Insight and alexithymia in adult outpatients with obsessive–compulsive disorder

Objective

To elucidate the relationships between insight and alexithymia in a sample of adult outpatients with obsessive–compulsive disorder (OCD).

Methods

112 adult outpatients with OCD were tested. Severity of OCD was assessed with the first 10–items of the Yale–Brown Obsessive Compulsive Scale (Y–BOCS) and score for item # 11 on the Y–BOCS was considered as a measure of insight. Alexithymia was measured with 20–item Toronto Alexithymia Scale (TAS–20). Additional measures were Maudsley Hospital Obsessive Compulsive Inventory (MOCI) and Montgomery Åsberg Depression Rating Scale (MADRS).

Results

Of the patients, 29.5% showed poor or no insight. Patients with poor or no insight were more alexithymic than patients with excellent, good and moderate insight. TAS–20 total score and subfactors positively correlated with score for item # 11 on the Y–BOCS, severity of OCD and MADRS scores. In stepwise regression model, MADRS scores, factor 3 of TAS–20 (Externally Oriented Thinking), somatic and hoarding–saving obsessions were significantly associated with lower insight.

Conclusions

Results show a relationship between poor or absent insight and high alexithymia levels in OCD patients.     

Myth of the pure obsessional type in obsessive--compulsive disorder

Background: Several studies have identified discrete symptom dimensions in obsessive–compulsive disorder (OCD), derived from factor analyses of the individual items or symptom categories of the Yale–Brown Obsessive–Compulsive Scale Symptom Checklist (YBOCS‐SC). This study aims to extend previous work on the relationship between obsessions and compulsions by specifically including mental compulsions and reassurance‐seeking. Because these compulsions have traditionally been omitted from prior factor analytic studies, their association to what have been called “pure obsessions” may have been overlooked. Method: Participants ( N =201) were recruited from two multi‐site randomized clinical treatment trials for OCD. The YBOCS‐SC was used to assess OCD symptoms, as it includes a comprehensive list of obsessions and compulsions, arranged by content category. Each category was given a score based on whether symptoms were present and if the symptom was a primary target of clinical concern, and a factor analysis was conducted. Mental compulsions and reassurance‐seeking were considered separate categories for the analysis. Results: Using an orthogonal geomin rotation of 16 YBOCS‐SC categories/items, we found a five‐factor solution that explained 67% of the total variance. Inspection of items that composed each factor suggests five familiar constructs, with mental compulsions and reassurance‐seeking included with sexual, aggressive, and religious obsessions (unacceptable/taboo thoughts). Conclusions: This study suggests that the concept of the “pure obsessional” (e.g., patients with unacceptable/taboo thoughts yet no compulsions) may be a misnomer, as these obsessions were factorially associated with mental compulsions and reassurance‐seeking in these samples. These findings may have implications for DSM‐5 diagnostic criteria. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Obsessive-compulsive disorder with and without tics in a clinical sample of children and adolescents

The purpose of this study was to discriminate subtypes of obsessive-compulsive disorder (OCD) in a clinical sample of children and adolescents. Sixty OCD patients were assessed in two outpatient psychiatric clinics; 15 patients had a lifetime history of tics and 45 patients had no tic history. Interviews were conducted with the patients and their parents by a child psychiatrist using the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). The symptom checklist of the CY-BOCS was used to categorize obsessions and compulsions. Discriminant function analysis was used to compare the two groups in their symptomatology. There was no difference between the two groups in seven obsession categories. However, there was a significant difference between the two groups in seven compulsion categories. Ordering, hoarding, and washing compulsions were more common in those with no tic history. The results indicate that tic-related OCD may be differentiated from non-tic-related OCD early in life by the presence or absence of certain compulsive symptoms.     

Repetitive Behaviour in Children with High Functioning Autism and Obsessive Compulsive Disorder

Children with Autism Spectrum Disorders (ASD) and children with Obsessive Compulsive Disorder (OCD) were compared on a range of repetitive behaviours. Parents reported similar levels of sameness behaviour and repetitive movements in the clinical groups, although children with OCD engaged in more repetitive behaviour focussed around routines and rituals. Children with OCD reported more compulsions and obsessions than children with ASD; both groups reported more compulsions and obsessions than a typically developing comparison group. Types of compulsions and obsessions tended to be less sophisticated in children with ASD than those with OCD. Sameness behaviour was more prevalent in younger children with OCD, but for children with ASD, age was not significantly related to sameness behaviour, repetitive movements, compulsions, or obsessions.     

