Is a schizo-obsessive subtype associated with cognitive impairment? Results from a large cross-sectional study in patients with psychosis and their unaffected relatives

Obsessive-Compulsive Disorder and Schizophrenia: Conceptualization, Assessment and Cognitive Behavioral Treatment

There is little doubt that schizophrenia (SZ) and obsessive-compulsive disorder (OCD) are among the most severe disorders to impact humanity. They are both common, significantly disabling and have the tendency to strike during critical developmental periods in a young person's life. Schizophrenia affects approximately 1% of the global population and OCD has a lifetime prevalence of between 2% and 3% in the general population. The comorbidities in both SZ and OCD are common and frequently diagnosed, and research has generally found that comorbidities are associated with conditions that are more complex to diagnose and treat, and often result in less favorable prognoses. We review the research that has taken place regarding the co-occurrence of SZ and OCD, discuss it's theoretical conceptulization and clinical differentiation and diagnosis. We then propose recommendations for the best practice of cognitive behavioral therapy in this difficult population, as well as areas that need exploration for future research.

Meta-analysis of cognitive functioning in patients with psychotic disorders and obsessive-compulsive symptoms

Obsessive-compulsive symptoms (OCS) in psychotic disorders are associated with unfavorable outcomes, whether this extends to cognitive function remains unclear. We conducted meta-analyses on several cognitive domains to investigate overall group differences between patients with a psychotic disorder and co-occurring OCS (OCS +) and those without OCS (OCS-). We used meta-regression to assess possible confounding effects. No overall associations between OCS + and OCS- in any of the 17 investigated cognitive domains were found. We predominantly found large heterogeneity in effect size and direction among studies. Post-hoc analyses of processing speed tasks not purely based on reaction-time showed worse performance in the OCS + group with a small effect size (SMD = - 0.190; p = 0.029). Meta-regression revealed advanced age was significantly correlated with worse performance of the OCS + group in processing speed (R² = 0.7), working memory (R² = 0.11), cognitive inhibition (R² = 0.59), and cognitive flexibility (R² = 0.34). Patients fulfilling the criteria for an obsessive-compulsive disorder showed less impairment in cognitive inhibition compared to the OCS + group (R² = 0.63). Overall, comorbid OCS were not associated with cognitive impairment. However, large heterogeneity between studies highlights the complex nature of factors influencing cognition in people with psychotic disorder and comorbid OCS and warrants further research into possible moderating factors.

Childhood trauma and coping in patients with psychotic disorders and obsessive-compulsive symptoms and in un-affected siblings

BACKGROUND

Research on environmental and individual risk-factors in patients with a psychotic disorder and co-occurring obsessive-compulsive symptoms (OCS) is limited.

OBJECTIVE

This study aimed to examine the role of childhood trauma and coping on the occurrence of OCS in patients with a psychotic disorder and on a subclinical level in siblings.

PARTICIPANTS AND SETTING

626 patients and 638 siblings from the Genetic Risk and Outcome of Psychosis (GROUP) study were included in the current study.

METHODS

Differences between patients and siblings with and without OCS were analyzed with between-group comparisons. Mediation analyses investigated the effect of coping on the association between trauma and OCS severity.

RESULTS

Patients and siblings with OCS reported more childhood traumatic events, particularly sexual (OR = 1.62 / 3.26) and emotional (OR = 1.47 / 2.04) abuse compared to those without OCS. Both patients (d = 0.69) and siblings (d = 0.49) with co-occurring OCS showed a higher tendency for dysfunctional passive coping strategies compared to the group without OCS. The tendency for passive coping mediated the association between sexual and emotional abuse and OCS severity in patients.

CONCLUSIONS

Results imply that childhood trauma is associated with the presence of co-occurring OCS. Enhancing active coping strategies might have a beneficial effect in the prevention and treatment of co-occurring OCS in patients with psychotic disorders.

