occurred when resistance was abandoned, and insight was lost. Once Cotard's syndrome had stabilised, OCD was no longer present. Additional distinctive features were the absence of psychiatric family history and the persistent nature of the affective psychosis. We concluded that Cotard's syndrome represented the evolution of the initial obsessive-compulsive disorder. Furthermore, we differentiated the clinical condition of our patient from other psychiatric diseases with similar clinical features. Larger-scale research is needed to consider topics other than comorbidity and also to explore significant elements of the patient's clinical history to discover what may influence the evolution and/or the persistence of the diseases.

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.

Neurological Soft Signs and Clinical Features of Tic-Related Obsessive-Compulsive Disorder Indicate a Unique Subtype

Tic-related obsessive-compulsive disorder (OCD) may be a unique OCD subtype. This study examined whether neurological soft signs (NSSs) of patients with tic-related and tic-free OCD enable discrimination of these subgroups. We used the Neurological Evaluation Scale to assess 32 patients with tic-related and 94 with tic-free OCD, as well as 84 controls. Most patients with tic-related OCD were male, with earlier illness onset and poorer insight scores than those of patients with tic-free OCD. Patients with tic-related OCD had poorer motor coordination, sensory integration, and motor sequencing than did tic-free patients. Logistic regression using NSS subscale scores predicted tic-related OCD. Patients with tic-related OCD displayed greater neurodevelopmental abnormalities than did tic-free patients. NSSs of the former group suggest the need to separate this subgroup. Our results also support the newly introduced tic-related specifier in the fifth edition of the Diagnostic and statistical manual of mental disorders.

Gender differences in obsessive-compulsive disorder: Findings from a multicentric study from India

Obsessive-compulsive disorder (OCD) is phenotypically heterogeneous. Gender is an important factor mediating this heterogeneity. We examined gender differences in a large sample (n = 945) of OCD patients under a multi-centric study in India. Cross-sectional assessments were done on consecutive adult (>18 years) treatment-seeking patients with a DSM-5 diagnosis of OCD. Subjects were assessed on Structured Clinical Interview for DSM-5-Research Version for comorbid psychiatric illnesses, Yale Brown Obsessive Compulsive Scale for OCD phenomenology and symptom severity, Brown Assessment of Beliefs Scale for insight, Beck's Depression Inventory for severity of depressive symptoms, and the Obsessive Beliefs Questionnaire. On multivariate backward Wald logistic regression analysis, males (59.7%) had more years of education, had a higher rate of checking compulsions and comorbid substance use disorders. Women were more likely to be married, more commonly reported precipitating factors, had a higher rate of hoarding compulsions and comorbid agoraphobia. Findings from this large study validate gender as an important mediator of phenotypic heterogeneity in OCD. The mechanistic basis for these differences might involve complex interactions between biological, cultural and environmental factors.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Symptom dimensions, clinical course and comorbidity in men and women with obsessive-compulsive disorder

The study aimed to compare male and female patients with obsessive-compulsive disorder (OCD) across symptom dimensions, clinical course and comorbidity. A cross-sectional study was undertaken with 858 adult OCD patients (DSM-IV) from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. Patients were evaluated using structured interviews, including the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) and the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). The sample was composed of 504 women (58.7%) and 354 men (41.3%) with a mean age of 35.4 years-old (range: 18-77). Men were younger, more frequently single and presented more tics, social phobia and alcohol use disorders. Among men, symptom interference occurred earlier and symptoms of the sexual/religious dimension were more common and more severe. Conversely, women were more likely to present symptoms of the aggressive, contamination/cleaning and hoarding dimension and comorbidity with specific phobias, anorexia nervosa, bulimia, trichotillomania, skin picking and "compulsive" buying. In the logistic regression, female gender remained independently associated with the aggressive and contamination/cleaning dimensions. In both genders the aggressive dimension remained associated with comorbid post-traumatic stress disorder, the sexual/religious dimension with major depression and the hoarding dimension with tic disorders. Gender seems to be relevant in the determination of OCD clinical presentation and course and should be considered an important aspect when defining more homogeneous OCD subgroups.