Neuroendocrine and behavioral responses to challenge with the indirect serotonin agonist dl-fenfluramine in adults with obsessive-compulsive disorder.

Neuroendocrine and behavioral responses to a single 60-mg oral dose of the indirect serotonin agonist dl-fenfluramine were assessed in unmedicated adults with obsessive-compulsive disorder (OCD) and neuroendocrine results contrasted with those in normal control subjects. Net fenfluramine-induced prolactin release did not differ significantly between OCD patients and normal controls. Prolactin responses in the OCD group were not significantly correlated with baseline Yale-Brown Obsessive Compulsive Scale scores for either obsessions or compulsions, but were positively correlated with the baseline Hamilton Depression Scale score and Hamilton Anxiety Scale score. No clear difference in the severity of patients' obsessions or compulsions was found following challenge with fenfluramine versus placebo. Although the present study does not demonstrate a serotonergic abnormality in OCD, this may be more a reflection of limitations of the test procedures than evidence that central nervous system (CNS) serotonergic function is normal in the disorder.     

Group behavioral therapy for adolescents with tic-related and non-tic-related obsessive-compulsive disorder

Prior research supports the distinction between tic-related and non-tic-related obsessive-compulsive disorder (OCD) based on phenomenologic, etiologic, and neurobehavioral data. The present study examines whether response to psychosocial treatment differs in adolescents, depending on the presence of comorbid tics. Nineteen adolescents, 12-17 years of age, participated in 7-week, uncontrolled trial of group cognitive-behavioral treatment (CBT) for OCD. Eight of the patients had tic-related and eleven had non-tic-related OCD. The group CBT program included psycho-education, exposure and response prevention, cognitive strategies, and family involvement. Significant improvement was observed for all subjects on the Yale-Brown Obsessive Compulsive Scale ratings of obsessions, compulsions, and total OCD symptoms. Outcomes were similar for subjects with tic-related and non-tic-related OCD. These preliminary results suggest that the presence of comorbid tic disorders may not attenuate response to behavioral group treatment among adolescents.     

Adults with early-onset obsessive-compulsive disorder.

OBJECTIVE: Obsessive-compulsive disorder (OCD) is a clinically heterogeneous disorder with a bimodal age at onset and range of treatment outcomes. This study attempted to ascertain the importance of the age at OCD symptom onset for a better phenotypic precision. Therefore, the authors compared adult OCD patients with an early symptom onset to OCD patients with a later symptom onset. METHOD: Forty-two adult outpatients with OCD were evaluated with semistructured interviews: 21 with symptom onset before the age of 10 (early-onset group) and 21 with symptom onset after the age of 17 (late-onset group). RESULTS: Early onset was associated with higher scores on the Yale-Brown Obsessive Compulsive Scale, higher frequencies of tic-like compulsions, higher frequency of sensory phenomena, and a higher rate of comorbid tic disorders. The early-onset group also responded less well to treatment with clomipramine and selective serotonin reuptake inhibitors. CONCLUSIONS: The results indicate that age at onset may be an important factor in subtyping OCD and that the phenotypic differences found were not restricted to childhood.     

Atypical symptom presentations in children and adolescents with obsessive compulsive disorder

BackgroundCommon symptom presentations in youth with Obsessive Compulsive Disorder (OCD) are easily recognized and are included in the Children's Yale Brown Obsessive Compulsive Scale (CY-BOCS) symptom checklist. However, some youth may occasionally present with atypical or unusual symptoms that are less readily recognized as OCD and may be confused with other disorders that sometimes overlap, such as autism spectrum disorder or even psychosis.MethodsCase synopses which are thematically linked and exemplify and illustrate two distinct types of unusual or atypical symptom presentations are described. These symptoms are embedded in the subjects' broader clinical picture, that more correctly identifies the atypical symptoms as a variant feature of OCD rather than some other diagnostic condition.ResultsWe describe twenty-four children with OCD. Twelve children had obsessions related to adverse experiences of places, times or other people that were felt as horrific, abhorrent or disgusting. These obsessions led to contamination fears of any thoughts or actions associated with those places, events or people. In those whose OCD was a reaction to another person, the contamination obsession often took the form of fear of acquiring an unwanted trait or characteristic by association, which was then avoided. Twelve other youth had obsessions driven by a primary sensory experience that was intolerable, including tactile, olfactory, and auditory stimuli. These sensory experiences were sometimes linked to specific objects or people, driving time-consuming repetitive behaviors to avoid or alleviate the sensory discomfort.ConclusionRecognition of atypical presentations of OCD, such as fear of contamination by association with adverse experiences and primary sensory intolerance leading to OCD will help clinicians to better identify and treat these unique symptoms.     

