Clinical characteristics of transformation obsessions in obsessive-compulsive disorder: A psychopathological study.

BACKGROUND: The obsession of turning into another person (transformation obsessions [TO]), and its related compulsions have been initially conceptualised as a form of mental contamination. Nevertheless, it has remained understudied in the current obsessive-compulsive disorder (OCD) literature. In parallel, disturbances of the self have been identified as markers of prodromal psychosis in patients with schizophrenia. Based on the later association, this study aimed to investigate the sociodemographic and clinical correlates of TO. METHODS: In all, 1001 OCD outpatients from the Brazilian OCD Research Consortium were included in this study. Several semi-structured and structured instruments were used to compare 48 OCD patients with TO with 953 OCD patients without TO. A repression model investigated the relationships between the presence of current TO and statistically significant univariate test outcomes. RESULTS: Participants with TO presented an overall younger age, a longer period of time between the onset of the OCD symptoms and an OCD diagnosis, greater severity of the sexual/religious dimension and increased suicidality symptoms. CONCLUSIONS: These results indicate that TO may be better conceptualised as a form of forbidden/taboo thoughts rather than contamination. While no significant associations with psychotic features (e.g. decreased insight) were observed, TO patients displayed increased suicidality, overall younger age and a significantly larger disparity between seeking treatment and OCD diagnosis. This demonstrates that further clinical awareness and research into TO as an OCD symptom is most needed.

Obsessional slowness in obsessive-compulsive disorder: identifying characteristics and comorbidities in a clinical sample.

BACKGROUND: Obsessional slowness (OS) is characterised by debilitating motor slowness during initiation and completion of daily tasks such as washing, dressing, eating or walking. Yet, the clinical features of OS are still poorly understood. METHODS: This study aimed to delineate demographics, comorbid disorders and obsessive-compulsive symptoms (OCS) associated with OS. Cross sectional data from 667 OCD outpatients aged 9-82 years (M = 37.86, SD = 12.78) who underwent comprehensive standardised assessments administered by trained clinicians were analysed. Participants with (n = 189) and without (n = 478) OS were compared and contrasted. RESULTS: Logistic regression revealed that being single, having tics and displaying higher severity of aggression, contamination, symmetry and hoarding symptoms significantly predicted participants having OS. CONCLUSIONS: This is the largest-scale descriptive study of OS, which also provides preliminary evidence that OS may be a more severe form of OCD. Further empirical validation of these findings is required, and future research should focus on developing OS assessment.Key PointsThis was the first large-scale descriptive study of obsessional slowness (OS), that provided preliminary evidence for an OS phenotype within obsessive-compulsive disorderOS is associated with increased severity of aggression, contamination, symmetry and hoarding obsessive-compulsive symptomsIndividuals with OS are more likely to have comorbid tics, suggesting that there may be underlying motor factors contributing to this conditionFuture research would benefit from collecting both qualitative and quantitative data when assessing OS.

Factor structure of the Dimensional Yale-Brown Obsessive-Compulsive Scale in a large sample of adults with obsessive-compulsive disorder

Objectives: Although the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) is a widely used instrument for assessing different obsessive-compulsive symptom dimensions, its factor structure has never been studied in a Brazilian population. Thus, we aimed to assess the goodness-of-fit indexes and factor loadings of two higher-order models of the DY-BOCS using confirmatory factor analysis (CFA) in a large obsessive-compulsive disorder (OCD) sample. Methods: We tested two CFA models in a sample of 955 adults with OCD who had been assessed with the DY-BOCS in a cross-sectional multi-site study. The first model encompassed the symptom checklist (present or absent), whereas the second focused on items related to severity scores. Results: Both models presented adequate goodness-of-fit indexes. The comparative fit index, Tucker-Lewis index, and omega were > 0.9, while the root mean square error of approximation was ≤ 0.06 for both models. Factor loadings for each item of each dimension are presented and discussed. Conclusion: Higher-order factor models showed adequate goodness-of-fit indexes, indicating that they appropriately measured OCD dimensions in this Brazilian population.

Factor structure of the Dimensional Yale-Brown Obsessive-Compulsive Scale in a large sample of adults with obsessive-compulsive disorder.