Brain structural alterations in obsessive-compulsive disorder patients with autogenous and reactive obsessions

Obsessive-compulsive disorder (OCD) is a clinically heterogeneous condition. Although structural brain alterations have been consistently reported in OCD, their interaction with particular clinical subtypes deserves further examination. Among other approaches, a two-group classification in patients with autogenous and reactive obsessions has been proposed. The purpose of the present study was to assess, by means of a voxel-based morphometry analysis, the putative brain structural correlates of this classification scheme in OCD patients. Ninety-five OCD patients and 95 healthy controls were recruited. Patients were divided into autogenous (n = 30) and reactive (n = 65) sub-groups. A structural magnetic resonance image was acquired for each participant and pre-processed with SPM8 software to obtain a volume-modulated gray matter map. Whole-brain and voxel-wise comparisons between the study groups were then performed. In comparison to the autogenous group, reactive patients showed larger gray matter volumes in the right Rolandic operculum. When compared to healthy controls, reactive patients showed larger volumes in the putamen (bilaterally), while autogenous patients showed a smaller left anterior temporal lobe. Also in comparison to healthy controls, the right middle temporal gyrus was smaller in both patient subgroups. Our results suggest that autogenous and reactive obsessions depend on partially dissimilar neural substrates. Our findings provide some neurobiological support for this classification scheme and contribute to unraveling the neurobiological basis of clinical heterogeneity in OCD.

Differential neural network of checking versus washing symptoms in obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is clinically heterogeneous. The aim of this study was to investigate differential neural responses to a symptom provocation task in drug-free patients who have predominantly aggression/checking symptoms (Checkers) and patients with contamination/washing symptoms (Washers). We compared the Checkers (n=10) and the Washers (n=12) separately to normal controls during the symptom provocation tasks using fMRI (functional magnetic resonance imaging). Moreover, we performed correlative analysis in each OCD group between brain activation and symptom severity. The Checkers showed hypoactivation in the left caudate and left anterior cingulate cortex (ACC) compared to the normal controls and a positive correlation between activated brain areas and symptom severity in the left ACC. The Washers showed hyperactivation in several bilateral cortico-cerebellar regions and a positive correlation between symptom severity and the bilateral fronto-temporal gyrus. We suggest that the caudate and ACC are associated with checking rituals and that large cortical brain regions are related to washing rituals.

Obsessive-compulsive disorder: Evidence-based treatments and future directions for research

Over the past three decades, obsessive-compulsive disorder (OCD) has moved from an almost untreatable, life-long psychiatric disorder to a highly manageable one. This is a very welcome change to the 1%-3% of children and adults with this disorder as, thanks to advances in both pharmacological and psychological therapies, prognosis for those afflicted with OCD is quite good in the long term, even though most have comorbid disorders that are also problematic. We still have far to go, however, until OCD can be described as either easily treatable or the effective treatments are widely known about among clinicians. This review focuses on the current state of the art in treatment for OCD and where we still are coming up short in our work as a scientific community. For example, while the impact of medications is quite strong for adults in reducing OCD symptoms, current drugs are only somewhat effective for children. In addition, there are unacceptably high relapse rates across both populations when treated with pharmacological alone. Even in the cognitive-behavioral treatments, which show higher effect sizes and lower relapse rates than drug therapies, drop-out rates are at a quarter of those who begin treatment. This means a sizable portion of the OCD population who do obtain effective treatments (which appears to be only a portion of the overall population) are not effectively treated. Suggestions for future avenues of research are also presented. These are primarily focused on (1) increased dissemination of effective therapies; (2) augmentation of treatments for those with residual symptoms, both for psychotherapy and pharmacotherapy; and (3) the impact of comorbid disorders on treatment outcome.

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.

