Compulsive Spectrum Disorders Research Articles

Neuropsychological Outcome of Ventral Capsular/Ventral Striatal Gamma Capsulotomy for Refractory Obsessive-Compulsive Disorder: A Pilot Study

Neuropsychological Outcome of Ventral Capsular/Ventral Striatal Gamma Capsulotomy for Refractory Obsessive-Compulsive Disorder: A Pilot Study

Selected highlights of the ISTSS 2008 Annual Meeting

This special section of the Journal of Traumatic Stress contains 10 articles based on some of the key presentations from the 24th International Society for Traumatic Stress Studies (ISTSS) Annual Meeting held in Chicago in November 2008. The articles reflect two of the many topics covered in the meeting. The conference theme was “Terror and Its Aftermath.” In the first part of the special section, there are articles by Danieli on reparative justice and by Steel, Bateman Steel, and Silove on human rights and the trauma model. They cover different ways of applying an understanding of human rights to the field of psychotraumatology. Danieli, for example, contrasts the harmful effects of the conspiracy of silence with the potential benefits available through the legal process of obtaining justice and reparation. Steel et al. outline three “generations” of human rights—civil and political; economic, social, and cultural; and collective or group rights—considering the relevance of each of these to work with trauma. Within the conference, therewas also a day-long special track on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V ). In the second part of the special section, there are eight articles covering many of the topics discussed in the meeting. The next revision of the DSM-V by the American Psychiatric Association (APA, Washington, DC) is underway and it is important that ISTSS makes an effective contribution to this task. We were able to hear from Katherine Phillips, chair of the Anxiety, Obsessive–Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group, and member of the DSM-V Task Force, about the process that has already been initiated, and from Matt Friedman about some of the important questions the group had to consider. This is not just an academic exercise. The decisions made by the APA may have an important influence on the way this whole field develops over the next 20 years. Invited lecturers were then asked to summarize current evidence relevant

Higher prevalence of obsessive–compulsive spectrum disorders in rheumatic fever

Objective This study aims to compare the prevalence of obsessive–compulsive spectrum disorders (OCSD) in psychiatric outpatients with and without a history of rheumatic fever (RF). Methods An analytical cross-sectional study assessing a large sample of consecutive psychiatric outpatients at a Brazilian private practice was conducted during a 10-year period. Psychiatric diagnoses were made by a senior psychiatrist based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Best-estimate diagnosis procedure was also performed. Results The total sample comprised 678 subjects, 13 of whom (1.92%) presented with a previous history of RF. This group showed a higher prevalence of subclinical obsessive–compulsive disorder ( P=.025) and OCSD ( P=.007) when compared to individuals with no such history. Conclusions A previous history of RF was associated with OCSD. These results suggest that clinicians should be encouraged to actively investigate obsessive–compulsive symptoms and related disorders in patients with a positive history of RF.

Onychophagia as a Spectrum of Obsessive-compulsive Disorder

Onychophagia can be explained as a kind of a compulsion that may cause destruction of the nails. Habitual nail biting is a common behaviour among children and young adults. By the age of 18 years the frequency of this behaviour decreases, but it may persist in some adults. Nail biting is an under-recognized problem, which may occur on a continuum ranging from mild to severe. Nail biting has received little attention in the psychiatric and dermatological literature. Its position in widely accepted classifications of psychiatric disorders (ICD-10 and DSM-IV) remains unclear. This disorder seems to be related to obsessive-compulsive spectrum disorder. Here, we present three case reports of onychophagia and co-occurring psychopathological symptoms and discuss the close relationship of onychophagia to obsessive- compulsive spectrum disorder and possible treatment modalities. Psychiatric evaluation of co-occurring psycho pathological symptoms in patients with onychophagia, especially those with chronic, severe or complicated nail biting, may be helpful in making a choice of individual therapy. Serotonin re-uptake inhibitors seem to be the treatment of choice in severe onychophagia.

