Obsessive-Compulsive Disorder Prepared by Anjené Musick Addington Summary

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1 Obsessive-Compulsive Disorder Prepared by Anjené Musick Addington Summary Obsessive-compulsive disorder (OCD) is characterized by recurrent obsessions and/or compulsions that cause marked distress, are time-consuming, or significantly interfere with the individual s social, academic, or occupational functioning (American Psychiatric Association, 1994). Obsessions are defined as persistent, intrusive ideas, thoughts, images, or impulses, such as fears of contamination or fears of potential harm to oneself or others, that may be perceived as inappropriate or unreasonable. Compulsions are repetitive, stereotyped behaviors, such as hand washing, or checking behaviors, or covert mental rituals that the individual feels compelled to perform in order to prevent or reduce anxiety or distress. These rituals may be performed in response to obsessions, or to prevent some dreaded situation or event. However, they are either not connected in a realistic way with what they are intended to prevent or neutralize, or are clearly excessive. Before 1984, OCD was thought to be a relatively rare disorder. However, after the Epidemiological Catchment Area (ECA) surveys were carried out in the U.S, new estimates of prevalence ranging from 1-3% identified OCD as a much more common problem than had been thought previously (Robins & Regier, 1991). In fact, OCD is now considered the fourth most common mental disorder, above schizophrenia and bipolar disorder. Approximately 2-3% of the U.S. population ages 18 to 54 suffers from OCD in a given year ( Further, the annual prevalence rates of OCD appear consistent across countries as well, ranging from 1.8% in Puerto Rico to 0.4% in Taiwan (Weissman et al., 1994). No consistent gender differences have been reported, as OCD tends to affect both men and women equally. OCD typically begins during adolescence or early childhood with 30-50% of adults with OCD reporting childhood onset (Rapoport, 1990). Further, in 1990, OCD cost the U.S. $8.4 billion in social and economic losses. Using the keyword search criteria of the literature databases described earlier, 658 articles were returned. After reviewing titles and abstracts, 593 of these were excluded for not meeting specific inclusion criteria. After closer examination of the remaining 65 articles, only 5 studies were retained for inclusion in this review. Most were discarded due to inappropriate samples (case-study or clinic-based samples), cross-sectional or retrospective designs, or review article format. Data for all five of the studies included in this review were prospectively gathered in a longitudinal fashion from a community sample. Crum and Anthony (1993) used the oneyear incidence data gathered from all five sites involved in the Epidemiologic Catchment Area (ECA) Program. The Diagnostic Interview Schedule (DIS) was used to determine DSM-III diagnoses. The ECA identified 105 incident cases of OCD out of 13,306 at-risk participants and found that cocaine and marijuana use increased risk for OCD. Additional risk factor were identified as, being female, not working for pay and having a prior history of psychiatric disorders. Douglass et al. (1995) reported on a cohort of 18-year