The somatic marker affecting decisional processes in obsessive-compulsive disorder

INTRODUCTION

Patients with obsessive-compulsive disorder (OCD) demonstrate impairment in decisional processes in which both cognition and emotion play a crucial role.

METHODS

We investigated the connection between decision-making performances and choice-related skin conductance responses (SCRs), to identify a somatic marker impairment affecting decisional processes in these patients. We explored SCRs during the Iowa Gambling Task in 20 OCD and 18 control, measuring anticipatory and posticipatory psychophysiological reactions according to card choices and to the outcomes of each selection.

RESULTS

Most patients exhibited weaker SCRs compared to HC, although there weren't substantial differences in magnitude between the two groups. In contrast with HC, patients with OCD showed no significant differences of SCRs activation according to card selections; they chose cards from neither favourable nor unfavourable decks.

CONCLUSIONS

The main finding of the study were the evidence of a dysfunctional biological marker in OCD subjects, affecting decision-making process. Dysfunctional patterns of SCRs could partially explain OCDs' impairment in this ability. Decision-making deficits in OCDs could be influenced in part by the lack of somatic differences in discriminating between advantageous and disadvantageous behaviour. These findings could lead to a more complete understanding of OCD.

Clinical features of tic-related obsessive-compulsive disorder: results from a large multicenter study

OBJECTIVE

To evaluate the clinical features of obsessive-compulsive disorder (OCD) patients with comorbid tic disorders (TD) in a large, multicenter, clinical sample.

METHOD

A cross-sectional study was conducted that included 813 consecutive OCD outpatients from the Brazilian OCD Research Consortium and used several instruments of assessment, including the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, the Yale Global Tic Severity Scale (YGTSS), the USP Sensory Phenomena Scale, and the Structured Clinical Interview for DSM-IV Axis I Disorders.

RESULTS

The sample mean current age was 34.9 years old (SE 0.54), and the mean age at obsessive-compulsive symptoms (OCS) onset was 12.8 years old (SE 0.27). Sensory phenomena were reported by 585 individuals (72% of the sample). The general lifetime prevalence of TD was 29.0% (n = 236), with 8.9% (n = 72) presenting Tourette syndrome, 17.3% (n = 141) chronic motor tic disorder, and 2.8% (n = 23) chronic vocal tic disorder. The mean tic severity score, according to the YGTSS, was 27.2 (SE 1.4) in the OCD + TD group. Compared to OCD patients without comorbid TD, those with TD (OCD + TD group, n = 236) were more likely to be males (49.2% vs. 38.5%, p < .005) and to present sensory phenomena and comorbidity with anxiety disorders in general: separation anxiety disorder, social phobia, specific phobia, generalized anxiety disorder, post-traumatic stress disorder, attention-deficit hyperactivity disorder, impulse control disorders in general, and skin picking. Also, the "aggressive," "sexual/religious," and "hoarding" symptom dimensions were more severe in the OCD + TD group.

CONCLUSION

Tic-related OCD may constitute a particular subgroup of the disorder with specific phenotypical characteristics, but its neurobiological underpinnings remain to be fully disentangled.

Comorbid major depression in obsessive-compulsive disorder patients

Although major depressive disorder (MDD) has been consistently considered the most frequent complication of obsessive-compulsive disorder (OCD), little is known about the clinical characteristics of patients with both disorders. This study assessed 815 Brazilian OCD patients using a comprehensive psychiatric evaluation. Clinical and demographic variables, including OCD symptom dimensions, were compared among OCD patients with and without MDD. Our findings showed that prevalence rates of current MDD (32%) and lifetime MDD (67.5%) were similar for both sexes in this study. In addition, patients with comorbid MDD had higher severity scores of OCD symptoms. There was no preferential association of MDD with any particular OCD symptom dimension. This study supports the notion that depressed OCD patients present more severe general psychopathology.