P01-151 Revisiting the obsessive-compulsive spectrum

In the DSM IV-TR, Obsessive-Compulsive Disorder (OCD) is categorized as an anxiety disorder. A wide range of psychiatric and medical disorders, not included in this category, has been hypothesized to be related to OCD and to form a family of disorders known as obsessive compulsive spectrum disorders (OCSD). OCSD would include several clinically heterogeneous disorders such as Body Dysmorphic Disorder, Tourette's Syndrome or Pathological Gambling. This construct is based on disorders’ similarities with OCD in a variety of domains such as phenomenology, comorbidity, neurotransmitter or peptide systems, neurocircuitry, family history, genetic factors and treatment response. This presentation provides an overview of the existing literature regarding the concept of the OCD spectrum and the relationships between the disorders included in OCSD. Although there are data supporting the inclusion of some disorders in the OC spectrum, more research is needed to clarify the relationships and the boundaries between these disorders. Ultimately, a better understanding of OC spectrum may have significant implications for clinical practice.

Body dysmorphic disorder and obsessive–compulsive disorder: similarities, differences and the classification debate

Obsessive–compulsive disorder and body dysmorphic disorder have many similarities in clinical presentation. Obsessive–compulsive disorder has historically been considered an anxiety disorder, whereas body dysmorphic disorder has been grouped among the somatoform disorders. Researchers in these areas are currently debating whether the similarities warrant the inclusion of body dysmorphic disorder within a proposed category of obsessive–compulsive spectrum disorders. This article describes the association between obsessive–compulsive disorder and body dysmorphic disorder as evidenced by the emerging literature, and presents theoretical and clinical implications of this association.

P.4.f.001 Genetic dissection of motor activity levels and anxiety-related behavior in mice using an automated home cage task

The Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) is the most commonly used instrument to assess the clinical severity of obsessive–compulsive symptoms. Treatment determinations are often based on Y-BOCS score thresholds. However, these benchmarks are not empirically based, which may result in non-evidence based treatment decisions. Accordingly, the present study sought to derive empirically-based benchmarks for defining obsessive–compulsive symptom severity.Nine hundred fifty-four adult patients with obsessive–compulsive disorder (OCD), recruited through the Brazilian Research Consortium on Obsessive–Compulsive Spectrum Disorders, were evaluated by experienced clinicians using a structured clinical interview, the Y-BOCS, and the Clinical Global Impressions–Severity scale (CGI-Severity).Similar to results in treatment-seeking children with OCD, our findings demonstrated convergence between the Y-BOCS and global OCD severity assessed by the CGI-Severity (Nagelkerke R2 = .48). Y-BOCS scores of 0–13 corresponded with ‘mild symptoms’ (CGI-Severity = 0–2), 14–25 with ‘moderate symptoms’ (CGI-Severity = 3), 26–34 with ‘moderate-severe symptoms’ (CGI-Severity = 4) and 35–40 with ‘severe symptoms’ (CGI-Severity = 5–6). Neither age nor ethnicity was associated with Y-BOCS scores, but females demonstrated more severe obsessive–compulsive symptoms than males (d = .34). Time spent on obsessions/compulsions, interference, distress, resistance, and control were significantly related to global OCD severity although the symptom resistance item pairing demonstrated a less robust relationship relative to other components of the Y-BOCS.These data provide empirically-based benchmarks on the Y-BOCS for defining the clinical severity of treatment seeking adults with OCD, which can be used for normative comparisons in the clinic and for future research.

Psychopathologic Aspects of Body Dysmorphic Disorder: A Literature Review

Body dysmorphic disorder (BDD) is a somatoform disorder characterized by the patient's excessive concern with an imagined or minor defect in physical appearance. Patients with BDD often have been observed in aesthetic surgery settings seeking surgical enhancement at a reported prevalence of 6% to 15%. Published studies in the general population tend to aggregate a prevalence of 0.7% to 2.3%. This review aimed to search the literature for data on the prevalence, psychopathologic aspects, and comorbidity of BDD, and to provide an update on current BDD research. Relevant literature was identified by searching the Medline, PubMed, PsycINFO, and EMBASE databases. The following search words were used alone or in combination when appropriate: "body dysmorphic disorder," "somatoform disorder," "obsessive compulsive spectrum disorder," "personality disorders," "presurgical counseling," "aesthetic surgery," "cosmetic surgery," and "plastic surgery." Further articles were sourced from the reference lists of the articles ascertained through the search. Recent findings include the relationship between BDD and the obsessive-compulsive spectrum, treatment of BDD based on pharmacologic and psychological approaches, and the hypothesis that the often distinguished delusional and nondelusional variants of BDD very likely are the expression of a single disorder with varying degrees of severity. Retrospective outcome studies suggest that patients affected by BDD typically do not benefit from surgical treatment. In contrast, serotonin reuptake inhibitors and cognitive-behavior therapy appear to be good practice in addressing the disorder. Further research is needed to identify effective interventions for patients who do not respond to these treatment methods.

