Gilles de la Tourette's syndrome with and without obsessive-compulsive disorder compared with obsessive-compulsive disorder without tics: which symptoms discriminate?

Stereotyped repetitive behaviors occur in Gilles de la Tourette's Syndrome (GTS) and obsessive-compulsive disorder (OCD). The present study was undertaken to compare the distribution of obsessive-compulsive and Tourette-related impulsive behaviors in GTS with (+) OCD, GTS without (-) OCD, tic-free OCD, and control subjects. Fourteen GTS + OCD, 18 GTS-OCD, 21 OCD-tic, and 29 control subjects were evaluated using a semistructured interview designed to assess GTS and OCD-related repetitive behaviors. Each reported item was evaluated on the presence of anxiety and goal-directedness. This information was subsequently used to define whether the repetitive behavior was an (anxiety-related) obsession or compulsion, or a (non-anxiety-related) OC-like behavior, impulsion. GTS + OCD subjects reported more overall Tourette-related impulsions than OCD-tic subjects, i.e., more mental play, echophenomena, and touching behaviors but similar frequencies of typical obsessive-compulsive behaviors. Further, GTS + OCD subjects exhibited more overall repetitive behaviors than GTS-OCD subjects, i.e., more Tourette-related impulsions as well as more obsessive-compulsive behaviors. The distribution of symptoms is similar in GTS with and without OCD, and differs from tic-free OCD. These differences suggest that GTS with OCD constitutes a form of GTS, not of OCD, although the possibility that GTS + OCD patients constitute a subgroup distinct from GTS and from OCD can not be excluded by this phenomenological study. Specific non-anxiety-related impulsions seem to discriminate between GTS and OCD-tic individuals. These impulsions possibly reflect differences in underlying mechanisms between GTS and OCD-tics.     

Is obsessive-compulsive disorder an anxiety disorder?

Obsessive-compulsive disorder (OCD) is classified as an anxiety disorder in the DSM-IV-TR [American Psychiatric Association, 2000. Diagnostic and statistical manual of mental disorders, Fourth ed., rev. Washington, DC: Author]; however, the notion of a spectrum of obsessive-compulsive (OC) related disorders that is comprised of such disparate disorders as OCD, body dysmorphic disorder, certain eating disorders, pathological gambling, and autism, is gaining acceptance. The fact that these disorders share obsessive-compulsive features and evidence similarities in patient characteristics, course, comorbidity, neurobiology, and treatment response raises the question of whether OCD is best conceptualized as an anxiety or an OC spectrum disorder. This article reviews evidence from comorbidity and family studies, as well as biological evidence related to neurocircuitry, neurotransmitter function, and pharmacologic treatment response that bear on this question. The implications of removing OCD from the anxiety disorders category and moving it to an OC spectrum disorders category, as is being proposed for the DSM-V, is discussed.     

Patients with obsessive-compulsive disorder and hoarding symptoms: a distinctive clinical subtype?

We investigated whether patients with obsessive-compulsive disorder (OCD) and hoarding symptoms can be differentiated from their counterparts with other types of obsessions and compulsions in terms of sociodemographic and clinical features. Ninety-seven patients with OCD were assessed with a sociodemographic and clinical questionnaire, the Structured Clinical Interview for DSM-IV (SCID-I), the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI), the Hamilton Rating Scale for Depression (HDRS), and the Global Assessment of Functioning (GAF). Fifteen patients who reported hoarding symptoms in the Y-BOCS checklist (15.6% of the total sample) were compared and contrasted with 82 patients without those symptoms using the Mann-Whitney U test for continuous variables and the Pearson's goodness-of-fit chi-square test for categorical ones; Fisher's exact test was employed when indicated. Hoarders were characterized by (1) higher educational levels (chi(2) = 7.49; df = 2; P =.02); (2) earlier age at onset (Z = -2.99; P =.003); (3) higher rates of symmetry obsessions (chi(2) = 7.03; df = 1; P =.01); (4) greater frequency of ordering (chi(2) = 10.08; df = 1; P =.004); (5) rituals repetition (chi(2) = 4.42; df = 1; P =.03); (6) counting compulsions (chi(2) = 5.92; df = 1; P =.02); and (7) significantly higher rates of comorbidity with bipolar II disorder (chi(2) = 10.62; df = 1; P =.02) and (8) with eating disorders (chi(2) = 7.42; df = 1; P =.02). In conclusion, patients with OCD exhibiting hoarding feature a distinctive sociodemographic and clinical profile. It remains to be investigated whether these phenotypical characteristics are underlined by specific neurobiological mechanisms.     