The "Obsessive Paradox": The Complex Relationship Between Cognitive and Obsessive Dimensions in Schizophrenia

The objective of the study was to investigate the relationship between cognitive functions and obsessive-compulsive dimension in schizophrenia and a possible moderating effect of schizophrenia symptom dimensions on this association. Sixty-one schizophrenia patients were administered the Positive and Negative Syndrome Scale, the Yale-Brown Obsessive-Compulsive Scale (YBOCS), and the Matrics Consensus Cognitive Battery. A U-shaped curve described a gradual transition from an inverse association to a positive relationship between YBOCS and processing speed scores, along a severity gradient of obsessive dimension. This effect ("the obsessive paradox") was not moderated by other symptom dimensions. The present study suggests that severe obsessive-compulsive symptoms may participate to counterbalance processing speed impairment independently from other symptom dimensions. These results highlight the complexity of the relationship between cognitive and obsessive dimensions in schizophrenia.

Patterns of obsessive-compulsive symptoms and social functioning in schizophrenia; a replication study

Research has found that Obsessive Compulsive Symptoms (OCS) in schizophrenia are associated with either more or less negative symptoms and either better or poorer cognitive functioning. In order to explain these contradictory results, (Lysaker et al., 2004), performed a cluster analysis resulting in 2 OCS positive (OCSpos) clusters, one with higher functioning (HF) and one with poorer functioning (PF) compared to 2 OCS negative (OCSneg) clusters. The OCSpos/HF cluster had less negative symptoms compared to all other clusters, while the OCSpos/PF cluster showed poorer executive functioning. We performed a replication study, in an almost 10 times larger, representative sample, using both a longitudinal and cross-sectional design. Similar to Lysaker et al., we found a group with mild OCS and HF (OCSmild/HF) showing less negative symptoms compared to the PF groups. We also found an OCSmild/PF group, which did not significantly differ in executive functioning from the other groups. Moreover, we did not find evidence for a better prognosis in the OCSmild/HF group, and thus found no support for the assumption that for some patients OCS might be an effective coping mechanism.

Schizo-obsessive spectrum disorders: an update

The presence of obsessive-compulsive symptoms (OCS) and obsessive-compulsive disorders (OCD) in schizophrenia is frequent, and a new clinical entity has been proposed for those who show the dual diagnosis: the schizo-obsessive disorder. This review scrutinizes the literature across the main academic databases, and provides an update on different aspects of schizo-obsessive spectrum disorders, which include schizophrenia, schizotypal personality disorder (SPD) with OCD, OCD with poor insight, schizophrenia with OCS, and schizophrenia with OCD (schizo-obsessive disorder). An epidemiological discussion on the discrepancies observed in the prevalence of OCS and OCD in schizophrenia across time is provided, followed by an overview of the main clinical and phenomenological features of the disorder in comparison to the primary conditions under a spectral perspective. An updated and comparative analysis of the main genetic, neurobiological, neurocognitive, and pharmacological treatment aspects for the schizo-obsessive spectrum is provided, and a discussion on endophenotypic markers is introduced in order to better understand its substrate. There is sufficient evidence in the literature to demonstrate the clinical relevance of the schizo-obsessive spectrum, although little is known about the neurobiology, genetics, and neurocognitive aspects of these groups. The pharmacological treatment of these patients is still challenging, and efforts to search for possible specific endophenotypic markers would open new avenues in the knowledge of schizo-obsessive spectrum.

The role of obsessive-compulsive symptoms in the perception of insincere speech in first-episode psychosis

OBJECTIVES

The aim of the present study was to investigate the effects of comorbid obsessive-compulsive symptoms (OCS) on the perception of insincere speech (e.g., sarcasm and white lies) in patients with first-episode psychosis.

DESIGN AND METHOD

Participants were 65 patients with nonaffective first-episode psychosis (FEP) and 47 healthy controls. The patient group was divided into two subgroups, those with (FEP+; n= 38) and those without OCS (FEP-; n = 27). The ability to process sarcasm and lie was assessed with the Perception of Social Inference Test (PESIT). Severity of psychotic symptoms and OCS was assessed with the Positive and Negative Syndrome Scale (PANSS) and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), respectively.

RESULTS

Deficits in the perception of sarcasm and lie were confirmed in patients with nonaffective first-episode psychosis compared to healthy controls. In patients, comorbidity with OCS was associated with worse performance on certain aspects of insincere speech (i.e., lie) compared to FEP- patients. Y-BOCS scores correlated significantly with the perception of lying. The cognitive factor of the PANSS predicted accuracy on the perception of sincere speech, paradoxical sarcasm, and white lies, while the presence of OCS predicted accuracy on the perception of sincere speech and white lies.