Re: Preferential Aggregation of Obsessive—Compulsive Spectrum Disorders in Schizophrenia Patients with OCD

Dear Editor: Dr Michael Poyurovsky and coauthors1 reported on an interesting study in which they assessed the rates of psychiatric disorders in schizophrenia patients with and without obsessive-compulsive disorders (OCD) and pure OCD patients. Body dysmorphic disorder, tic disorders (TD), and anxiety disorders were found in higher frequencies in the schizo-obsessive group when compared to pure schizophrenia. The findings support the notion that the schizo-obssesive group may be an intermediate phenotype between schizophrenia and OCD. We would like to comment on the specific findings of TD. Curiously, the authors found no cases of Tourette syndrome in the schizo-obsessive group, while the odds of having chronic motor tics in the schizo-obsessive group (16%) were 4 times higher than those of the schizophrenia group (4%). In the OCD group, the frequency of TD was the classical 34.3% found in the literature.2 The intermediate frequency of TD in the schizo-obsessive group speaks for a continuum between these disorders. One explanation for these higher frequencies of obsessive spectrum disorders could be the presence of common vulnerability genes. There are few reports of Tourette patients who later developed schizophrenia and also few reports of TD in schizophrenia.3-5 The low frequency of TD in schizophrenia could be owing to a real low incidence of tic disorders in schizophrenia, the use of antipsychotics in schizophrenia patients that would mask tics when present, and tics that may be misdiagnosed as Stereotypie behaviors, tardive diskinesia, and other extrapiramidal symptoms that might also lead to an underestimation of TD frequencies.6 To rule out these factors, the authors could have informed medication use in the 3 groups of patients as well as the diagnostic criteria used to differentiate between several involuntary movement disorders. The age of onset of the disorder, used as a covariable, showed no difference between OCD and schizo-obsessive patients. This is another important factor that reinforces the hypothesis that schizo-obsessive, have a place between schizophrenia and OCD, sharing specific comorbidity patterns with both.

P.1.f.007 Is there neuropsychological support for schizophrenia and obsessive compulsive spectrum disorders

P.1.f.007 Is there neuropsychological support for schizophrenia and obsessive compulsive spectrum disorders

Epilepsy and kleptomania

Kleptomania, defined in the American Psychiatric Association’s Diagnostic and Statistical Manua of Mental Disorders, Text Revision: DSM-IV-TR, as the inability to resist the impulse to steal objects that are not needed for personal use or for their monetary value, may reflect a form of obsessive–compulsive spectrum disorder and/or affective spectrum disorder. We report on a patient who developed kleptomania and left temporal lobe epilepsy around the same time; both disorders were completely resolved in this patient with topiramate.

Pharmacotherapy of pathological gambling: review of new treatment modalities

Pathological gambling is classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition as an impulse-control disorder. In the International Classification of Diseases of the WHO, pathological gambling is coded under the heading of ‘Habit and Impulse Disorders’. Pathological gambling is a chronic, progressive disorder, which has a prevalence of 1–3.4% among western civilizations. The enormous personal and social consequences of this disorder include a high rate of suicide attempts, job loss, marital and family problems, legal problems, and criminal behavior. Recent studies have demonstrated that pathological gambling patients respond well to treatment with selective serotonin reuptake inhibitors, mood stabilizers and opioid antagonists. These findings support the idea that pathological gambling and other disorders of impulse control may be conceptualized as part of the obsessive–compulsive spectrum disorders or addictive disorders. This article will discuss possible treatment strategies according to different behavior patterns in pathological gambling and also remind the physicians who intend to treat this disorder of the possible diagnosis of pathological gambling.