Is cognitive enhancement therapy equally effective for patients with schizophrenia and schizoaffective disorder?

Patients with schizoaffective disorder (SZA) experience significant deficits in cognitive functioning similar to those seen in patients with schizophrenia (SZ), which are associated with poor functional outcomes. Cognitive remediation (CR) has shown promise in improving cognitive and functional outcomes in patients with SZ: however, no studies have compared these effects across diagnoses. We compared patients with SZ and SZA after cognitive enhancement therapy (CET) or enriched supportive therapy (EST). Both patient groups improved in multiple domains after CET, and diagnosis did not significantly moderate this relationship. Extending CR to all patients in which cognitive dysfunction is a core feature may be indicated.     

Psychotherapy for obsessive-compulsive disorder: what is evidence based?

Obsessive-compulsive disorder is a severe, very disabling condition that usually takes a chronic course if no adequate treatment is applied. Up to now, cognitive behavioural therapy with exposure and response prevention (CBT) is the most thoroughly investigated and most effective intervention, leading to a clinically significant symptom reduction in 60-70% of the patients. Correctly applied, this treatment can be equally effective as its combination with pharmacological management. For a correct implementation, however, several points have to be considered which are described in the following review. Considering the fact that some of the patients are unable to benefit sufficiently from this approach, potential alternatives and extensions of CBT are discussed. To date, however, no other treatment approach has proven to be effective based on randomised controlled trials.     

Tic disorders and obsessive-compulsive disorder: is autoimmunity involved?

The precise cause of tic disorders and paediatric obsessive-compulsive disorder (OCD) is unknown. In addition to genetic factors, autoimmunity may play a role, possibly as a sequela of preceding streptococcal throat infections in susceptible children. Here we review the most recent findings, from July 2003 onwards, with regard to a possible relationship between tics/OCD and autoimmunity. Evidence about an intriguing correlation between streptococcal infections and tic disorders and OCD is accumulating. Specific criteria have been outlined for paediatric autoimmune disorders associated with streptococcal infections (PANDAS), but autoimmunity may also be involved in tic disorders and/or OCD in general. Anti-basal ganglia auto-antibodies are an important potential indicator of autoimmunity. Although the lack of a standardized methodology makes comparisons of findings difficult, new data has emerged pointing to the possible involvement of specific auto-antigens. Earlier findings of increased D8/17 B cell expression as a putative susceptibility marker could not be replicated, possibly due to instability of the D8/17-binding antibody. Although PANDAS patients have been reported to improve after therapeutic plasma exchange, and antibiotics may prevent symptom exacerbations, immune-based treatments should not be routinely given. In future studies, demonstrating the pathogenetic significance of anti-basal ganglia antibodies in animals is a major challenge to draw any firm conclusions about a role for autoimmunity. Future longitudinal studies should be aimed at assessing the precise relationship between symptom exacerbations, infections, and immune parameters, possibly along with gene expression profiles.     

Tic disorders and obsessive-compulsive disorder: Is autoimmunity involved?

The precise cause of tic disorders and paediatric obsessive-compulsive disorder (OCD) is unknown. In addition to genetic factors, autoimmunity may play a role, possibly as a sequela of preceding streptococcal throat infections in susceptible children. Here we review the most recent findings, from July 2003 onwards, with regard to a possible relationship between tics/OCD and autoimmunity. Evidence about an intriguing correlation between streptococcal infections and tic disorders and OCD is accumulating. Specific criteria have been outlined for paediatric autoimmune disorders associated with streptococcal infections (PANDAS), but autoimmunity may also be involved in tic disorders and/or OCD in general. Anti-basal ganglia auto-antibodies are an important potential indicator of autoimmunity. Although the lack of a standardized methodology makes comparisons of findings difficult, new data has emerged pointing to the possible involvement of specific auto-antigens. Earlier findings of increased D8/17 B cell expression as a putative susceptibility marker could not be replicated, possibly due to instability of the D8/17-binding antibody. Although PANDAS patients have been reported to improve after therapeutic plasma exchange, and antibiotics may prevent symptom exacerbations, immune-based treatments should not be routinely given. In future studies, demonstrating the pathogenetic significance of anti-basal ganglia antibodies in animals is a major challenge to draw any firm conclusions about a role for autoimmunity. Future longitudinal studies should be aimed at assessing the precise relationship between symptom exacerbations, infections, and immune parameters, possibly along with gene expression profiles.     