2 olds in New Zealand who had been prospectively studied since birth and assessed every two years since age 3 as part of the Dunedin Multidisciplinary Health and Development Study. Mental disorders at age 18 were assessed by a modified version of the DIS, leading to DSM-III-R diagnoses. A history of depression and substance abuse were reported as prospective risk factors for OCD. In contrast, none of the following measures were predictive of OCD at age 18: perinatal problems/complications, parental educational status, maternal IQ, parental SES, child behavior, or neuropsychological tests. Nestadt and colleagues (1998) utilized participants from the Baltimore cohort of the original ECA study who were reinterviewed 12 to 15 years later. In the baseline interviews, the DIS assessed DMS-III diagnoses, while in the follow-up DSM-III-R diagnoses were used. Nestadt et al. reported on 13 new cases of OCD over the follow-up period and did not find any significant predictors OCD among demographic characteristics, religious background, or oldest or only child status. However, there were higher lifetime rates of other psychiatric disorders among the incident OCD group as compared to controls. Peterson et al. (2001) prospectively followed a group of children from upstate New York for 15 years with diagnostic assessments at 3 follow-up time points. They used the Diagnostic Interview Schedule for Children (DISC) to obtain DSM-III (at time 2) and DSM-III-R (at times 3 and 4) diagnoses. They found different predictors of OCD at each time point. Childhood conduct disturbances predicted OCD symptoms in early adolescence, childhood tics and early adolescent separation anxiety predicted the development of OCD symptoms in late adolescence, and tics and ADHD in late adolescence predicted more OCD symptoms in adulthood. OCD also was associated with higher IQ. Finally, Valleni-Basile and others (1996) implemented a two-stage epidemiological study in a community sample of adolescents in the southeastern United States. The Schedule for Affective Disorders and Schizophrenia for School-Age Children was administered to mother-child pairs, which was used to determine DSM-III diagnoses. Valleni-Basile et al. reported that black race, age, desirable life events, undesirable life events, and socioeconomic status were significant predictors of incident OCD. There are a couple of issues that make comparisons across studies difficult. First the differences between DSM-III and DSM-III-R diagnoses may not trivial. Nestadt et al. (1998) reported the difference in diagnostic criteria between DSM-III and DSM-III-R substantially influenced the threshold for new case identification. While the DSM-III-R diagnosis tends to identify fewer cases due more stringent criteria, Nestadt et al. (1998) did not find significant differences between the DSM-III only group and the DSM-III-R OCD group in demographics, other risk factors, or lifetime comorbidity. However, Nelson and Rice (1997) raised additional concerns when they reported that the DIS/DSM-III diagnosis of OCD was unstable over a one-year period. This calls into question the validity of the DIS/DSM-III diagnosis of OCD. The other issue that must be kept in mind is that while the reports by Crum & Anthony and Nestadt et al. included samples of adults, the other three studies involved child/adolescent samples. A recent review of the literature on juvenile OCD by Geller and colleagues (1998) concluded that juvenile OCD might be a developmental subtype of the disorder, which has a unique set of correlates that appear to differ from studies of adult OCD subjects. Whether or not there is continuity between child/adolescent onset cases of OCD and adult-onset cases of

3 OCD should be explored further. In this review of the current literature, these weaknesses should be taken into consideration, and measures taken to overcome them when planning future studies of OCD.

4 Selection Figure for Obsessive-Compulsive Disorder 65 abstracts reviewed for inclusion criteria

5 Evidence Tables for Obsessive-Compulsive Disorder

6 Risk Factor: Gender and Age Pub Study Sample Sample Study Outcome Risk Factor Risk Factor RR/OR Author Date Design Description Size Period Criteria/Measure Measure (95% CI) Adjustment Crum R.M. & Anthony J.C Prospective ECA yr DIS/DSM-III self-report Female vs. Male 2.0 ( ) none RR Douglass H.M. et al Prospective New Zealand yrs DIS/DSM-III-R self-report Female vs. Male 1.51 ( )* none birth cohort RR Nestadt G. et al Prospective ECA: Balitmore yrs DIS/DSM-III-R self-report Female vs. Male 0.98 ( )** none follow-up OR Valleni-Basile L.A. life event, et al stage 7th,8th,9th graders yr K-SADS-P/ self-report Female vs. Male 0.85 ( ) family Prospective suburban SE US DSM-III RR sociodem, race Valleni-Basile L.A. life event, et al stage 7th,8th,9th graders yr K-SADS-P/ self-report Age: continuous 4.02 ( ) family Prospective suburban SE US DSM-III RR sociodem, race Nestadt G. et al Prospective ECA: Balitmore yrs DIS/DSM-III-R self-report Age: ( )** none follow-up ( )** ( )** (ref) OR *RR and CI were calculated by AMA. **CI calculated by AMA.

7 Risk factor: Marital Status Pub Study Sample Sample Study Outcome Risk Factor Risk Factor RR/OR Author Date Design Description Size Period Criteria/Measure Measure (95% CI) Adjustment Nestadt G. et al Prospective ECA: Balitmore yrs DIS/DSM-III-R self-report married 1.00 none follow-up never married 0.75 ( )** divorce,widow,single 0.70 ( )** OR **CI calculated by AMA. Risk Factor: Education and IQ Pub Study Sample Sample Study Outcome Risk Factor Risk Factor RR/OR Author Date Design Description Size Period Criteria/Measure Measure (95% CI) Adjustment Nestadt G. et al Prospective ECA: Balitmore yrs DIS/DSM-III-R self-report <8th grade 2.19 ( )** none follow-up 9-11th grade 1.44 ( )** 12th grade 1.81 ( )** >12th grade 1.00 OR Douglass H.M. et al Prospective New Zealand yrs DIS/DSM-III-R WISC-R IQ n.s. birth cohort Peterson B.S. et al Prospective children in yrs DISC/ Quick Test IQ significant, but no OR upstate NY DSM-III-R **CI calculated by AMA. Risk Factor: Employment Sex, ADHD, Tics