CONCLUSIONS

Our finding of impaired counterfactual information processing in patients with first-episode psychosis suggests that these deficits are already present at illness onset. Presence of OCS appears to have additional deleterious effects on the successful interpretation of intentional lying, further supporting that these patients are characterized by more extensive cognitive impairment.

Longitudinal association between cognitive performance and obsessive-compulsive symptoms in patients with psychosis and unaffected siblings

OBJECTIVE

Obsessive-compulsive symptoms (OCS) frequently occur in psychotic disorders. Cross-sectional associations between OCS and cognitive impairment have led to different causal explanations. Whereas one assumes that higher cognitive impairment reflects a risk factor for psychotic patients to develop OCS, another suggests that deficits reflect a consequence of OCS. This study investigated the longitudinal interrelation between OCS and cognitive functioning.

METHOD

Baseline and follow-up data from 622 patients and 670 un-affected siblings from the 'Genetic Risk and Outcome in Psychosis' study were analyzed. Participants were allocated to groups according to the presence or absence of OCS at assessments and compared on several cognitive domains.

RESULTS

Cross-sectional comparisons revealed no group differences in cognitive performance. Longitudinal analyses comparing the groups with changes in OCS revealed one significant group effect with more problems in set-shifting abilities in patient who reported OCS development at follow-up. Significant time and interaction effects were mainly due to improvement in immediate verbal recall and digit-symbol coding in patients and siblings who reported remission of OCS.

CONCLUSION

Although insight into causality needs further exploration, our results do not confirm the hypothesis of pre-existing cognitive risk constellations. Findings suggest that remission of comorbid OCS results in improved immediate verbal recall and processing speed.

Associations of obsessive-compulsive symptoms with clinical and neurocognitive features in schizophrenia according to stage of illness

This study aimed to investigate the association of obsessive-compulsive symptoms with clinical and neurocognitive features in patients with schizophrenia. This study enrolled 163 people with schizophrenia who were receiving risperidone monotherapy. Comorbid obsessive-compulsive symptoms were assessed using the Yale-Brown Obsessive-Compulsive Scale, and subjects with a score ≥ 10 constituted the obsessive-compulsive symptom group (n=30, 18.4%). The learning index was significantly higher in patients with obsessive-compulsive symptoms than in those without such symptoms after adjusting for age, stage (early and chronic), duration of illness, and CDSS score. However, there was no significant interaction between obsessive-compulsive symptoms and stage of illness. Scores on Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, and Beck Depression Inventory were significantly higher in the obsessive-compulsive symptom group. In addition, the Subjective Well-being under Neuroleptic Treatment score was significantly lower in the obsessive-compulsive symptom group. In conclusion, comorbid obsessive-compulsive symptoms in patients with schizophrenia were associated with a higher learning ability without a significant interaction with stage of illness. However, schizophrenia patients with obsessive-compulsive symptoms had more severe psychotic and depressive symptoms and poorer quality of life.

Neuropsychological profile and treatment-related features among patients with comorbidity between schizophrenia spectrum disorder and obsessive–compulsive disorder: is there evidence for a “schizo-obsessive” subtype?

Epidemiological studies have found that obsessive–compulsive disorder (OCD) is estimated to occur in 12% of patients with schizophrenia. Whether this “schizo-obsessive” subgroup may be posited as a clinical entity with a distinct neuropsychological profile and treatment-related features remains unclear. A sample of 30 patients who met DSM-IV criteria for both schizophrenia/schizoaffective disorder and OCD was compared with 30 OCD subjects and with 37 patients with schizophrenia/schizoaffective disorder. Neuropsychological domains were measured by the Wechsler Adult Intelligence Scale - Third Edition (WAIS-III), the Trail Making Test (TMT), and the verbal fluency test (FAS). Treatment-related variables were assessed with the Clinical Global Improvement scale (CGI), the Drug Attitude Inventory (DAI), and dosage/type of antipsychotic medications. One-way analysis of variance revealed statistically significant differences among the three groups in “working memory,” “block design,” “semantic fluency,” TMT-A, and TMT-B. However, the Bonferroni correction showed no statistical differences between both psychotic groups. In addition, there were no significant differences among the three groups in the CGI and DAI, although “schizo-obsessive” patients tended to display slightly higher scores on these variables than the other groups. Overall, these findings do not support the hypothesis that comorbidity between schizophrenia spectrum disorders and OCD may reflect a distinct clinical entity. However, further research with larger sample sizes and a more comprehensive clinical assessment are needed. Our findings also underscore the fact that divergences among assessment instruments, as well as confounding variables, may influence results on neuropsychological domains.