How specific are inhibitory deficits to obsessive-compulsive disorder? A neurophysiological comparison with panic disorder

ObjectiveImpaired inhibition may perpetuate repetitive symptoms in obsessive-compulsive disorder (OCD), however OCD-specific deficits have yet to be established. We investigated neural correlates of inhibition in OCD vs. healthy and anxious controls.MethodsERPs and reaction times (RTs) were compared between participants with OCD (n = 20), panic disorder (PD; n = 20) and healthy controls (HCs; n = 20) during an adapted Go/NoGo task, which manipulated inhibitory difficulty.ResultsA classic P3 NoGo anteriorisation effect occurred across groups. Both clinical groups showed RT impairment, and similar topographical anomalies of several (P2, N2 and P3) ERP components. Notably, both clinical groups lacked the strong frontally maximal N2 component topography seen in the HCs, across stimuli. Additionally, with increasing inhibitory difficulty, N2 latency increased in HCs but not in the clinical groups.ConclusionsUnexpectedly, ERP and behavioural anomalies during inhibition in OCD were not qualitatively different to those in PD, but were generally more severe. Common general and inhibitory deficits may underlie intrusive mental phenomena in both conditions.SignificanceThis first ERP response inhibition study in OCD to include anxious controls disconfirmed hypotheses regarding OCD-specific inhibitory deficits, indicating the importance of comparing OCD to other conditions, to evaluate neurobiological models.     

Are people with social anxiety disorder happier alone?

Quality contact with other people serves as a reliable mood enhancement strategy. We wondered if the emotional benefits of socializing are present even for those with a psychological disorder defined by social distress and avoidance: social anxiety disorder (SAD). We conducted two ecological momentary assessment (EMA) studies and analyzed 7243 total surveys. In both studies, community adults diagnosed with SAD and healthy controls received five surveys each day for 2 weeks. Consistent with research on positivity deficits in SAD, between-person analyses in both studies suggest that, on average, participants with SAD reported lower positive and higher negative affect in social and non-social situations than healthy controls. Within-person analyses, however, revealed that in both studies participants with SAD and healthy controls reported higher positive affect when with others than when alone; no differences were found for negative affect for those with SAD. The difference in positive affect between social and nonsocial situations was smaller for participants with SAD in Study 1, suggesting that people with SAD may experience diminished reward responding when socializing. Our results suggest that even those with a mental illness defined by interpersonal distress can and do derive positive emotions from social interactions.     

Is there a relationship between Parkinson's disease and obsessive-compulsive disorder?

Obsessive-compulsive (OC) symptoms and obsessive-compulsive disorder (OCD) have been reported in Parkinson's disease (PD). This is interpreted as an indirect evidence for the involvement of frontobasal ganglia circuitry in OCD. However, the evidence for relationship between the OC symptoms and PD is inconsistent. This study systematically assessed OC symptoms and OCD in non-demented idiopathic PD patients (n=69) and matched medically ill controls (n=69). The cases did not differ from controls with respect to OC symptoms, clinical and subclinical OCD, tics and other psychiatric diagnoses. There was no relationship between severity of PD and OC symptoms. The findings do not support relationship between OCD and PD. While the findings of this study do not in any way rule out the involvement of frontobasal ganglia circuitry in OCD, it is speculated that the involvement of different circuitry in the pathophysiology of OCD and PD explain the lack of association between PD and OCD.     

Psychodynamic and cognitive-behavioral approaches of obsessive-compulsive disorder: is it time to work through our ambivalence?

This paper provides an overview of the growing convergence among psychodynamic and cognitive-behavioral approaches of Obsessive-Compulsive Disorder (OCD). From a traditional psychoanalytic point of view, OCD is mainly conceptualized in terms of a constant conflict between feelings of love and hate. More recent psychodynamic theories of OCD, such as the object-relational model, focus on the role of ambivalent mental representations or cognitive-affective schemas of self and others. This notion of mental representations or schemas links psychodynamic formulations to cognitive-behavioral approaches of OCD. Moreover, there is increasing overlap between psychodynamic and cognitive-behavioral models concerning the core dynamics involved in OCD. Implications of this convergence for future research and clinical practice are discussed.     

Do the traits of autism-spectrum overlap with those of schizophrenia or obsessive-compulsive disorder in the general population?

