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ANXIETY DISORDERS

Obsessive-compulsive spectrum disorders: a comorbidity and family history perspective


Vlasios Brakoulias, Vladan Starcevic, Peter Sammut, David Berle, Denise Milicevic, Karen Moses and Anthony Hannan

Objective: The concept of obsessive-compulsive spectrum disorders (OCSDs) has become so inuential that there are proposals to introduce it into new diagnostic classicatory systems. The aim of this paper was to assess whether rates of comorbidity and family history of OCSDs in patients with obsessivecompulsive disorder (OCD) supported this concept. Method: Comorbidity and family history were assessed in a group of participants with a primary diagnosis of OCD, using structured clinical interviews. Rates of OCSDs and other anxiety disorders (OADs), excluding OCD, were compared. Results: Of the 77 OCD participants assessed, the most prevalent comorbid conditions were OADs: generalized anxiety disorder (34.6%), specic phobia (26.9%), social phobia (21.8%) and panic disorder (19.2%). The proposed OCSDs were less frequently comorbid: tic disorder (12.8%), trichotillomania (5.1%), hypochondriasis (3.8%) and body dysmorphic disorder (BDD) (3.8%). Similar trends were observed for a family history of these disorders. No participant reported a family history of an OCSD without a family history of an OAD. Conclusions: Although the concept of OCSDs has invigorated thinking in this complex diagnostic eld, these results support the current association of OCD with OADs rather than with OCSDs.
Vlasios Brakoulias Lecturer and Staff Specialist, Discipline of Psychiatry, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia. Vladan Starcevic Associate Professor, Discipline of Psychiatry, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia. Peter Sammut Research Assistant, Discipline of Psychiatry, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia. David Berle Clinical Psychologist, Nepean Anxiety Disorders Clinic, Nepean Hospital, Sydney, NSW, Australia. Denise Milicevic Clinical Psychologist, Nepean Anxiety Disorders Clinic, Nepean Hospital, Sydney, NSW, Australia. Karen Moses Clinical Psychologist, Nepean Anxiety Disorders Clinic, Nepean Hospital, Sydney, NSW, Australia. Anthony Hannan Clinical Psychologist, Nepean Anxiety Disorders Clinic, Nepean Hospital, Sydney, NSW, Australia. Correspondence: Dr Vlasios Brakoulias, Department of Psychiatry, Nepean Hospital, PO Box 63, Penrith, NSW 2751, Australia. Email: vbrakoulias@bigpond.com

Key words: disorder.

comorbidity, diagnosis, family history, obsessive-compulsive

bsessive-compulsive spectrum disorders (OCSDs) were rst proposed by Hollander in 1993.1 Since then the concept has become so inuential that it is now being considered for inclusion in the fth Diagnostic and Statistical Manual of Mental Disorders (DSM-V) which is due for release in 2012.2 It was initially proposed that OCSDs included hypochondriasis, body dysmorphic disorder (BDD), tic disorder, Tourettes syndrome, impulse control disorders (trichotillomania, compulsive buying, kleptomania, sexual compulsions, self-injurious behaviour and pathological gambling), eating disorders, depersonalization disorder, schizo-obsessive disorders, Huntingtons disease, autism, epilepsy, Sydenhams chorea, borderline personality disorder and antisocial personality disorder.3 Since then, there has been increasing support for proposals that the spectrum should be more narrow and only include hypochondriasis, BDD, trichotillomania and tic disorders.4,5 The common characteristic of OCSDs is the inability to delay or inhibit repetitive behaviours.6 The disorders are thought to lie on a spectrum from impulsive to compulsive where impulsivity is said to persist due to decits in the ability to inhibit repetitive behaviour with known negative consequences, while compulsivity persists as a consequence of decits in recognizing completion of tasks.6

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doi: 10.3109/10398562.2010.526718 2011 The Royal Australian and New Zealand College of Psychiatrists

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Hollander et al.6 further assert that the OCSDs are: (i) highly comorbid with OCD, (ii) have common associated features (e.g., family histories, age of onset, course) with OCD, (iii) have similar abnormalities in neurocircuitry and neurotransmitter functioning as OCD, and (iv) respond to similar treatments as OCD. Comorbidity studies have conrmed high prevalence rates of some OCSDs in patients with OCD710 and their rst-degree relatives.8,11,12 However, this has not been the case with all OCSDs and one study reported no difference in rates of OCSDs between relatives of patients with OCD and relatives of a control group.13 In addition, comorbidity rates for major depressive disorder and anxiety disorders have been shown to be higher than those for OCSDs.5,14,15 This paper aims to test the hypothesis that: (i) OCSDs are highly comorbid with OCD compared with other anxiety disorders (OADs) and major depressive disorder, and (ii) OCSDs are highly prevalent in relatives of patients with OCD compared with the prevalence of OADs and major depressive disorder. For the purpose of this study, a narrow denition4,5 of OCSDs has been favoured and includes hypochondriasis, BDD, trichotillomania and tic disorder.