Emotional perception and theory of mind in first episode psychosis: the role of obsessive-compulsive symptomatology

The aim of the present study was to investigate the effects of comorbid obsessive-compulsive symptoms on emotional perception and theory of mind (ToM) in patients with first-episode psychosis. Participants were 65 patients with non-affective first episode psychosis (FEP) and 47 healthy controls. The patient group was divided into two subgroups, those with (FEP+; n=38) and those without obsessive-compulsive symptomatology (FEP-; n=27). Emotion perception and ToM were assessed with the Perception of Social Inference Test. Severity of psychotic and obsessive-compulsive symptoms was assessed with the Positive and Negative Syndrome Scale (PANSS) and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), respectively. Deficits in emotion recognition and theory of mind were confirmed in patients with non-affective first-episode psychosis compared to healthy controls. In patients, comorbidity with obsessive-compulsive symptoms was associated with worse performance on certain aspects of social cognition (ToM 2nd order) compared to FEP- patients. Our findings of impaired emotion perception and ToM in patients with first-episode psychosis support the hypothesis that deficits are already present at illness onset. Presence of OCS appears to have further deleterious effects on social cognition, suggesting that these patients may belong to a schizo-obsessive subtype of schizophrenia characterized by more extensive neurobiological impairment.

Comorbid Obsessive-Compulsive Symptoms in Schizophrenia: Insight into Pathomechanisms Facilitates Treatment

Insight into the biological pathomechanism of a clinical syndrome facilitates the development of effective interventions. This paper applies this perspective to the important clinical problem of obsessive-compulsive symptoms (OCS) occurring during the lifetime diagnosis of schizophrenia. Up to 25% of schizophrenia patients suffer from OCS and about 12% fulfil the diagnostic criteria of obsessive-compulsive disorder (OCD). This is accompanied by marked subjective burden of disease, high levels of anxiety, depression and suicidality, increased neurocognitive impairment, less favourable levels of social and vocational functioning, and greater service utilization. Comorbid patients can be assigned to heterogeneous subgroups. It is assumed that second generation antipsychotics (SGAs), most importantly clozapine, might aggravate or even induce second-onset OCS. Several epidemiological and pharmacological arguments support this assumption. Specific genetic risk factors seem to dispose patients with schizophrenia to develop OCS and risk-conferring polymorphisms has been defined in SLC1A1, BDNF, DLGAP3, and GRIN2B and in interactions between these individual genes. Further research is needed with detailed characterization of large samples. In particular interactions between genetic risk constellations, pharmacological and psychosocial factors should be analysed. Results will further define homogeneous subgroups, which are in need for differential causative interventions. In clinical practise, schizophrenia patients should be carefully monitored for OCS, starting with at-risk mental states of psychosis and longitudinal follow-ups, hopefully leading to the development of multimodal therapeutic interventions.

Can cognitive deficits differentiate between schizophrenia with and without obsessive-compulsive symptoms?

BACKGROUND

The frequent occurrence of obsessive-compulsive symptoms (OCS) in the course of schizophrenia and their impact on the functional outcome of the illness underlie the suggestion that the presence of OCS represents a separate subtype of schizophrenia, with a distinct clinical presentation and prognosis and specific neurobiological characteristics. This study investigated whether the presence of OCS in schizophrenia is associated with worse cognitive functioning in the domains of processing speed, executive functions and visuospatial memory. We also explored whether the degree of impairment in any of these cognitive domains could predict group membership (i.e. Schizophrenia with OCS [Sch-OCS] and Schizophrenia without OCS) and if there was a relationship between cognitive functioning and severity of OCS within the Sch-OCS group.