OBJECTIVES: Although the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) is a widely used instrument for assessing different obsessive-compulsive symptom dimensions, its factor structure has never been studied in a Brazilian population. Thus, we aimed to assess the goodness-of-fit indexes and factor loadings of two higher-order models of the DY-BOCS using confirmatory factor analysis (CFA) in a large obsessive-compulsive disorder (OCD) sample. METHODS: We tested two CFA models in a sample of 955 adults with OCD who had been assessed with the DY-BOCS in a cross-sectional multi-site study. The first model encompassed the symptom checklist (present or absent), whereas the second focused on items related to severity scores. RESULTS: Both models presented adequate goodness-of-fit indexes. The comparative fit index, Tucker-Lewis index, and omega were > 0.9, while the root mean square error of approximation was ≤ 0.06 for both models. Factor loadings for each item of each dimension are presented and discussed. CONCLUSION: Higher-order factor models showed adequate goodness-of-fit indexes, indicating that they appropriately measured OCD dimensions in this Brazilian population.

The impact of generalized anxiety disorder in obsessive-compulsive disorder patients.

Despite generalized anxiety disorder (GAD) being one of the most prevalent comorbidities in obsessive-compulsive disorder (OCD), few studies have researched its impact on the OCD phenotype. The present study investigated how the sociodemographic and clinical profile of people with OCD with comorbid GAD differs from people with OCD without comorbid GAD. We hypothesised that the phenotype of the comorbid group would be closely related to GAD, in that it would more likely be female, have an earlier age at onset of OCD, and show an increased severity of fear-related OCD symptoms (aggressive, sexual/religious, and contamination dimensions), more avoidant behaviours, greater suicidality, more severe anxiety symptoms, and increased rates of comorbid anxiety and mood disorders. The study included 867 participants with OCD, with GAD being comorbid in 33.56%. Mann-Whitney U tests, chi-square tests with continuity correction, and logistic regressions were performed. Results showed that comorbid GAD was uniquely associated with an increased number of avoidant behaviours, greater anxiety severity, panic disorder without agoraphobia, social phobia, specific phobia, and type II bipolar disorder. These results illustrate the clinical severity associated with this comorbidity and highlight markers that can aid diagnosis of GAD in OCD. Future studies should investigate whether this comorbidity has an impact on the treatment of OCD.

Outbreak of hepatitis B and hepatitis C virus infections associated with a cardiology clinic, West Virginia, 2012-2014.

OBJECTIVE: To stop transmission of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in association with myocardial perfusion imaging (MPI) at a cardiology clinic. DESIGN: Outbreak investigation and quasispecies analysis of HCV hypervariable region 1 genome. SETTING: Outpatient cardiology clinic. PATIENTS: Patients undergoing MPI. METHODS: Case patients met definitions for HBV or HCV infection. Cases were identified through surveillance registry cross-matching against clinic records and serological screening. Observations of clinic practices were performed. RESULTS: During 2012-2014, 7 cases of HCV and 4 cases of HBV occurred in 4 distinct clusters among patients at a cardiology clinic. Among 3 case patients with HCV infection who had MPI on June 25, 2014, 2 had 98.48% genetic identity of HCV RNA. Among 4 case patients with HCV infection who had MPI on March 13, 2014, 3 had 96.96%-99.24% molecular identity of HCV RNA. Also, 2 clusters of 2 patients each with HBV infection had MPI on March 7, 2012, and December 4, 2014. Clinic staff reused saline vials for >1 patient. No infection control breaches were identified at the compounding pharmacy that supplied the clinic. Patients seen in clinic through March 27, 2015, were encouraged to seek testing for HBV, HCV, and human immunodeficiency virus. The clinic switched to all single-dose medications and single-use intravenous flushes on March 27, 2015, and no further cases were identified. CONCLUSIONS: This prolonged healthcare-associated outbreak of HBV and HCV was most likely related to breaches in injection safety. Providers should follow injection safety guidelines in all practice settings.

An epidemiological study of childhood development in an urban setting in Brazil

Objective: Mental illness is an important public health concern, often starting early in life and particularly impacting children from low-and middle-income countries. Our aims were to 1) determine, in a representative sample of public preschool 4- to 5-year old children in Brazil, the prevalence of internalizing and externalizing disorders and socioemotional development delays; and 2) to identify modifiable risk factors associated with mental, behavioral, or developmental disorders (MBDD), such as microsystem (i.e., parent-child relationship), mesosystem (social support), and macrosystem contextual factors (neighborhood disadvantage). Methods: A random sample of public preschool children was recruited in the city of Embu das Artes (São Paulo metropolitan area) (n=1,292 from 30 public preschools). Six-month prevalence of MBDD was measured using the Child Behavior Checklist (CBCL) and the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE). Results: Six-month prevalence estimates were 25.4% for internalizing disorders, 12.1% for externalizing disorders, and 30.3% for socioemotional development delays. MBDD prevalence estimates were higher in families with stressful relationships and parental depression or anxiety, and in families with lower social capital. Conclusion: At least 25% of preschool children living in an urban area in Brazil presented a mental health disorder. These mental disorder were associated with modifiable factors such as stressful family relationships and lower social capital. Prevention and intervention measures such as family therapy are needed to decrease such high prevalence.