8 Pub Study Sample Sample Study Outcome Risk Factor Risk Factor RR/OR Author Date Design Description Size Period Criteria/Measure Measure (95% CI) Adjustment Crum R.M. & Anthony J.C Prospective ECA yr DIS/DSM-III self-report unemployed female 3.9 ( ) age,census,drug use employed female 2.3 ( ) psychiatric disorder unemployed male 1.6 ( ) employed male 1.0 (ref) RR Risk Factor: Household Income and Occupational Prestige Pub Study Sample Sample Study Outcome Risk Factor Risk Factor RR/OR Author Date Design Description Size Period Criteria/Measure Measure (95% CI) Adjustment Nestadt G. et al Prospective ECA: Balitmore yrs DIS/DSM-III-R self-report <7, ( )** none follow-up 8,000-14, ( )** 15,000-24, ( )** >25, OR Douglass H.M. et al Prospective New Zealand yrs DIS/DSM-III-R self-report parental SES n.s. birth cohort Valleni-Basile L.A. et al stage 7th,8th,9th graders yr K-SADS-P/ self-report low vs med to high SES significant, but unestimable Prospective suburban SE US DSM-III Nestadt G. et al Prospective ECA: Balitmore yrs DIS/DSM-III-R self-report Nam decile 0.87 (n.s) follow-up **CI calculated by AMA. none

9 Risk Factor: Alcohol use disorders Pub Study Sample Sample Study Outcome Risk Factor Risk Factor RR/OR Author Date Design Description Size Period Criteria/Measure Measure (95% CI) Adjustment Crum R.M. & age,census 1993 Prospective ECA yr DIS/DSM-III self-report yes 2.2 ( ) Anthony J.C. tract no 1.0 sex,employ, RR & drug use 1.84 (0.40- Nestadt G. et 1998 Prospective ECA: yrs DIS/DSM-III-R self-report 7.28)* yes al. Balitmore follow-up no 1.0 RR *RR and CI were calculated by AMA. none

10 Risk Factor: Drug Use Pub Study Sample Sample Study Outcome Risk Factor Risk Factor RR/OR Author Date Design Description Size Period Criteria/Measure Measure (95% CI) Adjustment Crum R.M. & Anthony J.C Prospective ECA yr DIS/DSM-III Selfreport marijuana (mj) only mj & other drg (not coc) cocaine & mj coc & mj & other drug no drug use 2.9 ( ) 1.6 ( ) 7.2 ( ) 2.0 ( ) 1.0 (ref) age, census tract, sex, employment, & psych dis Nestadt G. et al Prospective ECA: Balitmore follow-up yrs DIS/DSM-III-R Selfreport mj abuse/depend sedative abuse/depend cocaine abuse/depend stimulant abuse/depend 18.5 ( )* 8.5 ( )* 2.7 ( )* 8.5 ( )* RR none Douglass 1995 Prospective New Zealand yrs DIS/DSM-III-R H.M. et al. *RR and CI were calculated by AMA. **OR calculated by AMA Selfreport substance abuse-age ** OR none

11 Risk Factor: Prior diagnoses--depression Risk Factor Author Pub Date Study Design Sample Description Sample Size Study Outcome Period Criteria/Measure Risk Factor Measure Crum R.M. & 1993 Prospective ECA yr DIS/DSM-III self-report MDD & grief Anthony J.C. rxn no 1993 Nestadt G. et al. Douglass H.M. et al Prospective ECA Baltimore follow-up 1995 Prospective New Zealand birth cohort Valleni-Basile stage 7th,8th,9th graders 247 L.A. et al. Prospective suburban SE US *OR and CI were calculated by AMA. **OR calculated by AMA yrs DIS/DSM-III-R self-report MDD yrs DIS/DSM-III-R self-report dep symptoms Age 11 Age 13 Age 15 1 yr K-SADS-P/ DSM-III CES-D dep symtom score RR/OR (95% CI) 2.4 ( ) 1.0 RR 5.7 ( )* OR 3.16** 2.93** 10.83** OR 1.08 ( ) OR Adjustment age,census tract sex,employ, & drug use none none sex, race

