Juvenile-onset OCD: clinical features in children, adolescents and adults.

OBJECTIVE: To examine clinical correlates of juvenile-onset OCD across the lifespan. METHOD: Data collected at the intake interview from 257 consecutive participants with juvenile-onset OCD (20 children, 44 adolescents and 193 adults) in a naturalistic study of the clinical course of OCD were examined. Participants and parents of juvenile participants completed a structured diagnostic interview, rater-administered severity measures and self-report questionnaires. RESULTS: Children and adolescents (i.e. juveniles) shared similar features with the exception of age at onset and OCD symptom expression. Clinically meaningful differences between juvenile and adult participants were also found. Compared with adults, juveniles were more likely to be male, recall an earlier age at OCD onset and have different lifetime comorbidity patterns. CONCLUSION: Juvenile-onset OCD symptom expression is remarkably similar across the lifespan. However, findings also suggest clinically meaningful differences between juveniles and adults. Future work using a prospective design will improve our understanding of course patterns of juvenile-onset OCD.

The use of antibody D8/17 to identify B cells in adults with obsessive-compulsive disorder.

Compared with healthy control subjects, individuals with childhood-onset obsessive-compulsive disorder (OCD) have been reported to have a higher percentage of B cells that react with the monoclonal antibody D8/17, a marker for rheumatic fever. This study sought to replicate these findings in adults with OCD. Double-blind analyses of blood samples from 29 consecutive adults with primary OCD and 26 healthy control subjects were conducted to determine the percentage of B cells identified by D8/17. Using a standard criterion of > or =12% labeled B cells to denote positivity, rates of D8/17 positive individuals did not significantly differ between the OCD (58.6%) and control (42.3%) groups. Early age of onset was not a predictor of D8/17 positivity in the OCD group. The percentage of B cells identified by the monoclonal antibody marker D8/17 did not distinguish adults with OCD from control subjects, nor did it distinguish a sub-group of adults with OCD who described pre-pubertal onset of their OCD symptoms.

Insight and treatment outcome in obsessive-compulsive disorder.

To determine whether (1) insight in obsessive-compulsive disorder (OCD) improves when OCD symptoms improve, and whether (2) degree of insight in OCD predicts response to sertraline, data were obtained from five sites participating in a larger multisite study of relapse in OCD. During the first 16 weeks of the study, 71 patients received open-label treatment with sertraline and were assessed using the Yale-Brown Obsessive-Compulsive Rating Scale (Y-BOCS) and a rating scale to evaluate insight, the Brown Assessment of Beliefs Scale (BABS), at study baseline and termination. Baseline total BABS score was not significantly correlated with change in Y-BOCS score. Change in BABS total score and change in Y-BOCS total score were significantly correlated. There was no significant difference in mean endpoint Y-BOCS scores for patients with poor insight (n = 14) compared to patients with good insight at baseline (n = 57). Thus, insight improved with decrease in OCD symptom severity. Degree of insight at baseline did not predict response to sertraline, i.e., patients with poor insight were just as likely to respond to sertraline as patients with good insight.

Delusionality and response to open-label fluvoxamine in body dysmorphic disorder.

BACKGROUND: Available data suggest that the delusional variant of body dysmorphic disorder (BDD), a type of delusional disorder, may respond to serotonin reuptake inhibitors (SRIs) and that delusionality (lack of insight) in BDD may improve with SRI treatment. However, this research has been hampered by the lack of a reliable and valid scale to assess delusionality. METHOD: Thirty subjects (21 women, 9 men; mean age = 33.3 +/- 9.0 years) with DSM-IV BDD were prospectively treated with open-label fluvoxamine for 16 weeks. Subjects were assessed at regular intervals with the Brown Assessment of Beliefs Scale (BABS), the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS; a measure of BDD severity), and other instruments. The BABS is a reliable and valid 7-item, semistructured, clinician-administered scale that assesses current delusionality. RESULTS: In this prospective, open-label study, 63% of BDD subjects responded to fluvoxamine. Delusional and nondelusional subjects had similar improvement in BDD symptoms. In addition, insight significantly improved in both delusional and nondelusional subjects. Baseline BABS scores did not contribute significantly to endpoint BDD-YBOCS scores in a regression analysis. CONCLUSION: Degree of delusionality did not predict fluvoxamine response, and delusionality significantly improved. These findings are preliminary and require confirmation in controlled trials. The implications of these findings for other types of delusions requires investigation.