Brazilian psychiatric brain bank: a new contribution tool to network studies

There is an urgent need for expanding the number of brain banks serving psychiatric research. We describe here the Psychiatric Disorders arm of the Brain Bank of the Brazilian Aging Brain Study Group (Psy-BBBABSG), which is focused in bipolar disorder (BD) and obsessive compulsive disorder (OCD). Our protocol was designed to minimize limitations faced by previous initiatives, and to enable design-based neurostereological analyses. The Psy-BBBABSG first milestone is the collection of 10 brains each of BD and OCD patients, and matched controls. The brains are sourced from a population-based autopsy service. The clinical and psychiatric assessments were done by an expert team including psychiatrists, through an informant. One hemisphere was perfused-fixed to render an optimal fixation for conducting neurostereological studies. The other hemisphere was comprehensively dissected and frozen for molecular studies. In 20 months, we collected 36 brains. A final report was completed for 14 cases: 3 BDs, 4 major depressive disorders, 1 substance use disorder, 1 mood disorder NOS, 3 obsessive compulsive spectrum symptoms, 1 OCD and 1 schizophrenia. The majority were male (64%), and the average age at death was 67.2 ± 9.0 years. The average postmortem interval was 16 h. Three matched controls were collected. The pilot stage confirmed that the protocols are well fitted to reach our goals. Our unique autopsy source makes possible to collect a fairly number of high quality cases in a short time. Such a collection offers an additional to the international research community to advance the understanding on neuropsychiatric diseases.

The clinical utility of symptom dimensions in obsessive-compulsive disorder

Factor analyses in obsessive-compulsive disorder (OCD) have consistently identified several different symptom dimensions. Nevertheless the clinical utility of identifying such symptom dimensions remains somewhat unclear. On the basis of their principal symptoms, 343 OCD patients were divided into four symptom dimension subgroups; 1) contamination/washing, 2) hoarding, 3) symmetry/repeating and ordering, and 4) forbidden thoughts/checking. Clinical variables including 1-year treatment outcome were compared across these patient subgroups. Most patients (74%) could distinctively be categorized as falling into a particular symptom subgroup. The groups were differentially characterized by some demographic and clinical features. For instance, both the symmetry and hoarding groups were significantly associated with decreased global functioning and greater OCD severity. Moreover the hoarding group was significantly more likely than the others to show longer duration of illness, lower rate of marriage, poor insight, and poorer outcome. However, about a quarter of the participants could not be classified definitively into a particular group. Our findings provide partial support for the clinical utility of a simple measure of symptom dimensions in OCD. In clinical settings, however, the limitations of such a simple measure of predominant symptom dimensions should be borne in mind and further work on their validity and utility is needed.

Bipolar disorder and comorbid obsessive-compulsive disorder is associated with higher rates of anxiety and impulse control disorders

Issler CK, Monkul ES, Amaral JAMS, Tamada RS, Shavitt RG, Miguel EC, Lafer B. Bipolar disorder and comorbid obsessive-compulsive disorder is associated with higher rates of anxiety and impulse control disorders.

OBJECTIVE

Although bipolar disorder (BD) with comorbid obsessive-compulsive disorder (OCD) is highly prevalent, few controlled studies have assessed this comorbidity. The objective of this study was to investigate the clinical characteristics and expression of comorbid disorders in female BD patients with OCD.

METHOD

We assessed clinically stable female outpatients with BD: 15 with comorbid OCD (BD+OCD group) and 15 without (BD/no-OCD group). All were submitted to the Structured Clinical Interview for DSM-IV, with additional modules for the diagnosis of kleptomania, trichotillomania, pathological gambling, onychophagia and skin picking.

RESULTS

The BD+OCD patients presented more chronic episodes, residual symptoms and previous depressive episodes than the BD/no-OCD patients. Of the BD+OCD patients, 86% had a history of treatment-emergent mania, compared with only 40% of the BD/no-OCD patients. The following were more prevalent in the BD+OCD patients than the BD/no-OCD patients: any anxiety disorder other than OCD; impulse control disorders; eating disorders; and tic disorders.