12 Study Design Sample Description Sample Size Study Period Outcome Criteria/Measure Risk Factor Measure Author Pub Date Crum R.M. & Anthony J.C Prospective ECA yr DIS/DSM-III Self-report ECA: Nestadt G. et al Prospective Baltimore follow-up yrs DIS/DSM-III-R Self-report Crum R.M. & Anthony J.C Prospective ECA yr DIS/DSM-III Self-report Nestadt G. et al Prospective Nestadt G. et al Prospective Douglas H.M. et al Prospective ECA: Baltimore follow-up yrs DIS/DSM-III-R Self-report ECA: Baltimore follow-up yrs DIS/DSM-III-R Self-report New Zealand birth cohort yrs DIS/DSM-III-R Self-report Risk Factor Any phobia no Simple Social Agoraphobia Panic No Panic No GAD No Anxiety Symptoms RR/OR (95% CI) 3.4 ( ) 1.0 RR 7.2 ( )* 8.4 ( )* 2.7 ( )* OR 4.6 ( ) 1.0 RR 2.7 ( )* OR 4.1 ( )* OR Age ** Age ** Age ** OR Adjustment Age, census tract, & sex, employ, drug use *OR and CI were calculated by AMA. **OR calculated by AMA

13 Risk Factor: Prior diagnoses--other Pub Study Sample Sample Study Outcome Risk Factor Risk Factor RR/OR Author Date Design Description Size Period Criteria/Measure Measure (95% CI) Adjustment Crum R.M. & Anthony ECA DIS/DSM-III self-report bipolar disorder 8.2 ( ) age,census tract J.C. Prospective yr 1.0 & sex,employ,drug no use RR Crum R.M. & Anthony J.C Prospective ECA yr DIS/DSM-III self-report schizophrenia 2.3 ( ) age,census tract no 1.0 & sex,employ,drug use RR 3.73 (1.22- Peterson B.S. et al Prospective children in yrs DISC/ self-report ADHD 11.35) none upstate NY DSM-III-R OR 6.36 (1.23- Peterson B.S. et al Prospective children in yrs DISC/ parental-report tics 32.76) none upstate NY DSM-III-R OR Rutter Douglass H.M. et al Prospective New Zealand yrs DIS/DSM-III-R tics Child birth cohort Behavior Quest. *OR and CI were calculated by AMA. **OR calculated by AMA n.s. none

14 Risk Factors for OCD Demographics: Gender and Age Color Category and Hued Forest Plot Gender: Crum & Anthonya Douglass et al. a Nestadt et al.a Valleni-Basile et al.a Age: Continuousb vs. 65+c vs 65+c vs. 65+ a. Female vs. male b. Valleni-Basile et al. (1996) DSM-III OCD for adolescent sample c. Nestadt et al. (1998) DSM-III-R OCD for ECA Baltimore sample

15 Marital Status a Never married Divorce/widow/ Single Education b <8 th grade 9-11 th grade 12 th grade a. Compared to married. Nestadt et al. (1998) DSM-III-R OCD for ECA Baltimore sample b. Compared to >12th grade. Nestadt et al. (1998) DSM-III-R OCD for ECA Baltimore sample

16 Risk Factors for OCD Demographics: Employment and Income Color Category and Hued Forest Plot Employment a Unmployed female Employed female Unemployed male Household Income b <$7,999 $8,000-14,999 $15,000-24,999 a. Compared to employed males. Crum & Anthony (1993) DSM-III OCD for ECA b. Compared to >$25,000. Nestadt et al. (1998) DSM-III-R OCD for ECA Baltimore sample

17 Alcohol use disorders Risk Factors for OCD Alcohol and Drug Use Color Category and Hued Forest Plot Crum & Anthony (1993) Nestadt et al. (1998) Drug use disorders Mj only a Mj & other drug a Mj abuse/depend b Cocaine & mja Cocaine & other a Cocaine abuse/depend b Stimulant abuse/depend b Sedative abuse/depend b a. Compared no drug use. Crum & Anthony (1993) DSM-III OCD for ECA b. Nestadt et al. (1998) DSM-III-R OCD for ECA Baltimore sample