Clinical features of obsessive-compulsive disorder.

The past decade has seen tremendous strides in the knowledge about the cause, epidemiology, and treatment of OCD. Research on clinical characteristics of the disorder have focused on several areas, including identification of subtypes, the role of insight, and patterns of comorbidity. Several studies looking at course of illness in OCD have found that, for adults with this disorder, the course is usually chronic, but increasing evidence shows that a subtype of OCD characterized by an episodic course may exist, and research is focusing on delineating that subtype more specifically. Another hypothesized subtype, which may be related to rheumatic fever, involves patients with both OCD and chronic tic disorders. Certain obsessions and compulsions are more common in patients with these two disorders; together with the familial transmission and treatment data, this suggests that these patients may represent a meaningful subtype. Another area of focus over the past 10 years has been the role of insight. Increasing evidence shows that a range of insight exists in patients with OCD. Whether patients with poor insight have a different treatment response or different course than do patients with better insight remains to be seen. Finally, comorbidity between OCD and schizophrenia has been an area of interest. Emerging evidence shows that obsessions and compulsions are more common in patients with schizophrenia than was previously thought. The effect of obsessions and compulsions on schizophrenia in terms of treatment response and course is being investigated. Despite tremendous advances in treatment of this potentially debilitating disorder, a significant percentage of patients do not respond to standard treatment. Continued research to identify meaningful subtypes in OCD is necessary to unravel important questions concerning cause and to develop specific treatment strategies for refractory patients.

Patterns of remission and relapse in obsessive-compulsive disorder: a 2-year prospective study.

OBJECTIVE: This study examined the course of illness in patients with obsessive-compulsive disorder (OCD) over a 2-year period. METHOD: Sixty-six patients with a primary diagnosis of DSM-III-R OCD were followed prospectively for 2 years. Baseline information was collected on demographic characteristics, Axis I and II diagnoses, and severity of OCD symptoms. Follow-up measures obtained at 3, 6, 12, and 24 months after baseline assessment included information on symptomatic and diagnostic status as well as behavioral and somatic treatments received. RESULTS: The probability of full remission from OCD over the 2-year period was 12%. The probability of partial remission was 47%. After achieving remission from OCD, the probability of relapse was 48%. No factors were identified that significantly predicted full or partial remission. Seventy-seven percent (N = 51) of the subjects received a serotonin reuptake inhibitor (SRI) for > or =12 weeks, and 68% (N = 45) received medium-to-high doses of SRIs for > or =12 weeks. Only 18% received a full trial of behavior therapy. CONCLUSION: Despite exposure to at least 1 adequate trial of an SRI, the likelihood of full remission of OCD in this study was low. Results of this study also suggest that behavior therapy may be under-utilized.

The Brown Assessment of Beliefs Scale: reliability and validity.

OBJECTIVE: The authors developed and evaluated the reliability and validity of the Brown Assessment of Beliefs Scale, a clinician-administered seven-item scale designed to assess delusions across a wide range of psychiatric disorders. METHOD: The authors developed the scale after reviewing the literature on the assessment of delusions. Four raters administered the scale to 20 patients with obsessive-compulsive disorder (OCD), 20 patients with body dysmorphic disorder, and 10 patients with mood disorder with psychotic features. Audiotaped interviews of scale administration conducted by one rater were independently scored by the other raters to evaluate interrater reliability. The scale was administered to 27 patients twice to determine test-retest reliability. Other insight instruments as well as scales that assess symptom severity were administered to assess convergent and discriminant validity. Sensitivity to change was assessed in a multicenter treatment study of sertraline for OCD. RESULTS: Interrater and test-retest reliability for the total score and individual item scores was excellent, with a high degree of internal consistency. One factor was obtained that accounted for 56% of the variance. Scores on the Brown Assessment of Beliefs Scale were not correlated with symptom severity but were correlated with other measures of insight. The scale was sensitive to change in insight in OCD but was not identical to improvement in severity. CONCLUSIONS: The Brown Assessment of Beliefs Scale is a reliable and valid instrument for assessing delusionality in a number of psychiatric disorders. This scale may help clarify whether delusional and nondelusional variants of disorders constitute the same disorder as well as whether delusionality affects treatment outcome and prognosis.