CONCLUSION

Female BD patients with OCD may represent a more severe form of disorder than those without OCD, having more depressive episodes and residual symptoms, and being at a higher risk for treatment-emergent mania, as well as presenting a greater anxiety and impulse control disorder burden.

Clinical features and treatment characteristics of compulsive hoarding in Japanese patients with obsessive-compulsive disorder

INTRODUCTION

Compulsive hoarding has been studied primarily in Western countries. Here we sought to examine compulsive hoarding in Japanese patients with obsessive-compulsive disorder (OCD). The heterogeneous nature of hoarding was also investigated.

METHODS

One hundred and sixty-eight OCD outpatients were initially assessed to determine the presence or absence of compulsive hoarding, and whether hoarding was primary or secondary to another symptom dimension for which they had received treatment for 1 year.

RESULTS

Of the participants, 54 patients were found to have compulsive hoarding. Hoarders were significantly more likely than non-hoarding patients to have more severe psychopathology including elevated severity of OCD symptoms, poorer insight, higher prevalence of comorbid schizotypal or obsessive-compulsive personality disorder, closer association with symmetry dimension, and poorer treatment outcome. Comparisons of subjects with primary and secondary hoarding found that the former group had more severe clinical features, while the latter group hoarded a wider variety of items, including apparently bizarre ones.

CONCLUSION

The prevalence and clinical characteristics of compulsive hoarding in OCD subjects was similar to those reported in Western countries, supporting its trans-cultural consistency. The distinction between primary and secondary hoarding in OCD is clinically useful, and may contribute to the debate about whether hoarding should be a separate diagnostic entity.

Obsessive-compulsive disorder with poor insight: a three-year prospective study

Available evidence about the relationship between poor insight and other clinical characteristics in patients with obsessive-compulsive disorder (OCD) is inconclusive and conflicting. There is also a paucity of data on the long-term course and treatment outcome of OCD patients with poor insight. The present study reports the findings of a relatively large sample (n=106) of outpatients fulfilling DSM-IV criteria for OCD, treated with serotonin reuptake inhibitors (SRIs) and prospectively followed up for 3 years. Baseline information was collected on demographic and clinical characteristics, using standardized instruments. Insight was assessed by means of the Brown Assessment of Beliefs Scale (BABS). Eighty-three patients were followed prospectively and evaluated systematically by validated measures of psychopathology. Compared to their good insight counterparts, the OCD patients with poor insight (22%) showed a greater severity of obsessive-compulsive and depressive symptomatology; an earlier age at onset; a higher rate of schizophrenia spectrum disorder in their first-degree relatives; a higher comorbidity with schizotypal personality disorder. During the follow-up period, poor insight OCD patients were less likely to achieve at least a partial remission of obsessive-compulsive symptoms; required a significantly greater number of therapeutic trials; received more frequently augmentation with antipsychotics. The results suggest that the specifier "poor insight" helps to identify a subgroup of patients at the more severe end of OCD spectrum, characterized by a more complex clinical presentation, a diminished response to standard pharmacological interventions, and a poorer prognosis. Further research is needed to identify alternative strategies for the management of these patients.

The Padua Inventory: do revisions need revision?

The purpose of the present study was to examine the psychometric properties, factorial structure, and validity of the Padua Inventory-Washington State University Revision and of the Padua Inventory-Revised in a large sample of patients with obsessive-compulsive disorder (n = 228) and with anxiety disorders and/or depression (n = 213). The five-factor structures of both revisions were not replicated. A 24-item revision, referred to as the Padua Inventory-Palatine Revision (PI-PR), was developed on the basis of both theoretical and statistical considerations. The PI-PR assesses six subscales: Contamination and Washing, Checking, Numbers, Dressing and Grooming, Rumination, and Harming Obsessions and Impulses. The results demonstrate that the PI-PR is a brief, psychometrically sound, and valid measure for the assessment of a broad range of obsessive-compulsive symptoms, which has important advantages over both previous revisions.