METHODS

Forty patients with schizophrenia, 20 with and 20 without OCS, individually matched for age, gender, years of education and severity of psychotic symptoms and 20 healthy controls underwent a comprehensive neuropsychological assessment.

RESULTS

Only lower performance in processing speed discriminated patients with OCS from patients without OCS. Processing speed impairment not only classified patients in OCS or non-OCS group but was also independent of the severity of OCS symptoms.

CONCLUSIONS

The notion of additive effects of both schizophrenia and OCD on the structural and functional integrity of the brain circuits that support cognitive functions warrants further investigation in longitudinal neuropsychological and neuroimaging studies with larger samples and sufficient variation in the severity of OCS.

Stable cognitive deficits in schizophrenia patients with comorbid obsessive-compulsive symptoms: a 12-month longitudinal study

BACKGROUND

Amongst schizophrenia patients, a large subgroup of up to 25% also suffers from comorbid obsessive-compulsive symptoms (OCSs). The association between comorbid OCSs in these patients and neuropsychological impairment remains unclear and somewhat contradictory. Longitudinal approaches investigating the stability of OCS-associated cognitive deficits are missing.

METHODS

Thirty-seven patients with schizophrenia and comorbid OCSs and 43 schizophrenia patients without OCS were assessed with a comprehensive cognitive test battery and compared at baseline and, again, 12 months later.

RESULTS

Schizophrenia patients with comorbid OCSs showed significant pronounced deficits, with increasing effect sizes over the 12-month assessment period in specific cognitive areas such as visuospatial perception and visual memory (WAIS-R block design, Rey-Osterrieth Complex Figure Test), executive functioning (perseveration in the Wisconsin Card Sorting test), and cognitive flexibility (Trail Making test B). These cognitive domains are correlated with OCS severity and are known to be candidate cognitive domains in obsessive-compulsive disorder (OCD).

CONCLUSIONS

OCSs in schizophrenia is associated with specific and longitudinally stable cognitive deficits, strongly arguing for at least partially overlapping neurobiological mechanisms with OCD. Prospective studies involving patients with at-risk mental states for psychosis are necessary to decipher the interaction of cognitive impairment and the clinical manifestations of schizophrenia and OCSs. This might facilitate the definition of patients at high risk for OCSs, an early detection of subclinical levels, therapeutic interventions, and clinical monitoring.

Comorbid obsessive-compulsive symptoms in schizophrenia: contributions of pharmacological and genetic factors

A large subgroup of around 25% of schizophrenia patients suffers from obsessive-compulsive symptoms (OCS) and about 12% fulfill the diagnostic criteria of an obsessive-compulsive disorder (OCD). The additional occurrence of OCS is associated with high subjective burden of disease, additional neurocognitive impairment, poorer social and vocational functioning, greater service utilization and high levels of anxiety and depression. Comorbid patients can be assigned to heterogeneous subgroups. One hypothesis assumes that second generation antipsychotics (SGAs), most importantly clozapine, might aggravate or even induce second-onset OCS. Several arguments support this assumption, most importantly the observed chronological order of first psychotic manifestation, start of treatment with clozapine and onset of OCS. In addition, correlations between OCS-severity and dose and serum levels and duration of clozapine treatment hint toward a dose-dependent side effect. It has been hypothesized that genetic risk-factors dispose patients with schizophrenia to develop OCS. One study in a South Korean sample reported associations with polymorphisms in the gene SLC1A1 (solute carrier family 1A1) and SGA-induced OCS. However, this finding could not be replicated in European patients. Preliminary results also suggest an involvement of polymorphisms in the BDNF gene (brain-derived neurotrophic factor) and an interaction between markers of SLC1A1 and the gene DLGAP3 (disc large associated protein 3) as well as GRIN2B (N-methyl-D-aspartate receptor subunit 2B). Further research of well-defined samples, in particular studies investigating possible interactions of genetic risk-constellations and pharmacodynamic properties, are needed to clarify the assumed development of SGA-induced OCS. Results might improve pathogenic concepts and facilitate the definition of at risk populations, early detection and monitoring of OCS as well as multimodal therapeutic interventions.