A linkage analysis between obsessive compulsive spectrum disorders and candidate genes of group II metabotropic glutamate receptor

目的 了解代谢型谷氨酸受体mGlu2受体(mGluR2)基因、mGlu3受体(mGluR3)基因等与强迫谱系障碍(OCSDs)的连锁关系.方法 选取一个连续三代发病的强迫谱系障碍家系,采集到该家系中12个正常个体,8个受累个体的血样,选取mGluR2、mGluR3基因附近7对微卫星标记引物,采用两点和多点非参数分析的方法对该家系进行连锁分析.结果 7对微卫星标记位点的两点和多点非参数分析LOD值(NPL值),位于mGluR3基因附近的标记D7S644两点非参数分析NPL值为1.719(P=0.078),多点非参数分析NPL值为1.712(P=0.078),达到验证性连锁的阈值(NPL=1.2),但未达到提示性连锁的阈值(NPL=2.2),D7S2481两点非参数分析NPL值为0.628(P=0.179),多点非参数分析NPL值为0.852(P=0.141),接近验证性连锁的阈值,其余5对微卫星标记位点非参数分析NPL值均未达到验证性连锁的阈值.结论 提示mGluR3基因与OCSDs可能存在连锁关系,不能排除mGluR2基因与OCSDs的相关性。

Preferential Aggregation of Obsessive—Compulsive Spectrum Disorders in Schizophrenia Patients with Obsessive—Compulsive Disorder

To validate a complex association between schizophrenia and obsessive-compulsive disorder (OCD). We used the Structured Clinical Interview for DSM-IV Axis I disorders to compare the rate of OCD spectrum and additional Axis I disorders in 100 patients who met criteria for both schizophrenia and OCD, non-OCD schizophrenia (n = 100), and OCD (n = 35). There was a robust between-group difference in the number of patients with one or more OCD spectrum disorders (schizo-obsessive n = 30, compared with schizophrenia n = 8; P = 0.001), that is, higher rates of body dysmorphic (8% compared with 0%) and tic (16% compared with 4%) disorders. No difference was revealed in affective, anxiety, and substance use disorders. We found comparable rates of OCD spectrum disorders in the schizo-obsessive and OCD groups (30% and 42.8%, respectively; P = 0.32). Preferential aggregation of OCD spectrum disorders in the schizo-obsessive group supports this unique clinical association. Whether a schizo-obsessive interface represents comorbidity or a specific subtype of schizophrenia warrants further investigation.

Structural brain abnormalities in the frontostriatal system and cerebellum in pedophilia

Even though previous neuropsychological studies and clinical case reports have suggested an association between pedophilia and frontocortical dysfunction, our knowledge about the neurobiological mechanisms underlying pedophilia is still fragmentary. Specifically, the brain morphology of such disorders has not yet been investigated using MR imaging techniques. Whole brain structural T1-weighted MR images from 18 pedophile patients (9 attracted to males, 9 attracted to females) and 24 healthy age-matched control subjects (12 hetero- and 12 homosexual) from a comparable socioeconomic stratum were processed by using optimized automated voxel-based morphometry within multiple linear regression analyses. Compared to the homosexual and heterosexual control subjects, pedophiles showed decreased gray matter volume in the ventral striatum (also extending into the nucl. accumbens), the orbitofrontal cortex and the cerebellum. These observations further indicate an association between frontostriatal morphometric abnormalities and pedophilia. In this respect these findings may support the hypothesis that there is a shared etiopathological mechanism in all obsessive–compulsive spectrum disorders.

Strategic memory in adults with anorexia nervosa: Are there similarities to obsessive compulsive spectrum disorders?

There is growing interest in the relationship between anorexia nervosa (AN) and obsessive-compulsive (OC) spectrum disorders (e.g., OCD, body dysmorphic disorder [BDD]). Previous neuropsychological investigations of OC spectrum disorders have identified problems with the efficient use of strategy on complex measures of learning and memory. This study evaluated nonverbal strategic memory in AN outpatients using an approach previously applied to OC spectrum disorders. Eighteen patients with AN and 19 healthy control participants completed the Rey-Osterrieth Complex Figure Test (RCFT), a widely used measure of nonverbal strategic planning, learning, and memory. Individuals with AN differed significantly from healthy controls in the organizational strategies used to copy the RCFT figure, and they recalled significantly less information on both immediate and delayed testing. Multiple regression analyses indicated that group differences in learning were mediated by copy organizational strategies. These results are identical to study findings in OCD and BDD, indicating important shared neuropsychological features among AN and these OC spectrum disorders. As in OCD and BDD, the essential cognitive deficit in AN was impaired use of organizational strategies, which may inform our understanding of the pathophysiology of AN and potentially offer treatment implications.