Early onset obsessive-compulsive disorder with and without tics

INTRODUCTION

Research suggests that obsessive-compulsive disorder (OCD) is not a unitary entity, but rather a highly heterogeneous condition, with complex and variable clinical manifestations.

OBJECTIVE

The aims of this study were to compare clinical and demographic characteristics of OCD patients with early and late age of onset of obsessive-compulsive symptoms (OCS); and to compare the same features in early onset OCD with and without tics. The independent impact of age at onset and presence of tics on comorbidity patterns was investigated.

METHODS

Three hundred and thirty consecutive outpatients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for OCD were evaluated: 160 patients belonged to the "early onset" group (EOG): before 11 years of age, 75 patients had an "intermediate onset" (IOG), and 95 patients were from the "late onset" group (LOG): after 18 years of age. From the 160 EOG, 60 had comorbidity with tic disorders. The diagnostic instruments used were: the Yale-Brown Obsessive Compulsive Scale and the Dimensional Yale-Brown Obsessive Compulsive Scale (DY-BOCS), Yale Global Tics Severity Scale, and Structured Clinical Interview for DSM-IV Axis I Disorders-patient edition. Statistical tests used were: Mann-Whitney, full Bayesian significance test, and logistic regression.

RESULTS

The EOG had a predominance of males, higher frequency of family history of OCS, higher mean scores on the "aggression/violence" and "miscellaneous" dimensions, and higher mean global DY-BOCS scores. Patients with EOG without tic disorders presented higher mean global DY-BOCS scores and higher mean scores in the "contamination/cleaning" dimension.

CONCLUSION

The current results disentangle some of the clinical overlap between early onset OCD with and without tics.

Loss of vision secondary to obsessive-compulsive disorder: a case report

OBJECTIVE

To report a rare case of self-inflicted eye injury secondary to obsessive-compulsive disorder (OCD).

METHOD

Case report.

RESULTS

A 41 year-old patient had significant bilateral visual loss and blunt trauma through touching his ocular cavities due to recurrent doubts regarding their shape and urges to check the format of bones and cartilages. Differential diagnosis with tic disorders is discussed, and the patient's treatment approach is described.

CONCLUSION

Although rare, severe clinical complications can occur in OCD.

Sex differences in the phenotypic expression of obsessive-compulsive disorder: an exploratory study from Brazil

Previous studies have shown differences in clinical features of obsessive-compulsive disorder (OCD) between men and women, including mean age at onset of obsessive-compulsive symptoms (OCS), types of OCS, comorbid disorders, course, and prognosis. The aim of this study was to compare male and female Brazilian patients with OCD on several demographic and clinical characteristics. Three hundred thirty outpatients with OCD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV], criteria) who sought treatment at 3 Brazilian public universities and at 2 private practice clinics in the city of São Paulo were evaluated. The assessment instruments used were the Yale-Brown Obsessive-Compulsive Scale to evaluate OCD severity and symptoms, the Beck Depression and Anxiety Inventories, the Yale Global Tic Severity Scale, and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders to assess psychiatric comorbidity. Fifty-five percent of the patients (n = 182) were men who were significantly more likely than women to be single and to present sexual, religious, and symmetry obsessions and mental rituals. They also presented earlier onset of OCS and earlier symptom interference in functioning, and significantly more comorbid tic disorders and posttraumatic stress disorder. Women, besides showing significantly higher mean scores in the Beck Depression and Anxiety Inventories, were more likely to present comorbid simple phobias, eating disorders in general and anorexia in particular, impulse control disorders in general, and compulsive buying and skin picking in particular. No significant differences were observed between sexes concerning family history of OCS or OCD, and global symptoms severity, either in obsession or compulsive subscale. The present study confirms the presence of sex-related differences described in other countries and cultures. The fact that the OCS start earlier and probably have a worse impact in men can eventually lead to more specific and efficacious treatment approaches for these patients.