18 Risk Factors for OCD Prior Diagnoses: Depression Hued Forest Plot Depression MDD & grief rxn a MDD b Dep symptoms c Age 11 Age 13 Age 15 Dep symptom score d a. Compared no drug use. Crum & Anthony (1993) DSM-III OCD for ECA b. Nestadt et al. (1998) DSM-III-R OCD for ECA Baltimore sample c. Douglass et al. (1995) DSM-III-R OCD for New Zealand birth cohort d. From CES-D. Valleni-Basile et al. (1996) DSM-III OCD for adolescent population sample

19 Risk Factors for OCD Prior Diagnoses: Phobias and Anxiety Color Category and Hued Forest Plot Phobias Any phobia a Simple b Social b Agoraphobia b Panic Crum & Anthony Nestadt et al Anxiety GAD b Anxiety sx age 11 c Anxiety sx age 13 c Anxiety sx age 15 c a. Crum & Anthony (1993) DSM-III OCD for ECA b. Nestadt et al. (1998) DSM-III-R OCD for ECA Baltimore sample c. Douglass et al. (1995) DSM-III-R OCD for New Zealand birth cohort

20 Risk Factors for OCD Prior Diagnoses: Other Color Category Forest Plot Bipolar disorder a Schizophrenia a ADHD b tics b a. Crum & Anthony (1993) DSM-III OCD for ECA b. Peterson et al. (2001) DSM-III-R OCD adolescent population sample

21 Obsessive-Compulsive Disorder Bibliography American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4 th ed.) Washington, DC. Crum, R.M. and Anthony, J.C. (1993) Cocaine use and other suspected risk factors for obsessive-compulsive disorder: a prospective study with data from the Epidemiologic Catchment Area surveys. Drug Alcohol Depend. 31, Douglass, H.M., Moffitt, T.E., Dar, R., McGee, R. and Silva, P. (1995) Obsessivecompulsive disorder in a birth cohort of 18-year-olds: prevalence and predictors. J.Am.Acad.Child Adolesc.Psychiatry 34, Geller, D.A., Biederman, J., Jones, J., Shapiro, S., Schwartz, S. and Park, K.S. (1998) Obsessive-compulsive disorder in children and adolescents: a review. Harv.Rev.Psychiatry 5, Nelson, E. and Rice, J. (1997) Stability of diagnosis of obsessive-compulsive disorder in the Epidemiologic Catchment Area study. Am.J.Psychiatry 154, Nestadt, G., Bienvenu, O.J., Cai, G., Samuels, J. and Eaton, W.W. (1998) Incidence of obsessive-compulsive disorder in adults. J.Nerv.Ment.Dis. 186, Peterson, B.S., Pine, D.S., Cohen, P. and Brook, J.S. (2001) Prospective, longitudinal study of tic, obsessive-compulsive, and attention-deficit/hyperactivity disorders in an epidemiological sample. J.Am.Acad.Child Adolesc.Psychiatry 40, Rapoport, J.L. (1990) The waking nightmare: an overview of obsessive compulsive disorder. J Clin Psychiatry 51 Suppl, Robins, L.N. and Regier, D.A. (1991) Psychiatric Disorders in America: the Epidemiological Catchment Area Study. New York: The Free Press. Valleni-Basile, L.A., Garrison, C.Z., Waller, J.L., Addy, C.L., McKeown, R.E., Jackson, K.L. and Cuffe, S.P. (1996) Incidence of obsessive-compulsive disorder in a community sample of young adolescents. J.Am.Acad.Child Adolesc.Psychiatry 35, Weissman, M.M., Bland, R.C., Canino, G.J., Greenwald, S., Hwu, H.G., Lee, C.K., Newman, S.C., Oakley-Browne, M.A., Rubio-Stipec, M., Wickramaratne, P.J. and et, a.l. (1994) The cross national epidemiology of obsessive compulsive disorder. The Cross National Collaborative Group. J Clin Psychiatry 55 Suppl, 5-10.