Table 1: Demographic and clinical characteristics of the sample n Mean age, years (SD) Sex, male (%) Marital status (%) Never married Married Mean age (years) at onset of OCD (SD) Mean Y-BOCS total score (SD) Primarya obsessions (%) Aggressive Contamination Hoarding Miscellaneous Sexual Symmetry/order Religious Primary compulsions (%) Washing/cleaning Checking Hoarding Counting Mental rituals Miscellaneous Repeating/arranging
aPrimary

77

44.3 (15.7) 33 (42.9) 27 (35.1) 28 (36.4) 16.6 (9.9) 23.0 (7.1) 32 (41.6) 19 (24.7) 9 (11.7) 7 (9.1) 5 (6.5) 5 (6.5) 1 (1.3) 22 (28.6) 19 (24.7) 10 (13.0) 10 (13.0) 7 (9.1) 7 (9.1) 2 (2.6)

METHODS
Subjects The Nepean OCD Study recruits participants with a primary diagnosis of OCD who are over the age of 18 and able to give informed consent. Participants were recruited from the Nepean Anxiety Disorders Clinic, general practitioners, private psychiatrists, OCD support groups and newspaper advertisements. Included in this study were 77 consecutive patients. Assessment After informed consent was obtained, participants were interviewed by a psychiatrist or clinical psychologist associated with the Nepean Anxiety Disorders Clinic, who had been trained in the use of diagnostic interviews. Inter-rater reliability for a subsample of the rst 40 participants where two clinicians rated the same patient independently was obtained using BlandAltman analysis.16 The assessment was conducted by clinicians who were not involved in treating the participant. Assessment tools included the MINI Neuropsychiatric Interview17 (MINI), Shapiro Tic Severity Scale,18 a modied Family History Screen19 and the Yale-Brown obsessive-compulsive scale20 (Y-BOCS). The MINI is a semi-structured diagnostic interview that was used to establish principal and co-morbid diagnoses according to DSM-IV criteria. The Shapiro Tic Severity Scale provides an assessment of the severity of tics and was used in order to determine the presence or absence of tics. The Family History Screen is a validated tool designed

refers to the patients most distressing and/or disabling obsession or compulsion.

to screen for the presence of a positive family history for a range of common psychiatric disorders and was modied to include a screen for potential OCSDs. The Y-BOCS is used widely and it is designed to assess for symptoms of OCD and its severity. It has an item that enquires specically about compulsive hair pulling and this was used to approximate rates of comorbid trichotillomania. Analyses Rates of current and lifetime comorbidity of OCSDs, OADs and major depression were compared to each other. Diagnoses were also pooled as OCSDs (hypochondriasis, body dysmorphic disorder, trichotillomania and tic disorders including Tourettes syndrome) and OADs, excluding OCD (panic disorder, agoraphobia, generalized anxiety disorder, social phobia, specic phobia and post-traumatic stress disorder). This enabled a group comparison between OCSDs and OADs. Lifetime prevalence rates for OCSDs and OADs in rstdegree relatives were compared using Pearsons 2 test. Comparisons were also made with a family history of obsessive-compulsive disorder and major depressive disorder.

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Table 2:

Current and lifetime rates of comorbidity in patients with OCD and their rst degree relatives Current diagnosis (n 77) n (%) Lifetime diagnosis (n 77) n (%) 30 (38.5) 57 (73.1) 24 (27.3) 26 (33.3) 26 (33.3) 15 (19.2) 7 (9.0) 13 (16.7) 9 (11.5) 6 (7.8) 4 (5.1) 4 (5.1) 3 (3.8) Lifetime diagnosis in a rst degree relative (n 77) n (%) 49 (63.6) 38 (49.4) 50 (64.9) 23 (29.9) 21 (27.3) 26 (33.8) 12 (15.6) 3 (3.9) 6 (7.8) 17 (22.1) 1 (1.3) 17 (22.1) 6 (7.8) 6 (7.8) 6 (7.8)

Obsessive-compulsive disorder Generalized anxiety disorder Major depressive episode Specic phobia Social phobia Panic disorder Agoraphobia Ticsa Psychosisb Post traumatic stress disorder Trichotillomaniac Hypochondriasis Body dysmorphic disorder Bulimia nervosa Anorexia nervosa
aData bPatients

27 (34.6) 22 (28.2) 21 (26.9) 17 (21.8) 15 (19.2) 10 (12.8) 10 (12.8) 5 (6.4) 4 (5.1) 3 (3.8) 3 (3.8) 1 (1.3) 0 (0.0)

were obtained from the Shapiro Tic Severity Scale18 and did not include lifetime comorbidity. with a current diagnosis of psychosis were not included in the study. cData were obtained from the Y-BOCS20 item assessing for trichotillomania.

