OBSESSIVE-COMPULSIVE DISORDER AND COMORBIDITY
No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.
OBSESSIVE-COMPULSIVE DISORDER AND COMORBIDITY
RUTH GROSS-ISSEROFF AND
ABRAHAM WEIZMAN EDITORS
Nova Science Publishers, Inc. New York
Copyright © 2006 by Nova Science Publishers, Inc.
All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter cover herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal, medical or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Library of Congress Cataloging-in-Publication Data Obsessive-compulsive disorder and comorbidity / Ruth Gross-Isseroff and Abraham Weizman (Editors). p. cm. Includes bibliographical references and index. ISBN: 978-1-60876-235-4 (E-Book) 1. Obsessive-compulsive disorder--Complications. 2. Comorbidity. I. Gross-Isseroff, Ruth. II. Weizman, Abraham. [DNLM: 1. Obsessive-Compulsive Disorder. 2. Comorbidity. WM 176 O14265 2006] RC533.O2643 2006 616.85'227--dc22 2006001270
Published by Nova Science Publishers, Inc. New York
DEDICATION This book is dedicated with love to our parents: Drs. Jeana and Harry Gross & Bath-Sheva and Mendel Weizman
CONTENTS Chapter 1
Comorbidity of Obsessive-Compulsive Disorder Ruth Gross-Isseroff and Abraham Weizman
Chapter 2
Obsessive-Compulsive Disorder and Major Depression: Associated and Different Richard B. Rosse, Lynn H. Deutsch, Abraham Weizman, Judy Eller and Stephen I. Deutsch
Chapter 3
Obsessive-Compulsive Disorder: Comorbidity with Obsessive-Compulsive Spectrum Disorders Christine Lochner and Dan J. Stein
1
5
17
Chapter 4
Schizo-Obsessive Disorder Michael Poyurovsky, Abraham Weizman and Ronit Weizman
Chapter 5
Obsessive-Compulsive Disorder and Attention Deficit Disorder: A Challenging Comorbidity Tamar Steinberg and Alan Apter
47
Autism Spectrum Disorders, Autistic Traits and Personality Disorders in Obsessive-Compulsive Disorder Susanne Bejerot
59
Chapter 6
Chapter 7
Neurological Disorders of the Basal Ganglia and Obsessive-Compulsive Disorder Roberto Cavallaro, Cristina Cavallini and Laura Bellodi
Chapter 8
Antipsychotics in OCD Joseph Zohar, Leah Fostick, Rachel Sonnino, Eran Harari and Yehuda Sasson
Chapter 9
State of the Art and Future Directions in the Pathophysiology of Obsessive-Compusive Disorder Donatella Marazziti, Francesco Mungai and Bernardo Dell’Osso
Index
35
103
131
145
161
In: Obsessive-Compulsive Disorder and Comorbidity Editors: R. Gross-Isseroff and A. Weizman, pp. 1-3
ISBN 1-59454-884-6 © 2006 Nova Science Publishers, Inc.
Chapter 1
COMORBIDITY OF OBSESSIVE-COMPULSIVE DISORDER Ruth Gross-Isseroff∗ and Abraham Weizman Research Unit, Geha Mental Health Center, Petach Tikva, Israel
INTRODUCTION The subject of comorbidity in psychiatric disorders has received renewed attention during the last decade. Though definitions of comorbidity vary it is common to assume that the term refers to the co-occurrence of two or more psychiatric disorders as defined by a standard diagnostic criteria (Wittchen, 1996). Obsessive-compulsive disorder (OCD) is a relatively well defined entity. As many clinicians and basic scientists have noted, it rarely occurs by itself. It is usually accompanied by other psychiatric and/or neurologic disorders. Is the context of the occurrence of OCD relevant to the pathophysiology of the disorder? To its treatment? To prognosis? These questions will be discussed in the present book, and if not providing definitive answers, we hope to, at least, highlight some questions which will undoubtedly be raised in future research efforts. Depression in its various manifestations and more specifically major depressive disorder is by far the most common disorder to co-occur with OCD (e.g. Dunner, 2001). The epidemiology of this combination of disorders, issues of definition and treatment are discussed in the present volume. One of the major concerns when OCD is accompanied by depression is the diagnostic priority of the two disorders. Is depression secondary? Does the fact that the patient suffers from prolonged OCD induce the state of depression or are the two disorders independent? Or, conversely, does depression predispose the patient to OCD? Diverse anxiety disorders, such as social anxiety disorder, panic disorder and generalized anxiety disorder are also common in OCD patients (Dunner, 2001). Again, is there a common pathophysiological basis in anxiety disorders that predisposes patients to other anxiety ∗
Research Unit, Geha Mental Health Center, P.O.B. 102, Petach Tikva 49100, Israel; Phone: 972-3-9258439, Fax: 972-3-9258388,
[email protected];
[email protected] 2
Ruth Gross-Isseroff and Abraham Weizman