Prevalence of obsessive compulsive symptoms (OCS) in a sample of Egyptian adolescents

The aim of this work was to determine the prevalence of OCS among a community sample of Egyptian students. The sample was selected using a multistage stratified random sample of students from El Abasseya educational area in Cairo. The tools used in this study included the General Health Questionnaire for screening of psychiatric morbidity and the Arabic Obsessive Scale for obsessive traits. The Yale Brown Obsessive Compulsive Scale was used to determine the profile of OCS and the ICD-10 research criteria for diagnosis of OCD among OCS positive subjects. The prevalence of psychiatric morbidity among the total sample was 51.7%, whilst that of obsessive traits was 26.2% and that of obsessive compulsive symptoms was 43.1%. OCS were more prevalent among the younger students, among female students and first born subjects. Aggressive, contamination and religious obsessions and cleaning compulsions were the commonest among the sample; 19.6% of subjects with OCS fulfilled ICD-10 criteria for OCD.     

Situation awareness in obsessive-compulsive disorder

Past studies have suggested that OCD patients suffer memory impairment on tasks using complex stimuli that require memory for combined elements to be maintained, but not for more simplistic memory tests. We tested this with 42 OCD patients and 42 healthy controls performed a computerized situation awareness task. In addition, participants completed the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) and Maudsley Obsessive-Compulsive Inventory (MOCI). The OCD patients had poorer accuracy in integration/comprehension and perception levels than controls. There were significant correlations between situational awareness scores (i.e., visuo-spatial monitoring and processing) and Y-BOCS obsession–compulsion and slowness and doubt scores of MOCI in OCD patients. In addition, there were also significant correlations between situational awareness and controlling, cleaning, slowness, rumination and total scores of MOCI in control group. Results indicated that (I) OCD patients have problems of perception, integration, and comprehension of complex visual perceptions; (II) situation awareness deficits associated with severity and prevalence of obsessions and compulsions.     

The Yale-Brown Obsessive Compulsive Scale: factor analysis, construct validity, and suggestions for refinement

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is widely acknowledged as the gold standard measure of obsessive-compulsive disorder (OCD) symptom severity. Despite its popularity, a number of questions remain regarding the Y-BOCS' psychometric properties including: (a) whether obsessional and compulsive symptoms contribute independently to global OCD severity and (b) whether the Y-BOCS subscales are valid with respect to other measures of OCD. We examined these issues in a sample of 100 patients with a diagnosis of OCD. While our confirmatory factor analyses failed to reproduce any previously reported models of the Y-BOCS factor structure, exploratory factor analysis indicated a two-factor solution that assessed symptom severity (i.e., time, distress, and interference from obsessions and compulsions) as separate from resistance and control of obsessions and compulsions. In contrast to the Resistance/Control Subscale, the Severity Subscale demonstrated good psychometric properties and construct validity. Based on our findings we recommend revisions to scoring the Y-BOCS.     

Symptom dimensions in obsessive-compulsive disorder: factor analysis on a clinician-rated scale and a self-report measure

Although obsessive-compulsive disorder (OCD) is regarded as a unitary nosological entity, it encompasses a rich variety of heterogeneous mental and behavioural phenomena. The identification of clinical subtypes within this broad concept has been a focus of attention in recent years. In the present study, we administered a clinician-rated scale, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) with the Y-BOCS Symptom Checklist (Y-BOCS CL), as well as a self-report questionnaire, the Padua Inventory revised (PI-R), to 150 outpatients with OCD. A principal component analysis on the Y-BOCS CL, along with the PI-R, identified 6 consistent symptom clusters: (1) contamination obsessions and cleaning compulsions, (2) sexual/religious/somatic obsessions and checking, (3) high risk assessment and checking, (4) impulses and fear of loss of control, (5) need for symmetry and exactness, and ordering and counting compulsions, and finally (6) rumination. The Y-BOCS CL and PI-R showed great overlap and consistency regarding content and severity of the OCD symptoms. On inspection of items with identical content, only half of the items showed significant agreement. Both inventories have unique factors: rumination is represented solely in the PI-R, somatic obsessions and checking solely in the Y-BOCS CL. This means that the use of both clinician-administered and self-report measures is recommended, so that the entire spectrum of symptoms is represented.     