Obsessive-compulsive disorder in patients with schizophrenia or schizoaffective disorder.

OBJECTIVE: The authors evaluated the frequency of DSM-III-R obsessive-compulsive disorder in patients with a primary diagnosis of schizophrenia or schizoaffective disorder. METHOD: Patients with schizophrenia (N = 52) or schizoaffective disorder (N = 25) were evaluated for the presence of obsessions and compulsions by means of the Structured Clinical Interview for DSM-III-R, the Yale-Brown Obsessive Compulsive Scale, chart review, and contact with the treating clinicians. RESULTS: Six (7.8%) of the 77 patients met the DSM-III-R criteria for both obsessive-compulsive disorder and schizophrenia or schizoaffective disorder. CONCLUSIONS: These findings suggest that obsessive-compulsive disorder occurs in a substantial percentage of patients with schizophrenia or schizoaffective disorder. The addition of medications targeted at obsessive-compulsive disorder may be beneficial to these patients but requires systematic evaluation.

Treatment strategies for chronic and refractory obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD), despite our increasing understanding of its causes and its effective treatment, remains a chronic and underdiagnosed disorder. Both treatment with SSRIs and the behavioral treatment strategy of exposure with response prevention have been proved by clinical trials to be effective and safe in treating OCD; however, even these treatments sometimes elicit only moderate patient response, and some OCD patients do not respond to them at all. Preliminary data suggest that OCD has lifelong persistence and that discontinuation of pharmacotherapy often leads to relapse. Nonetheless, further prospective, controlled, maintenance studies of OCD are needed to determine factors in and predictors of recovery, remission, and relapse. Finally, new procedures for treatment-refractory patients are needed; neurosurgical and new pharmacologic approaches have shown promise in treating these patients and should be studied in controlled trials.

The epidemiology and differential diagnosis of obsessive compulsive disorder.

Originally considered a rare disorder, obsessive compulsive disorder (OCD) has been shown to be quite common with a 1% point prevalence in many cultures. Comorbidity with other psychiatric disorders is common, with a lifetime history of major depression present in two thirds of OCD patients. This disorder also coexists with a number of other Axis I disorders including panic disorder, social phobia, eating disorders, and Tourette's disorder. Data collected on phenomenological subtypes have shown that most OC patients have multiple obsessions and compulsions. Another model for subtyping OC symptoms categorizes core features that underlie obsessions and compulsions. These core features such as abnormal risk assessment or incompleteness may be useful in identifying homogeneous subgroups that have distinct treatment responses. The presence of compulsions is helpful in distinguishing this disorder from other anxiety disorders as well as depression. The differential diagnosis of OCD is presented.

Obsessive compulsive disorder with psychotic features.

BACKGROUND: The purpose of this study was to systematically identify and characterize the demographic and clinical features of patients with obsessive compulsive disorder (OCD) and psychotic symptoms. METHODS: From a total of 475 patients with DSM-III-R OCD evaluated and/or treated in an outpatient OCD clinic, 67 patients (14%) were identified as having psychotic symptoms in addition to OCD. Psychotic symptoms were defined as hallucinations, delusions, and/or thought disorder. Clinical and demographic data on these probands were collected from semistructured interviews and compared with data collected on the nonpsychotic OCD probands. RESULTS: We identified 27 (6%) of 475 probands with DSM-III-R OCD whose only psychotic symptom was lack of insight and high conviction about the reasonableness of the obsessions ("OCD without insight"). The remainder of the patients with psychotic symptoms and OCD met criteria for distinct DSM-III-R psychotic disorders as well as OCD: 18 probands (4%) had OCD and schizophrenia, 8 probands (2%) had OCD and delusional disorder. Fourteen patients (3%) met criteria for both OCD and schizotypal personality disorder. Compared with the OCD patients without psychosis, probands with OCD and psychotic features were more likely to be male, be single, have a deteriorative course, and have had their first professional contact at a younger age. The data suggest that these differences were largely due to those patients with OCD and schizophrenia-spectrum disorders and not those probands whose only psychotic symptom was complete conviction and lack of insight about their obsessions. CONCLUSION: There appears to be considerable heterogeneity in the clinical features of OCD patients who also have psychotic symptoms. The implications of these findings for understanding delusional states and for diagnostic classification are discussed.