Kleptomania: Differential Diagnosis and Treatment Modalities

Kleptomania is classified in the psychiatric nomenclature as an impulse control disorder. Patients with kleptomania, however, often suffer from repetitive intrusive thoughts about stealing, an inability to avoid the compulsion to steal as well as a relief of tension following the theft. These associated symptoms suggest that kleptomania may be a form of obsessive compulsive spectrum disorder. On the other hand, some authors describe kleptomania as a nonpharmacological addiction because of the inability to control maladaptive behavior. A broad range of pharmacotherapeutic agents has been found to be beneficial in the treatment of kleptomania including serotonin reuptake inhibitors (SSRIs), mood stabilizers, and opioid receptor antagonist medications. Adjuvant cognitive behavioral therapy (CBT) is recommended. Keywords: Kleptomania, impulse control, addiction, obsessive-compulsive spectrum, SSRI

Does work on obsessive–compulsive spectrum disorders contribute to understanding the heterogeneity of obsessive–compulsive disorder?

Background There is a growing literature on the concept of an obsessive–compulsive spectrum of disorders. Here, we consider the different dimensions on which obsessive–compulsive spectrum (OCSDs) lie, and focus on how the concepts from this literature may help understand the heterogeneity of obsessive–compulsive disorder (OCD). Methods A computerized literature search (MEDLINE: 1964–2005) was used to collect studies addressing different dimensions on which the OCSDs lie. Against this backdrop, we report on a cluster analysis of OCSDs within OCD. Results OCSDs may lie on several different dimensions. Our cluster analysis found that in OCD there were 3 clusters of OCD spectrum symptoms: (1) “Reward deficiency” (including trichotillomania, pathological gambling, hypersexual disorder and Tourette's disorder), (2) “Impulsivity” (including compulsive shopping, kleptomania, eating disorders, self-injury and intermittent explosive disorder), and (3) “Somatic” (including body dysmorphic disorder and hypochondriasis). Conclusions It is unlikely that OC symptoms and disorders fall on any single phenomenological dimension; instead, multiple different constructs may be required to map this nosological space. Although there is evidence for the validity of some of the relevant dimensions, additional work is required to delineate more fully the endophenotypes that underlie OC symptoms and disorders.

Recognizing and Treating Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a relatively common and often-disabling obsessive compulsive spectrum disorder that often goes unrecognized in clinical practice. The present review examines the clinical features of BDD, its relationship to other disorders, and what is known about effective treatment. BDD consists of a distressing and impairing preoccupation with imagined or slight defects in appearance that can focus on any body area. Insight is usually poor or absent; nearly half of patients are delusional. Typical associated behaviors include skin picking, mirror checking, excessive grooming, and camouflaging. It appears that higher doses of serotonin reuptake inhibitors and longer treatment trials than those used for many other psychiatric disorders, including depression, are often needed to effectively treat BDD. Cognitive-behavioral therapy also appears efficacious and is currently considered the psychotherapy of choice for BDD. Core techniques are cognitive restructuring, behavioral experiments, response (ritual) prevention, and exposure. Further research is needed to minimize the underrecognition of BDD and to improve proper treatment. Because of the high rates of comorbidity in patients with BDD, treatment studies need to include subjects with co-occurring disorders and thereby attempt to understand how these other disorders affect treatment response. Finally, more research needs to address the pathophysiology of BDD (for example, by incorporating imaging and genetics).

Sustained-release bupropion in the treatment of SSRI nonresponder pathologic gamblers: pilot study and review of the literature

Background: Pathologic gambling (PG) is a prevalent and disabling impulse-control disorder. Recent studies have consistently demonstrated that PG patients respond well to treatment with selective serotonin reuptake inhibiters (SSRIs), mood stabilizers and opioid antagonists. These findings have supported the observation that PG is strongly associated with mood disorders, obsessive–compulsive spectrum disorders, panic disorder and addictive disorders. The aim of the study was to show the effectiveness of bupropion sustained release in PG. Methods: A total of 16 male PGs who had failed two previous trials of SSRI pharmacotherapy were enrolled in the study and were treated with bupropion sustained release for 12 weeks. A comprehensive psychiatric diagnostic evaluation was performed on all patients at baseline, and patients were screened for symptoms of gambling, depression and anxiety using the South Oaks Gambling Screen, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale and the Clinica...