Symptom correspondence between clinicians and patients on the Yale–Brown Obsessive Compulsive Scale

The present study examined concordance between the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) and its self-report version (Y-BOCS-SR), as well as theoretically derived moderators. Sixty-seven adults (ages 18–67) with obsessive–compulsive disorder (OCD) were administered the Y-BOCS prior to completing self-report measures. The Y-BOCS-SR generated lower scores relative to the clinician-administered Y-BOCS (5.3 points lower). Strong correspondence was shown between the Y-BOCS and Y-BOCS-SR; however, many items exhibited fair to moderate agreement, particularly the resistance and control against obsessions/compulsions items. Depression significantly moderated correspondence such that Y-BOCS-SR scores significantly predicted Y-BOCS scores in the presence of low and average depression levels in our sample, but not for patients with high levels of depression relative to the rest of our sample; gender, generalized anxiety and obsessionality did not significantly impact agreement. Synthesizing the present data, the Y-BOCS-SR demonstrates modest agreement with the Y-BOCS and may underestimate clinical severity especially for those with high levels of depression.     

The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication

Despite significant advances in the study of obsessive-compulsive disorder (OCD), important questions remain about the disorder's public health significance, appropriate diagnostic classification, and clinical heterogeneity. These issues were explored using data from the National Comorbidity Survey Replication, a nationally representative survey of US adults. A subsample of 2073 respondents was assessed for lifetime Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) OCD. More than one quarter of respondents reported experiencing obsessions or compulsions at some time in their lives. While conditional probability of OCD was strongly associated with the number of obsessions and compulsions reported, only small proportions of respondents met full DSM-IV criteria for lifetime (2.3%) or 12-month (1.2%) OCD. OCD is associated with substantial comorbidity, not only with anxiety and mood disorders but also with impulse-control and substance use disorders. Severity of OCD, assessed by an adapted version of the Yale-Brown Obsessive Compulsive Scale, is associated with poor insight, high comorbidity, high role impairment, and high probability of seeking treatment. The high prevalence of subthreshold OCD symptoms may help explain past inconsistencies in prevalence estimates across surveys and suggests that the public health burden of OCD may be greater than its low prevalence implies. Evidence of a preponderance of early onset cases in men, high comorbidity with a wide range of disorders, and reliable associations between disorder severity and key outcomes may have implications for how OCD is classified in DSM-V.     

Gender-related differences among Turkish patients with obsessive-compulsive disorder

The purpose of the present study was to investigate gender-related sociodemographic and clinical differences among Turkish patients with obsessive-compulsive disorder (OCD). A total of 169 patients diagnosed with OCD by DSM-III-R or DSM-IV criteria were included in this study. Male (n = 73) and female (n = 96) OCD patients were compared with respect to the demographic variables and the scores obtained from the Hamilton Rating Scale for Anxiety (HRSA), the Hamilton Rating Scale for Depression (HRSD) and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). We found a significantly earlier age at onset in male patients. No significant difference in terms of HARS, HDRS, and Y-BOCS scores was detected between the two groups. We observed a significantly higher frequency of contamination obsessions in females, and that of aggression and sexual obsessions in males. There was no significant difference in terms of the frequency of compulsions between the two groups. We also found that compulsion severity on obsessions/compulsions was higher in females and comorbidity rates of social phobia and schizophrenia were higher in males. Considering our results in combination with those of other studies, similarities rather than differences in gender-related sociodemographic and clinical characteristics of OCD patients across different populations seem to be present.     

Obsessive-compulsive disorder in youth with and without a chronic tic disorder

The goal of this study was to discriminate subtypes of pediatric obsessive-compulsive disorder (OCD) among youth with and without a comorbid tic disorder. Seventy-four youth (M(age)=9.7+/-2.3 years) with a principal diagnosis of OCD, with (n=46) or without (n=28) a comorbid tic disorder, were assessed with a semi-structured diagnostic interview and the Children's Yale Brown Obsessive-Compulsive Scale (CY-BOCS). The CY-BOCS Symptom Checklist was used to categorize obsessions and compulsions. Group differences were analyzed by t tests, chi(2), and discriminant function analyses. Results suggested that subjects without tics had significantly more contamination obsessions, sexual obsessions, and counting compulsions than youth with comorbid tics. Generally speaking, however, youth with and without tics had similar symptom presentations. These data suggest that pediatric OCD patients with and without comorbid tics may have some aspects of symptom presentation that differ, but generally have more OCD symptoms in common than different. Implications of these findings on clinical presentation and treatment efficacy are highlighted.     