Current issues in the pharmacologic management of obsessive compulsive disorder.

In spite of significant advances in the development of behavioral and pharmacologic strategies for the treatment of obsessive compulsive disorder, little is known about the comparative efficacy and safety of those treatments. In addition, questions about the dose and duration in maintenance treatment remain unknown. This article reviews current issues in the pharmacologic management of patients with obsessive compulsive disorder.

The epidemiology and clinical features of obsessive compulsive disorder.

During the past decade, there has been rapid growth in understanding the clinical features, pathophysiology, and treatment of obsessive compulsive disorder (OCD). This article reviews the current state of knowledge of the epidemiology and clinical features of OCD with a focus on the disorder's phenomenologic heterogeneity and its comorbidity with other Axis I and Axis II syndromes.

The epidemiology and differential diagnosis of obsessive compulsive disorder.

Obsessive compulsive disorder is now recognized as a common psychiatric disorder. The lifetime prevalence of 2% to 3% found in the United States has also been found in epidemiologic studies in several other countries with diverse cultures. This disorder has previously been underestimated due to a number of factors that include patients' reluctance to spontaneously admit to obsessions and compulsions and the omission of screening questions about obsessive compulsive disorder on routine mental status examinations. Depression and other anxiety disorders frequently co-occur with obsessive compulsive disorder, which may contribute to misdiagnosis. Patients with eating disorders, Gilles de la Tourette's syndrome, and schizophrenia have a greater comorbid risk compared with the general population. Differential diagnosis of obsessive compulsive disorder includes generalized anxiety disorder, panic disorder, phobias, compulsive personality disorder, and hypochondriasis. While many of these syndromes are characterized by intrusive thoughts, few have associated rituals. The complex tics seen in some patients with Tourette's syndrome may be difficult to distinguish from the compulsions seen in obsessive compulsive disorder, and, in fact, there is significant overlap in symptoms between the two disorders. Currently, the impulse control disorders, such as compulsive gambling and the paraphilias, are not considered to be part of obsessive compulsive disorder. Although the phenomenology of obsessive compulsive disorder appears to be quite diverse, with many distinct kinds of obsessions and compulsions, there are three important core features: abnormal risk assessment, pathologic doubt, and incompleteness. These features cut across phenomenological subtypes and may be useful in defining homogeneous subgroups with distinct treatment outcomes.

Epidemiology of obsessive compulsive disorder.

Until the early 1980s, the only estimate of the prevalence of obsessive compulsive disorder (OCD) in the general population was 0.05%. Data collected from the Epidemiology Catchment Area (ECA) survey have suggested that OCD is 50 to 100 times more common than previously believed and twice as common as schizophrenia or panic disorder in the general population. These results have been corroborated in a second, more carefully designed epidemiologic study. Several reasons account for the previous underestimation of the prevalence of the disorder: (1) reluctance of patients to divulge their symptoms; (2) lack of recognition of the diversity of presenting symptoms in OCD by professionals; (3) misdiagnosis; (4) failure to ask OCD screening questions in the routine mental status examination. Demographic and clinical characteristics of the disorder have been consistent across studies and time, supporting the validity of current nosologic criteria and the disorder's relative homogeneity. OCD appears to be familial, suggesting that genetic factors play a prominent role in the phenotypic expression of illness.

Coexisting obsessive compulsive disorder and alcoholism.

Fifty patients with the diagnosis of alcohol dependence or abuse who were admitted to a university-based alcohol rehabilitation program were screened for obsessions and compulsions. Six percent (3) of the patients met DSM-III-R criteria for obsessive compulsive disorder (OCD), which is three times the lifetime prevalence for OCD found in the general population. The diagnosis of OCD is easily overlooked, so screening questions should be asked of all alcoholics during the routine clinical interview. Identifying those patients with dual diagnoses is important because treatment of the underlying OCD should improve overall clinical outcome.