RESULTS
Demographic and clinical characteristics of the sample are shown in Table 1. The mean difference in Y-BOCS scores for the same patients rated by different raters was 0.1 (95% CI 1.8 to 2.0). Most ratings resulted in identical scores. Rates of comorbidity for major depressive episode, OADs, psychosis and OSCDs are shown in Table 2. On assessing rates of OADs and OCSDs within the sample, 53 (68.8%) had either a current or past OAD compared to 25 (32.5%) having a current or past OCSD. Comorbidity for OADs without OCSDs occurred in 36 (46.8%) participants and comorbidity for OSCDs

without OADs occurred in six (7.8%) participants. Similarly, 55 (74.3%) reported having had a rst-degree relative with an OAD and 21 (28.4%) reported having had a rst-degree relative with an OCSD. The results of a 2 analysis are shown in Table 3. It should be noted that no participant had a family history of OCSDs without a family history of an OAD. To control for the high prevalence of OADs in patients rst-degree relatives, the analysis in Table 3 was conducted with major depression which was also highly prevalent in patients rst-degree relatives (Table 4). Tables 3 and 4 show that a very similar percentage of patients with a family history of OCD, but no family

Table 3: A comparison of rates of family history of other anxiety disorders (OADs) and obsessive-compulsive spectrum disorders (OCSDs) in rst degree relatives Family history of an OAD and an OCSD n (%) Family history of OCDa No family history of OCD Total 15 (71.4) 6 (28.6) 21 (100.0) Family history of neither an OAD nor an OCSD n (%) 8 (42.1) 11 (57.9) 19 (100.0) Family history of an OAD without a family history of an OCSD n (%) 24 (70.6) 10 (29.4) 34 (100.0) Family history of an OCSD without a family history of an OAD n (%) 0 (0.0) 0 (0.0) 0 (100.0)

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Total 47 (63.5) 27 (36.5) 74 (100.0)

aThere was a signicant association between a family history of an OAD and a family history of OCD (2 5.056, df 3, p 0.025), such that participants with a family history of OCD (n 47; 63.5%) were proportionately more likely than those without (n 27; 36.5%) to have a family history of an OAD (n 39 (83%) vs n 16 (59%) respectively).

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Table 4: A comparison of rates of family history of other anxiety disorders (OAD) and major depression in rst degree relatives Family history of Family history of neither an OAD an OAD and major nor major depression n (%) depression n (%) Family history of OCDa No family history of OCD Total
aThe

Family history of an OAD without a family history of major depression n (%) 13 (72.2) 5 (27.8) 34 (100.0)

Family history of major depression without a family history of an OAD n (%) 6 (54.5) 5 (45.5) 11 (100.0)

Total 47 (63.5) 27 (36.5) 74 (100.0) 6.820,

26 (70.3) 11 (29.7) 37 (100.0)

2 (25.0) 6 (75.0) 8 (100.0)

df

association between a family history of major depression and a family history of OCD was not signicant (2 3, p 0.078).

history of OCSD or major depression, had a family history of OADs.

suicide attempts.19 A family study method involving the direct assessment of rst-degree relatives would give a more accurate assessment of rates of comorbidity in rst-degree family members. In conclusion, this study shows high rates of comorbidity for OADs in patients with OCD, which contrasts with the comparatively low rates of comorbid OCSDs. It also suggests a strong association between a family history of OADs and OCD in rst-degree relatives of participants with OCD in this sample. No participants had a family history of OCSDs without a family history of an OAD and hence an aetiological association between OCD and OCSDs in the absence of an OAD seems unlikely.

DISCUSSION
This study reveals high rates of comorbidity and family history of OADs and major depression in patients with OCD. These results have been seen in other studies.7,8,15 Although the ndings support an association between OCD and OADs, they do not imply an aetiological association.5,14,21 A parallel could be drawn with depression, where some authors see depression as a complication of OCD as its onset is thought to follow the onset of OCD in some patients.21 Regardless, support for the concept of OCSDs on the basis of high rates of comorbidity with OCD should be viewed with caution as OCD has clearly much higher comorbidity rates of OADs than OCSDs. An advantage of this study is that rates of family history for these co-morbid disorders among patients with OCD have been compared and analysed. The resulting association of a family history of OADs with a family history of OCD suggests a genetic and possibly aetiological association between OADs and OCD. The evidence for a family history association between OCSDs and OCD was not supported. Tables 3 and 4 clearly illustrate that a family history of OADs alone was more likely to occur with a family history of OCD, unlike OCSDs and the equally highly prevalent condition of major depression. The apparently small contribution of a family history of OCSDs in patients with OCD is further highlighted by the nding that no participant had a family history of an OCSD in the absence of an OAD. A major limitation of this study was the absence of a control group. Without a control group, analyses are limited to comparisons within the group of patients. In addition, the family history screen was developed as a screen whose validity was best demonstrated only for major depression, anxiety disorders, substance dependence and

ACKNOWLEDGEMENTS
We would like to thank Adrienne Kirby for her assistance with the statistical analysis.

DISCLOSURE
This study was supported by the funding bodies for the Nepean OCD Study: the Nepean Medical Research Foundation and the Pzer Neuroscience Grant Program. The authors alone are responsible for the content and writing of the paper.

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