Scrupulosity disorder: an overview and introductory analysis

Scrupulosity is a psychological disorder primarily characterized by pathological guilt or obsession associated with moral or religious issues that is often accompanied by compulsive moral or religious observance and is highly distressing and maladaptive. This paper provides a comprehensive overview of scrupulosity and an original conceptualization of the disorder based on an exhaustive literature review to increase awareness of the disorder among practicing clinicians and stimulate further research. It explores the clinical features of scrupulosity, classified as cognitive, behavioral, affective, and social features, as well as the epidemiology, etiology, and treatment of the disorder. Additionally, it is suggested that scrupulosity, despite its similarity to OCD, may merit a distinctive diagnosis, particularly considering its unique constellation and severity of symptoms and its treatment refractoriness, as supported by statistical analysis.

[Resistance and refractoriness in obsessive-compulsive disorder]

OBJECTIVE AND METHOD

Despite the existence of effective therapeutic alternatives for obsessive-compulsive disorder, a significant number of patients does not achieve or does not maintain remission after adequate treatment. The relief of these patients' suffering with the available treatments is a clinical challenge related to many unanswered questions. The objective of this literature review is to evaluate the current concepts of treatment resistance and refractoriness, to describe the intrinsic and extrinsic factors of obsessive-compulsive disorder's phenomenology that might influence treatment response to conventional treatment, and to present a fluxogram of therapeutic alternatives for resistant or refractory obsessive compulsive disorder patients.

CONCLUSION

The literature evinces that intrinsic and/or extrinsic phenomenological aspects of obsessive-compulsive disorder may collaborate to the fact that, at least 30% of obsessive-compulsive disorder patients do not respond to conventional treatment. Several therapeutic or augmentation alternatives, psychopharmacological, biological or even psychotherapeutical exist, but more studies are necessary to evince the correct way to symptom remission.

Obsessive–Compulsive Disorder: Influence of Age at Onset on Comorbidity Patterns

Purpose.

This study investigates the influence of age at onset of OCS on psychiatric comorbidities, and tries to establish a cut-off point for age at onset.

Methods.

Three hundred and thirty OCD patients were consecutively recruited and interviewed using the following structured interviews: Yale-Brown Obsessive Compulsive Scale; Yale Global Tic Severity Scale and the Structured Clinical Interview for DSM-IV. Data were analyzed with regression and cluster analysis.

Results.

Lower age at onset was associated with a higher probability of having comorbidity with tic, anxiety, somatoform, eating and impulse–control disorders. Longer illness duration was associated with lower chance of having tics. Female gender was associated with anxiety, eating and impulse–control disorders. Tic disorders were associated with anxiety disorders and attention-deficit/hyperactivity disorder. No cut-off age at onset was found to clearly divide the sample in homogeneous subgroups. However, cluster analyses revealed that differences started to emerge at the age of 10 and were more pronounced at the age of 17, suggesting that these were the best cut-off points on this sample.

Conclusions.

Age at onset is associated with specific comorbidity patterns in OCD patients. More prominent differences are obtained when analyzing age at onset as an absolute value.

Switching from serotonin reuptake inhibitors to duloxetine in patients with resistant obsessive compulsive disorder: a case series

Obsessive compulsive disorder (OCD) is a chronic disorder, currently recognized as one of the most common psychiatric disorder as well as one of the most disabling of all medical disorders. OCD is characterized by high rates of partial and/or absent response to standard, recommended treatments (serotonin reuptake inhibitors and psychotherapy). Recent investigation showed that Venlafaxine, a dual serotonin and norepinephrine reuptake inhibitor (SNRI), may be a valid alternative for some treatment-refractory patients. We present the cases of four OCD patients with comorbid mood or anxiety disorders, who were treated with serotonin reuptake inhibitors (SRIs) at adequate doses for at least 12 weeks, showing partial/no response. Patients were then switched to Duloxetine up to 120 mg/day and followed up for 12 weeks. Three out of four patients showed a Yale-Brown Obsessive Compulsive Scale(Y-BOCS) score reduction >or=35%. Duloxetine may be helpful in patients with treatment-resistant OCD, although larger and controlled studies are warranted to confirm this preliminary observation.