disorders? Anxiety disorders have been said to involve an overactivation of the amygdala, while OCD involves an overactivation of the orbitofrontal cortex. It is of interest to note, in the context of comorbidity between these disorders, the neural connections between these two brain regions. Of special interest is the comorbidity of OCD with schizophrenia (e.g. Poyurovsky et al., 2004). At different points in the history of psychopathology, obsessions were regarded as an extreme form of delusions, thus predisposing OCD patients to schizophrenia. Conversely, at other times it was claimed that the two disorders cannot co-occur and, moreover, that OCD is a defense against the disintegration of schizophrenia. Lately rates of comorbidity of the two disorders have been assessed and have reached as high a value as 15% (Tibbo and Warneke, 1999). Several brain regions are involved in the two disorders as shown by neuroimaging studies (Gross-Isseroff et al., 2003). The treatment of the comorbidity of the two is intriguing. OCD is part of a spectrum of disorders, including, among others, Tourette syndrome, trychotilomania, compulsive gambling (Jaisoorya et al., 2003; Richter et al., 2003). Is there a predisposition of patients with any one of these disorders to develop the others? Genetic studies point to a possible common mechanism in this cluster of disorders (Cuker et al., 2004). Some neurologic diseases such as Parkinson's and Sydenham's chorea are sometimes accompanied by OCD. Is the involvement of the basal ganglia the underlying mechanism? Some brain injuries, either mechanical or as a result of cerebro-vascular eventss are followed by OCD-like symptoms (Grados, 2003). Again, the mechanism and the brain region specificity are not clear. Beside the obvious clinical challenges posed by the problem of comorbidity, it seems that this problem is much more relevant to basic science than previously thought. Different types of OCD have different patterns of comorbidity and different patterns of heredity (Mataix-Cols et al., 2005). Moreover, age at onset of OCD is correlated with clusters of comorbid disorders and early vs late age at onset appear to have different patterns of comorbidity as well as different patterns of inheritance (Diniz et al., 2004; Millet et al., 2004). Need we stress the importance of these finding to deciphering the genetic basis of the disorder? Thus, comorbidity in OCD seems to have genetic implications, which in turn may be significant in the biological sub-typing of the disorder. These issues, we feel, are far beyond any predictions we would have been able to foresee a decade or two ago. We hope that the present volume will address some of these issues and help to illuminate them with the cumulative light provided by state of the art research. We would like to thank all authors for their efforts to meet the challenge we posed them.
REFERENCES Cuker A, State MW, King RA, Davis N, Ward DC (2004) Candidate locus for Gilles de la Tourette syndrome/obsessive-compulsive disorder/chronic tic disorder at 18q22. Am. J. Med. Genet., 130, 37-39. Diniz JB, Rosario-Campos MC, Shavitt RG, Curi M, Hounie AG, Brotto SA, Miguel EC (2004) Impact of age at onset and duration of illness on the expression of comorbidities in obsessive-compulsive disorder. J. Clin. Psychiatry, 65, 22-27.
Comorbidity of Obsessive-Compulsive Disorder
3
Dunner DL (2001) Management of anxiety disorders: the added challenge of comorbidity. Depress. Anxiety, 13, 57-71. Grados MA (2003) Onsessive-compulsive disorder after traumatic brain injury. Int. Rev. Psychiatry, 15, 350-358. Gross-Isseroff R, Hermesh H, Zohar J, Weizman A (2003) Neuroimaging communality between schizophrenia and obsessive-compulsive disorder: a putative basis for schizoobsessive disorder? World J. Bio. Psychiatry, 4, 129-134. Jaisoora TS, Reddy YC, Srinath S (2003) The relationship of obsessive-compulsive disorder to putative spectrum disorders: results from an Indian study. Compr. Psychiatry, 44, 317323. Mataix-Cols D, Rosario-Campos MCd, Leckman JF (2005) A multidimensional model of obsessive-compulsive disorder. Am. J. Psychiatry, 162, 228-238. Millet B, Kochman F, Gallarda T, Krebs MO, Demonfaucon F, Barrot I, Bourdel MC, Olie JP, Loo H, Hantouche EG (2004) Phenomenological and comorbid features associated in obsessive-compulsive disorder: influence of age of onset. J. Affect. Disord., 79, 241-246. Poyurovsky M, Weizman A, Weizman R (2004) Obsessive-compulsive disorder in schizophrenia: clinical characteristics and treatment. CNS Drugs, 18, 989-1010. Richter MA, Sumerfeld LJ, Antony MM, Swinson RP (2003) Obsessive-compulsive spectrum conditions in obsessive-compulsive disorder and other anxiety disorders. Depress. Anxiety, 18, 118-127. Tibbo P, Warneke L (1999) Obsessive-compulsive disorder in schizophrenia: epidemiologic and biologic overlap. J. Psychiatry Neurosci., 24, 15-24. Wittchen H-U (1996) Critical issues in the evaluation of comorbidity in psychiatric disorders. Br. J. Psychiatry, 168 (Suppl. 30), 9-16.
In: Obsessive-Compulsive Disorder and Comorbidity Editors: R. Gross-Isseroff and A. Weizman, pp. 5-15
ISBN 1-59454-884-6 © 2006 Nova Science Publishers, Inc.
