Early recognition of obsessive-compulsive disorder

Internet-based acceptance and commitment therapy for obsessive-compulsive symptoms: A randomized controlled trial

Subthreshold obsessive-compulsive symptoms (OCS) are associated with increased distress, help seeking behaviours, and functional problems, and may predict progression into further mental health problems. This study investigated the effectiveness of a four-module internet-based acceptance and commitment therapy (iACT) for adults with OCS compared to internet-based progressive relaxation training (iPRT). Eighty-nine adults with OCS participated in a single-blinded randomised controlled trial of iACT or iPRT. Self-report assessments of OCS, psychological flexibility, and quality of life, among others, were measured at baseline, post-treatment, and at three-month follow-up. Both iACT and iPRT showed large pre-post improvements in OCS (b = 6.32, p < 0.001, d = 0.8) and medium improvements in psychological flexibility (b = -0.38, p = 0.011, d = 0.47) and quality of life (b = -5.26, p = 0.008, d = 0.58), with no significant differences in effects between groups. All improvements were maintained at follow-up. There were no differences in attrition or adherence between groups. iACT was rated more favourably by participants at post-treatment, and there were some differences in qualitative feedback across groups. These findings suggest both iPRT and iACT may be helpful in improving mental health in adults with OCS, but that iACT may be more acceptable.

Late development of OCD-like phenotypes in Dlgap1 knockout mice

RATIONALE

Despite variants in the Dlgap1 gene having the two lowest p-value in a genome-wide association study of obsessive compulsive disorder (OCD), previous studies reported the absence of OCD-like phenotypes in Dlgap1 knockout (KO) mice. Since these studies observed behavioral phenotypes only for a short period, development of OCD-like phenotypes in these mice at older ages was still plausible.

OBJECTIVE

To examine the presence or absence of development of OCD-like phenotypes in Dlgap1 KO mice and their responsiveness to fluvoxamine.

METHODS AND RESULTS

Newly produced Dlgap1 KO mice were observed for a year. Modified SHIRPA primary screen in 2-month-old homozygous mutant mice showed only weak signs of anxiety, stress conditions and aggression. At older ages, however, these mutant mice exhibited excessive self-grooming characterized by increased scratching which led to skin lesions. A significant sex difference was observed in this scratching behavior. The penetrance of skin lesions reached 50% at 6-7 months of age and 90% at 12 months of age. In the open-field test performed just after the appearance of these lesions, homozygous mutant mice spent significantly less time in the center, an anxiety-like behavior, than did their wild-type and heterozygous littermates, none and less than 10% of which showed skin lesions at 1 year, respectively. The skin lesions and excessive self-grooming were significantly alleviated by two-week treatment with fluvoxamine.

CONCLUSION

Usefulness of Dlgap1 KO mice as a tool for investigating the pathogenesis of OCD-like phenotypes and its translational relevance was suggested.

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.

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.

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.

The speed of progression towards obsessive-compulsive disorder

BACKGROUND

There is current interest in the elaboration of early intervention programs for obsessive-compulsive disorder (OCD). To this end, it is important to investigate the speed of progression from subthreshold symptoms to diagnosable OCD. In this study, we have retrospectively investigated the speed of progression towards full-blown OCD and sociodemographic and clinical factors associated with a faster transition.

METHODS

Patients enrolled in the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (N = 954) were interviewed with a comprehensive assessment battery that included the interval (in years) between the onset of subthreshold OCD symptoms and the onset of full-blown OCD.

RESULTS

It took a median of 7 years (interquartile range: 2-13 years) for subthreshold symptoms to convert to diagnosable OCD. Faster OCD onset was associated with lower age at the time of assessment, male gender, being in new romantic states as precipitants for compulsions, greater severity of sexual/religious symptoms and lower severity of hoarding and YBOCS compulsions severity scores, greater rates of generalized anxiety disorder and agoraphobia without panic disorder, and negative family history for OCD.