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.

Predicting marriage and divorce in obsessive-compulsive disorder.

Single (N = 472, 51.7%), married or living in stable cohabitation (N = 375, 41.1%) and divorced or separated (N = 66, 7.2%) patients with obsessive-compulsive disorder (OCD) were compared in terms of their sociodemographic features, OCD phenotypes, and comorbidity profile. Using single status as a reference group, a multinominal regression analysis found increased age, lower severity of hoarding, increased rates of panic disorder without agoraphobia, and lower rates of dysthymic disorder to be associated with married or stable cohabitation status. Concomitantly, increased age, higher severity of symmetry symptoms, and increased rates of skin picking disorder were found to be associated with divorced status. These findings suggest that there is a relationship between marital status and different OCD phenotypes.

An epidemiological study of childhood development in an urban setting in Brazil.

OBJECTIVE: Mental illness is an important public health concern, often starting early in life and particularly impacting children from low-and middle-income countries. Our aims were to 1) determine, in a representative sample of public preschool 4- to 5-year old children in Brazil, the prevalence of internalizing and externalizing disorders and socioemotional development delays; and 2) to identify modifiable risk factors associated with mental, behavioral, or developmental disorders (MBDD), such as microsystem (i.e., parent-child relationship), mesosystem (social support), and macrosystem contextual factors (neighborhood disadvantage). METHODS: A random sample of public preschool children was recruited in the city of Embu das Artes (São Paulo metropolitan area) (n=1,292 from 30 public preschools). Six-month prevalence of MBDD was measured using the Child Behavior Checklist (CBCL) and the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE). RESULTS: Six-month prevalence estimates were 25.4% for internalizing disorders, 12.1% for externalizing disorders, and 30.3% for socioemotional development delays. MBDD prevalence estimates were higher in families with stressful relationships and parental depression or anxiety, and in families with lower social capital. CONCLUSION: At least 25% of preschool children living in an urban area in Brazil presented a mental health disorder. These mental disorder were associated with modifiable factors such as stressful family relationships and lower social capital. Prevention and intervention measures such as family therapy are needed to decrease such high prevalence.

The rates of co-occurring behavioural addictions in treatment-seeking individuals with obsessive-compulsive disorder: a preliminary report.

Objectives: To assess the rates of co-occurring putative 'behavioural addictions' in patients with obsessive-compulsive disorder (OCD).Methods: Twenty-three international centres specialising in the treatment of OCD were invited to participate in a survey of the rates of behavioural addictions and other relevant comorbidity within their samples.Results: Sixteen of 23 (69.6%) invited centres from 13 countries had sufficient data to participate in the survey. The use of validated diagnostic tools was discrepant, with most centres relying on a 'clinical diagnosis' to diagnose behavioural addictions. The final sample comprised of 6916 patients with a primary diagnosis of OCD. The reported rates of behavioural addictions were as follows: 8.7% for problematic internet use, 6.8% for compulsive sexual behaviour disorder, 6.4% for compulsive buying, 4.1% for gambling disorder and 3.4% for internet gaming disorder.Conclusions: Behavioural addictions should be better assessed for patients with OCD. The absence of diagnostic scales developed specifically for behavioural addictions and overlapping obsessive-compulsive phenomena such as compulsive checking of information on the internet may explain the relatively high rate of problematic internet use in this sample. The study encourages better efforts to assess and to conceptualise the relatedness of behavioural addictions to obsessive-compulsive 'spectrum' disorders.

Bipolar disorder comorbidity in patients with obsessive-compulsive disorder: Prevalence and predictors.