Chapter 2
OBSESSIVE-COMPULSIVE DISORDER AND MAJOR DEPRESSION: ASSOCIATED AND DIFFERENT Richard B. Rosse1,2, Lynn H. Deutsch2, Abraham Weizman3, Judy Eller1 and Stephen I. Deutsch,1,2∗ 1
Mental Health Service Line, Department of Veterans Affairs Medical Center, NW, Washington 2 Department of Psychiatry, Georgetown University School of Medicine, NW, Washington 3 Department of Psychiatry, Sackler School of Medicine, Tel-Aviv University, Israel
ABSTRACT Overall, the epidemiologic data show that obsessive-compulsive disorder (OCD) and major depression present as concurrent comorbid conditions with a lifetime frequency that is considerably higher than would be expected based on the lifetime rate of occurrence of either disorder alone in the general population. These data and the fact that major depression, OCD alone, and their concurrent comorbid presentation respond, albeit not completely, to pharmacotherapy with serotonin reuptake inhibitors (SRIs) stimulated speculation that OCD and major depression share some common pathophysiological substrate. Clearly, in terms of a neurotransmitter abnormality, serotonin is likely to figure prominently; however, the major serotonergic projections arising from the raphe nucleus are diffuse and elaborate. In fact, PET data evaluating regional glucose utilization, both before and after treatment with a representative SRI (i.e., paroxetine), suggest important differences in the neurobiological substrates for major depression and OCD. Further, OCD and major depression can influence the metabolic responses of depressive and OCD symptoms, respectively, to this treatment intervention. Moreover, some of the regional differences (e.g., high pretreatment rates of glucose utilization in the right putamen in ∗
[email protected] 6
Richard B. Rosse, Lynn H. Deutsch, Abraham Weizman et al. OCD) implicate other neurotransmitters in addition to serotonin (e.g., L-glutamate). Finally, behavioral syndromes associated with cocaine dependence and abuse (e.g., “compulsive foraging”) could serve as heuristic “models” for exploring the relatedness and differences between OCD and major depression.
EPIDEMIOLOGIC CONSIDERATIONS: HIGH RATES OF COMORBIDITY The lifetime rates of comorbidity for OCD among patients with bipolar disorder, unipolar depression and any other Axis I disorder were determined from an analysis of the Epidemiologic Catchment Area (ECA) data base (Chen & Dilsaver, 1995). Diagnoses were derived from data obtained with the Diagnostic Interview Schedule and made according to DSM III criteria. In order to make the comorbid diagnosis of OCD in the context of bipolar disorder, unipolar depression and other Axis I disorders, the “hierarchical” rules of the DSM III were suspended; ordinarily, according to DSM III, a diagnosis of OCD would not be rendered in the context of bipolar disorder or unipolar depression. The study sample included 167 persons with bipolar disorder, 796 persons with unipolar depression, and 5,659 persons with other Axis I disorders; all of whom were age 18 or older. The lifetime rates of comorbid OCD among the persons with bipolar disorder, unipolar depression and other Axis I disorders were 21.0%, 12.2%, and 5.9%, respectively. Interestingly, the likelihood of comorbid OCD among persons with bipolar disorder was two times higher than among persons with unipolar depression. The rates of comorbid OCD among persons with affective disorders must be considered high because the estimate of the lifetime rate of OCD in the general population based on the ECA data was 2.6%. Comorbid OCD was associated with higher lifetime rates of suicidal ideation for persons with bipolar disorder and unipolar depression, and a higher lifetime rate of suicide attempts for persons with bipolar disorder. The authors conjectured that the data support an association between bipolar disorder and OCD. A similar association between unipolar depression and OCD is confounded by the possibility that the onset of OCD can precede the initial episode of major depression; thus, OCD could be primary and depression secondary (Chen & Dilsaver, 1995). Studies show that a high percentage of patients attending primary care clinics have potentially remediable and often unrecognized psychiatric disorders, especially anxiety and depressive disorders (e.g., Von Korff et al., 1987). In fact, it is not uncommon for patients to have mixed symptoms of anxiety and depression and comorbid disorders. In the study by Von Korff et al. (1987), an average of 1.86 of the following diagnoses was assigned to 86 primary care patients: major depression, dysthymia (lifetime diagnosis), panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder. Major Depression is a common diagnosis in primary care settings; estimates suggest that about 5% of general medical patients attending ambulatory medical settings meet criteria for major depression (Cooper-Patrick et al., 1994). Further, at least twice as many of these general medical patients have at least one depressive symptom. In an analysis of NIMH Epidemiologic Catchment Area (ECA) data, patients with major depression attending general medical clinics (n=387) and specialty mental health clinics (n=172) were compared to each other (Cooper-Patrick et al., 1994). This comparison confirmed the high prevalence of comorbid major depression and OCD; however, a significantly higher percentage of patients
Obsessive-Compulsive Disorder and Major Depression: Associated and Different
7
receiving care in the specialty mental health clinics (p