LIMITATIONS

The retrospective design of this study allowed for susceptibility to memory bias about age at onset of OCD symptoms. We were unable to capture progressions taking less than 12 months.

CONCLUSIONS

We could identify a specific phenotype that was more likely to escalate rapidly to clinical levels within this large clinical sample. This phenomenon may be particularly relevant in the context of selecting individuals for early intervention initiatives in situations when resources are scarce.

The relationship between obsessive-compulsive disorder and anxiety disorders: A question of diagnostic boundaries or simply severity of symptoms?

BACKGROUND

A growing number of studies are questioning the validity of current DSM diagnoses, either as "discrete" or distinct mental disorders and/or as phenotypically homogeneous syndromes. In this study, we investigated how symptom domains in patients with a main diagnosis of obsessive-compulsive disorder (OCD), panic disorder (PD) and social anxiety disorder (SAD) coaggregate. We predicted that symptom domains would be unrelated to DSM diagnostic categories and less likely to cluster with each other as severity increases.

METHODS

One-hundred eight treatment seeking patients with a main diagnosis of OCD, SAD or PD were assessed with the Dimensional Obsessive-Compulsive Scale (DOCS), the Social Phobia Inventory (SPIN), the Panic and Agoraphobia Scale (PAS), the Anxiety Sensitivity Index-Revised (ASI-R), and the Beck Depression and Anxiety Inventories (BDI and BAI, respectively). Subscores generated by each scale (herein termed "symptom domains") were used to categorize individuals into mild, moderate and severe subgroups through K-means clusterization and subsequently analysed by means of multiple correspondence analysis.

RESULTS

Broadly, we observed that symptom domains of OCD, SAD or PD tend to cluster on the basis of their severities rather than their DSM diagnostic labels. In particular, symptom domains and disorders were grouped into (1) a single mild "neurotic" syndrome characterized by multiple, closely related and co-occurring mild symptom domains; (2) two moderate (complicated and uncomplicated) "neurotic" syndromes (the former associated with panic disorder); and (3) severe but dispersed "neurotic" symptom domains.

CONCLUSION

Our findings suggest that symptoms domains of treatment seeking patients with OCD and anxiety disorders tend to be better conceptualized in terms of severity rather than rigid diagnostic boundaries.

Longitudinal association between motor and obsessive compulsive symptoms in patients with psychosis and their unaffected siblings

Little is known about the co-prevalence of obsessive compulsive symptoms (OCS) and motor symptoms in patients with psychotic disorders. Cross-sectional associations between OCS and motor symptoms were assessed at baseline and at 3 years follow-up in patients (n = 726) with psychotic disorders and in their unaffected siblings (n = 761) from the Dutch Genetic Risk and Outcome of Psychosis (GROUP) study. Furthermore, longitudinal associations between changes in OCS and motor symptoms were evaluated. At baseline, OCS was not associated with any motor symptom (akathisia, dyskinesia, parkinsonism or dystonia) in patients. At follow-up, patients with OCS reported significantly more akathisia. Dividing the patients into four groups-no OCS, OCS remission with OCS only at baseline, OCS de novo with OCS only at follow-up and a persistent OCS group-revealed that the OCS de novo group already reported more akathisia at baseline compared to the no-OCS group. At follow-up, both the OCS de novo and the persistent OCS group reported more akathisia. These results remained significant after correcting for relevant confounders clozapine, GAF score, PANSS-negative score and IQ. Motor symptoms at baseline were significantly associated with OCS at follow-up, but not the other way around. In siblings, OCS at baseline was associated with akathisia, but this association was lost at follow-up. Results suggest that motor symptoms might precede co-occurring OCS in patients with psychotic disorders. However, no inference can be made about causality, and further prospective research is needed to investigate this assumption.