The role of perfectionism in obsessive–compulsive symptoms: “Not just right” experiences and checking compulsions

Perfectionism has long been considered an important cognitive variable in obsessive–compulsive disorder (OCD). However, little research has examined the components of perfectionism and their role in specific OCD symptoms. The current study is the first to examine the role of maladaptive perfectionism in predicting checking compulsions and “not just right” (NJR) obsessions. Using an undergraduate sample, linear structural relations were applied to these constructs. A mediational model was tested, where trait anxiety was hypothesized to mediate the relationship between obsessive–compulsive symptoms, as assessed with the Vancouver Obsessive–Compulsive Inventory (VOCI) and maladaptive perfectionism, as measured by four subscales of the Frost Multidimensional Perfectionism Scale (FMPS). Trait anxiety was assessed with the Spielberger State-Trait Anxiety Inventory (STAI). The results support the fully mediated model for checking and NJR compulsions. These findings suggest that perfectionism plays a specific role in certain forms of obsessive–compulsive symptoms, and that the model of OCD requires adjustment to account for this specificity.     

Sensory phenomena associated with repetitive behaviors in obsessive-compulsive disorder: an exploratory study of 1001 patients

A substantial number of patients with obsessive-compulsive disorder (OCD) report compulsions that are preceded not by obsessions but by subjective experiences known as sensory phenomena. This study aimed to investigate the frequency, severity, and age at onset of sensory phenomena in OCD, as well as to compare OCD patients with and without sensory phenomena in terms of clinical characteristics. We assessed 1,001 consecutive OCD patients, using instruments designed to evaluate the frequency/severity of OC symptoms, tics, anxiety, depression, level of insight and presence/severity of sensory phenomena. All together, 651 (65.0%) subjects reported at least one type of sensory phenomena preceding the repetitive behaviors. Considering the sensory phenomena subtypes, 371 (57.0%) patients had musculoskeletal sensations, 519 (79.7%) had externally triggered "just-right" perceptions, 176 (27.0%) presented internally triggered "just right," 144 (22.1%) had an "energy release," and 240 (36.9%) patients had an "urge only" phenomenon. Sensory phenomena were described as being as more severe than were obsessions by 102(15.7%) patients. Logistic regression analysis showed that the following characteristics were associated with the presence of sensory phenomena: higher frequency and greater severity of the symmetry/ordering/arranging and contamination/washing symptom dimensions; comorbid Tourette syndrome, and a family history of tic disorders. These data suggest that sensory phenomena constitute a poorly understood psychopathological aspect of OCD that merits further investigation.     

Lack of effect of intravenous immunoglobulins on tics: a double-blind placebo-controlled study

BACKGROUND: Case studies and a placebo-controlled study previously suggested the effectiveness of immunomodulatory therapy in patients with tic or related disorders whose symptoms show a relationship with streptococcal infections. No data are available on the effectiveness of intravenous immunoglobulins (IVIG) on tic severity in unselected tic disorder patients. METHOD: Thirty patients with a DSM-IV tic disorder were randomly assigned to IVIG (1 g/kg on 2 consecutive days; mean age = 28.71 years; range, 14-53 years) or placebo (mean age = 30.73 years; range, 14-63 years). Symptoms were rated with the Yale Global Tic Severity Scale, the Yale-Brown Obsessive Compulsive Scale, and the Clinical Global Impressions scale of symptom change with regard to tic severity. These were used at baseline and on weeks 2, 4, 6, 10, and 14 posttreatment, after which blinding was broken. The study was conducted from March through August 2002. RESULTS: We observed no significant differences between both treatment groups regarding posttreatment changes in tic severity. Severity of obsessions and compulsions, which was in the subclinical range, decreased significantly in the IVIG group compared with the placebo group at week 6 (p =.02). Then, there was a 32.3% improvement in the IVIG group compared with baseline. Though this improvement was maintained over the following 8 weeks, no statistically significant differences between the IVIG and the placebo group with regard to improvements in obsessions and compulsions were detected at subsequent assessments. IVIG treatment was associated with significantly more side effects than placebo, most notably headache. CONCLUSION: Based on the present results, IVIG cannot be recommended in tic disorders.     

Acute onset and remission of obsessions and compulsions following medical illnesses and stress

Obsessive Compulsive Disorder (OCD) is generally chronic. Episodic OCD with complete remission has been rarely reported. Two cases of brief, episodic obsessions and compulsions that appeared for the first time following psychological stress and in the context of medical illness are reported. The possibility of brief episodes of OCD precipitated by stress is illustrated. Exploration of this phenomenon may help us learn more about OCD in general.