BACKGROUND: Patients with obsessive-compulsive disorder (OCD) often present with comorbidities, mainly anxiety and affective disorders, which may influence OCD course, help-seeking and treatment response. Some authors have studied bipolar disorder (BD) comorbidity in patients with OCD, but usually in small samples. The objective was to estimate the lifetime prevalence of BD in a large clinical sample of OCD patients, and to compare demographic and clinical features of patients with and without BD comorbidity. METHOD: This cross-sectional study with 955 adult OCD patients from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (C-TOC) used several assessment instruments, including the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, the Beck Depression and Anxiety Inventories, and the Structured Clinical Interview for DSM-IV Axis I Disorders. Descriptive and bivariate analyses were followed by logistic regression. RESULTS: The lifetime prevalence of BD was 7.75% (N = 74). The variables that were independently associated with BD comorbidity were: panic disorder with agoraphobia, impulse control disorders, and suicide attempts. LIMITATIONS: The cross-sectional design does not permit causal inferences; the external validity may be limited, as the participants were from tertiary services. Despite the large sample size, some analyses may have been underpowered due to the relatively low prevalence of the outcome and of some explanatory variables. CONCLUSIONS: Patients with OCD comorbid with BD have some clinical features indicative of greater severity, including higher suicide risk, and require a careful therapeutic approach for the appropriate treatment of both disorders.

The impact of attention deficit hyperactivity disorder in obsessive-compulsive disorder subjects.

BACKGROUND: Recent findings suggest an association between attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). Thus, we evaluated the clinical associated features of ADHD in a large sample of adult OCD patients. METHODS: A cross-sectional study including 955 adult patients with OCD from the Brazilian Research Consortium of Obsessive-Compulsive Spectrum Disorders (C-TOC). Clinical characteristics in adult OCD patients with and without comorbid ADHD were compared using Fisher's exact test, t-tests or Mann-Whitney tests. Bivariate analyses were followed by logistic regression analysis to identify clinical characteristics independently associated with ADHD comorbidity. RESULTS: The lifetime prevalence of ADHD in adult OCD patients was 13.7%. The current results indicate that OCD + ADHD patients were more severe, had an earlier onset of the obsessive-compulsive symptoms, a higher history of rheumatic fever, with higher frequencies of sensory phenomena and comorbidity with Tourette syndrome. They also had an increased risk for academic impairment and suicide attempts. CONCLUSION: Adult OCD patients with ADHD present some specific clinical features and may represent a special subgroup of adult OCD. Future studies should focus on the development of interventions more tailored to the phenotype of this subgroup of patients.

Reaction time variability and attention-deficit/hyperactivity disorder: is increased reaction time variability specific to attention-deficit/hyperactivity disorder? Testing predictions from the default-mode interference hypothesis.

Increased reaction time variability (RTV) is one of the most replicable behavioral correlates of attention-deficit/hyperactivity disorder (ADHD). However, this may not be specific to ADHD but a more general marker of psychopathology. Here we compare RT variability in individuals with ADHD and those with other childhood internalizing and externalizing conditions both in terms of standard (i.e., the standard deviation of reaction time) and alternative indices that capture low-frequency oscillatory patterns in RT variations over time thought to mark periodic lapses of attention in ADHD. A total of 667 participants (6-12 years old) were classified into non-overlapping diagnostic groups consisting of children with fear disorders (n = 91), distress disorders (n = 56), ADHD (n = 103), oppositional defiant or conduct disorder (ODD/CD; n = 40) and typically developing controls (TDC; n = 377). We used a simple two-choice reaction time task to measure reaction time. The strength of oscillations in RTs across the session was extracted using spectral analyses. Higher RTV was present in ADHD compared to all other disorder groups, effects that were equally strong across all frequency bands. Interestingly, we found that lower RTV to characterize ODD/CD relative to TDC, a finding that was more pronounced at lower frequencies. In general, our data support RTV as a specific marker of ADHD. RT variation across time in ADHD did not show periodicity in a specific frequency band, not supporting that ADHD RTV is the product of spontaneous periodic lapses of attention. Low-frequency oscillations may be particularly useful to differentiate ODD/CD from TDC.

Low frequency fluctuation of brain spontaneous activity and obsessive-compulsive symptoms in a large school-age sample.