From Treatment Response to Recovery: A Realistic Goal in OCD

Despite longitudinal studies reporting symptomatic remission rates ranging from 32% to 70%, Obsessive-Compulsive Disorder is considered a persistent and very disabling disorder. However, these studies suggest that recovery can be a realistic goal for a subgroup of the Obsessive-Compulsive Disorder population and that a clear definition of recovery is timely in Obsessive-Compulsive Disorder. The aim of this paper is to discuss the dimensions of and propose an operational definition of recovery in Obsessive-Compulsive Disorder. Considering the impact generated by the definition of recovery for other mental disorders, this article discusses how this concept may shape the future of research and clinical practice in Obsessive-Compulsive Disorder. Ultimately, the hope is that the management of Obsessive-Compulsive Disorder may parallel, and expand upon, some of the current approaches implemented in the care of schizophrenia, so that early diagnosis, stepped-care techniques, and a personalized approach can be used to create recovery-oriented treatment programs and influence policy making for Obsessive-Compulsive Disorder.

[Help-seeking behavior and pathways to care for patients with obsessive-compulsive disorders]

BACKGROUND

Obsessive-compulsive disorder (OCD) is a chronic and debilitating disorder that is relatively common and is associated with a wide range of functional impairments. This is partly associated with delayed help-seeking behavior of OCD patients, which shows a lag of up to 10 years after onset of the obsessive-compulsive symptoms to the first attempt at seeking professional treatment. The reasons for the delay in initial help-seeking behavior by OCD patients are manifold but still not clear. Early detection and early treatment might, however, have beneficial effects on the treatment-seeking behavior.

AIM

The aim of the study was to examine the help-seeking behavior and the pathways to care of patients with OCD using a modified version of the structured pathways to care questionnaire initially designed for research into schizophrenia.

RESULTS

For the 40 outpatients with OCD who completed the interview retrospectively, the latent period between symptom onset and first seeking professional contact was on average 6.5 years, while the median delay to a third attempt at seeking treatment was nearly 15 years. Although the majority of participants consulted a professional neurological and psychotherapeutic practice even at the first attempt and 90% complained of specific OCD symptoms, only 20% received the standard treatment consisting of cognitive behavioral therapy and medication with a selective serotonin reuptake inhibitor (SSRI). The most common reason for delaying seeking treatment was that the patient was not convinced of having a mental illness such as OCD and of the necessity for treatment. Even so, approximately 40% of the participants reported fear of stigmatization and discrimination as a major reason for the delay in the first attempt at seeking help.

CONCLUSION

Psychoeducation and broad utilization of evidence-based treatment still appears necessary and can contribute to improvement in the help-seeking behavior of OCD patients.

Longitudinal relationship between Personal and Social Performance (PSP) and anxiety symptoms in schizophrenia

BACKGROUND

We aimed to examine the longitudinal relationship between the personal and social functioning and anxiety symptoms in patients with schizophrenia. For this purpose, we confirmed the validity of the anxiety subscale of the Symptom-Checklist-90-Revised (SCL-90-R) and then applied the latent growth modeling method for longitudinal causal relationships.

METHODS

Five hundred and seventy-eight patients diagnosed with schizophrenia were evaluated and 369 patients were included in the study at baseline. After conducting Rasch model analyses for the validation of the anxiety subscale in the SCL-90-R, we applied latent growth model to determine the causal relationship between the PSP and the anxiety symptoms.

RESULTS

The validity of the anxiety subscale of the SCL-90-R was confirmed based on the Rasch rating model, where the criteria for Infit, Outfit, item difficulty, and point-measure correlations were satisfied. The results from the latent growth model showed that the intercept and slope (rate of change) of the PSP negatively predicted the slope of anxiety symptoms along the longitudinal trajectory. Together with previous studies examining the predictive role of anxiety symptoms on quality of life, our longitudinal findings lend evidence for bidirectional effects between quality of life and anxiety symptoms. The transactional nature of the relationship between anxiety symptoms and quality of life warrant further investigation using a longitudinal cross-lagged design.

CONCLUSION

The anxiety subscale of the SCL-90-R may be utilized by clinicians and researcher to make inferences about quality of life in addition to assessing anxiety symptoms in patients with schizophrenia.