Association analysis between a VNTR intron 8 polymorphism of the dopamine transporter gene (SLC6A3) and obsessive- compulsive disorder in a Brazilian sample

Family, twin and segregation analysis have provided evidences that genetic factors are implicated in the susceptibility for obsessive-compulsive disorder (OCD). Several lines of research suggest that the dopaminergic system may be involved in the pathophysiology of OCD. Thus, the aim of the present study was to investigate a possible association between a polymorphism located in intron 8 of the dopamine transporter gene (SLC6A3) and OCD in a Brazilian sample composed by 208 patients and 865 healthy controls. No statistically differences were observed in allelic and genotype distributions between cases and controls. No association was also observed when the sample was divided according to specific phenotypic features such as gender, presence of tic disorders co-morbidity and age at onset of obsessive-compulsive symptoms (OCS). Our results suggest that the intron 8 VNTR of the SLC6A3 investigated in this study is not related to the susceptibility for OCD in our Brazilian sample.

Symptom dimensions in obsessive-compulsive disorder: implications for the DSM-V

In the absence of definitive etiological markers of vulnerability or a unitary profile of pathophysiology for obsessive-compulsive disorder (OCD), obsessive-compulsive (OC) symptom dimensions seem to offer a fruitful point of orientation. The complex clinical presentation of OCD can be summarized using a few consistent and temporally stable symptom dimensions. These can be understood as a spectrum of potentially overlapping features that are likely to be continuous with "normal" worries and extend beyond the traditional nosological boundaries of OCD. Although the understanding of the dimensional structure of obsessive-compulsive symptoms (OCS) is still imperfect, this quantitative approach to phenotypic traits has the potential to advance our understanding of OCD and may aid in the identification of more robust endophenotypes. Preliminary data suggest that these dimensional phenotypes may be useful in studies of the natural history, genetics, neurobiology, and treatment outcome of OCD. A dimensional approach is not mutually exclusive of other methods to parse the larger spectrum of disorders related to OCD. Thus far, age-of-onset of OCS and the individual's "tic-related" status seem to be particularly useful categorical distinctions. Finally, existing assessment methods are inadequate and new dimensional scales are needed to take full advantage of a dimensional approach in clinical and population-based studies.

Level of insight and clinical features of obsessive-compulsive disorder with and without body dysmorphic disorder

INTRODUCTION

Body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD) have several similarities and are included among the obsessive-compulsive spectrum of disorders. However, the content of preoccupations and level of insight of BDD patients differ from OCD patients.

OBJECTIVE

To compare the level of insight regarding obsessive-compulsive symptoms (OCS) and other clinical features in OCD patients with and without comorbid BDD.

METHODS

We evaluated 103 OCD patients (n=25, comorbid BDD), according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria using the Structured Clinical Interview for DSM-IV, the Yale-Brown Obsessive-Compulsive Scale, the University of Sao Paulo Sensory Phenomena Scale, the Beck Depression and Anxiety Inventories, and the Brown Assessment of Beliefs Scale.

RESULTS

The study groups differed significantly on several clinical features, including level of insight. A worse level of insight regarding OCS was independently associated with the presence of comorbid BDD. Lower educational level, more psychiatric comorbidities, presence of somatic and hoarding obsessions, and presence of intrusive images were associated with BDD comorbidity, even after adjusting for possible confounders.

CONCLUSION

The presence of BDD in OCD patients is associated with poorer insight into obsessional beliefs and higher morbidity, reflected by lower educational levels and higher number of psychiatric comorbid disorders in general.