Social and communicative deficits, restricted interests and repetitive behaviors are diagnostic features of autism spectrum disorders (ASD). The present study examined the relationship between autistic characteristics and schizophrenia-spectrum traits as well as between autistic characteristics and obsessive-compulsive traits in typically developed young adults. The Autism-Spectrum Quotient (AQ) was given separately to two large samples. In addition, one sample (N = 662) was given the Schizotypal Personality Questionnaire (SPQ) to assess schizophrenia-spectrum traits, whereas the other sample (N = 347) was given the Padua Inventory (PI) to assess obsessive-compulsive disorder (OCD) traits. The results revealed a moderate correlation between the AQ and the SPQ total scores; however, multiple regression analyses showed that the “Cognitive-Perceptual” factor did not predict the autism-spectrum degree, although autistic characteristics and schizophrenia-spectrum traits had common social-emotional difficulties. Similarly, there was a moderate correlation between the AQ and PI total scores, which suggests that they had common problems in cognitive aspects; however, autism-spectrum and OCD traits differed with regard to other behavioral characteristics including repetitive or impulsive behaviors. Therefore, there was not a large overlap of the autism-spectrum and either the schizophrenia- or obsessive-compulsive spectrums, although certain traits were correlated with each other.     

Symptom subtypes of obsessive-compulsive disorder: are they relevant for treatment?

Several symptom subtypes of obsessive-compulsive disorder (OCD) have been identified on the basis of the predominant obsessions and compulsions. The objectives of the present article were to review the literature on the relationship between OCD symptom subtypes and treatment response and to suggest strategies that might assist with the choice of treatment and improve treatment outcome in patients with various subtypes. An extensive literature search was performed, relevant studies were identified, and their results reported. Overt compulsions were generally associated with a relatively good response to the behaviour therapy technique of exposure and response prevention (ERP) and with poorer response to serotonin re-uptake inhibitors (SRIs). Washing/cleaning and checking compulsions tend to respond well to ERP, whereas the majority of studies show that washing/cleaning compulsions are associated with a poorer response to SRIs. Most studies suggest that patients with the symmetry, ordering and arranging subtype do not fare worse with ERP and SRIs than patients with other symptom subtypes. Some studies suggested that obsessions might respond to SRIs somewhat better than to ERP. In the majority of the studies, hoarding and the subtype characterized by sexual or religious obsessions and absence of overt compulsions ('pure obsessions') have been associated with poor response to ERP and SRIs. It was concluded that treatment strategies cannot be precisely tailored to OCD symptom subtypes. Many other factors influence the outcome of treatment and need to be considered along with the symptom subtypes when making decisions about treatment. While ERP and SRIs remain the mainstay of treatment regardless of the symptom subtype, the addition of cognitive therapy techniques and/or antipsychotic medications may enhance treatment response in the presence of certain features discussed in the article.     

How intensive does anomia therapy for people with aphasia need to be?

The intensity of aphasia therapy has been a key clinical question. The aim of this case-series study was to compare the outcome of intensive and non-intensive therapy in the relearning of words for people with aphasia. Eight participants took part in a study comparing the intensity of delivery of the therapy. Participants received two courses of the same therapy (each lasting 10 sessions) delivered either intensively or non-intensively. Therapy consisted of confrontation naming with progressive phonemic and orthographic cues. Post-therapy assessments were carried out immediately after the study and one month later. Performance was also monitored during each therapy session. Immediately post-therapy, both types of therapy had improved naming accuracy considerably and there was no significant difference between the two interventions. One month later, seven out of eight participants showed a small yet significant difference in naming accuracy, favouring non-intensive over intense therapy. There were no differences in the learning patterns during the therapy sessions between the intensive and non-intensive therapies. For the majority of people with aphasia post-stroke, both intense and non-intense therapy for anomia leads to improved naming performance. Retention at one-month post therapy is relatively superior after non-intensive therapy.     

Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder?

Abstract. Juvenile obsessivecompulsive disorder (OCD) has been hypothesized to be different from adult-onset OCD suggesting that juvenile OCD may be a developmental subtype of the disorder. There is some evidence that juvenile OCD may be phenotypically different from juvenile-onset adult OCD. This study examines the phenotypic characteristics of juvenile OCD (current age 18 years, n = 39), juvenile-onset adult OCD (onset 18 years,cur rent age>18 years, n = 87) and adult-onset OCD (onset > 18 years, n = 105). Qualified psychiatrists expert in evaluating OCD subjects conducted clinical and structured interviews. In the multinomial logistic regression analysis, controlling for chronological age and gender, the juvenile OCD was associated with male preponderance, elev ated rates of certain obsessive-compulsive symptoms, a ttention-deficit hyperactivity disorder, chronic tics, body dysmorphic disorder and major depression. In addition, juvenile-onset adult OCD differed from juvenile OCD by having later age-atonset and low rate of ADHD. The juvenile-onset adult OCD was positively associated with social phobia and chronic tics compared to adult-onset OCD. The juvenile OCD appears to be different from both juvenile-onset adult OCD and adult-onset OCD supporting previous observations that juvenile OCD could be a developmental subtype of the disorder.