BACKGROUND: The present study was designed to explore alterations in brain dynamics at rest that are associated with Obsessive Compulsive Symptoms (OCS) in childhood by measuring low frequency fluctuation of spontaneous brain activity in a large school community sample from a developing country. METHOD: Resting state functional magnetic resonance imaging data were collected in a sample of 655 children and adolescents (6-15 years old) from the brazilian 'High Risk Cohort Study for Psychiatric Disorders (HRC)'. OCS were assessed using items from the Compulsion and Obsessions section of the Development and Well-Being Assessment (DAWBA). The correlation between the fractional amplitude of low frequency fluctuations (fALFF) and the number of OCS were explored by using a general linear model, considering fALFF as response variable, OCS score as regressor and age, gender and site as nuisance variables. RESULTS: The number of OCS was positively correlated with the fALFF coefficients at the right sensorimotor cortex (pre-motor, primary motor cortex and post-central gyrus) and negatively correlated with the fALFF coefficients at the insula/superior temporal gyrus of both hemispheres. Our results were specific to OCS and not due to associations with overall psychopathology. CONCLUSIONS: Our results suggest that brain spontaneous activity at rest in the sensorimotor and insular/superior-temporal cortices may be involved in OCS in children. These findings need independent replication and future studies should determine whether brain spontaneous activity changes within these regions might be predictors of risk for obsessive-compulsive disorder latter in life.

Psychopathology and friendship in children and adolescents: disentangling the role of co-occurring symptom domains with serial mediation models.

The consolidation of social friendship groups is a vital part of human development. The objective of this study is to understand the direct and indirect influences of three major symptomatic domains-emotional, hyperkinetic, and conduct-on friendship. Specifically, we aim to study if the associations of one domain with friendship may be mediated by co-occurring symptoms from another domain. A total of 2512 subjects aged 6-14 years participated in this study. Friendship was evaluated by the Development and Well-Being Assessment's friendship section. We evaluated two main constructs as outcomes: (1) social isolation and (2) friendship latent construct. Emotional, hyperkinetic, and conduct symptomatic domains were evaluated with the Strengths and Difficulties Questionnaire (SDQ). All SDQ domains were positively associated with social isolation and negatively associated with friendship latent construct in univariate analysis. However, serial mediation models showed that the association between conduct domains with social isolation was mediated by emotion and hyperkinetic domains. Moreover, the associations between emotional and hyperkinetic domains with friendship latent construct in non-isolated children were mediated by the conduct domain. Emotion and hyperkinetic domains were directly and indirectly associated with social isolation, whereas conduct was directly and indirectly associated with overall friendship in non-isolated children. Results suggest that interventions aimed to improve social life in childhood and adolescence may have stronger effects if directed towards the treatment of emotion and hyperkinetic symptoms in socially isolated children and directed towards the treatment of conduct symptoms in children with fragile social connections.

A cross-cultural clinical comparison between subjects with obsessive-compulsive disorder from the United States and Brazil.

Although OCD is a global problem, the literature comparing, in a direct and standardized way, the manifestations across countries is scarce. Therefore, questions remain as to whether some important clinical findings are replicable worldwide, especially in the developing world. The objective of this study was to perform a clinical comparison of OCD patients recruited in the United States (U.S.) and Brazil. Our sample consisted of 1187 adult, treatment-seeking OCD outpatients from the U.S. (n=236) and Brazil (n=951). With regards to the demographics, U.S. participants with OCD were older, more likely to identify as Caucasian, had achieved a higher educational level, and were less likely to be partnered when compared to Brazilians. Concerning the clinical variables, after controlling for demographics the two samples presented largely similar profiles. Brazilian participants with OCD, however, endorsed significantly greater rates of generalized anxiety disorder and post-traumatic stress disorder, whereas U.S. subjects were significantly more likely to endorse a lifetime history of addiction (alcohol-use and substance-use disorders). This is the largest direct cross-cultural comparison to date in the OCD field. Our results provide much needed insight regarding the development of culture-sensitive treatments.

Hospital Impact After a Chemical Spill That Compromised the Potable Water Supply: West Virginia, January 2014.

In January 2014, a chemical spill of 4-methylcyclohexanemethanol and propylene glycol phenyl ethers contaminated the potable water supply of approximately 300,000 West Virginia residents. To understand the spill's impact on hospital operations, we surveyed representatives from 10 hospitals in the affected area during January 2014. We found that the spill-related loss of potable water affected many aspects of hospital patient care (eg, surgery, endoscopy, hemodialysis, and infection control of Clostridium difficile). Hospital emergency preparedness planning could be enhanced by specifying alternative sources of potable water sufficient for hemodialysis, C. difficile infection control, and hospital processing and cleaning needs (in addition to drinking water). (Disaster Med Public Health Preparedness. 2017;11:621-624).