Obsessivecompulsive symptoms in first

episode psychosis and in subjects at ultra

high risk for developing psychosis; onset
and relationship to psychotic symptoms

Bouke Sterk, Kay Lankreijer, Don H Linszen, Lieuwe de Haan

Objective: To determine the prevalence of obsessivecompulsive symptoms and obsessive

compulsive disorder in patients with schizophrenia or related disorders or subjects at ultra
high risk for development of psychosis. Secondly, to determine the time of occurrence of
obsessivecompulsive symptoms related to the onset of first psychosis.
Method: We collected data on all patients who were referred consecutively to our special-
ized clinic for first episode psychosis patients and ultra high risk subjects in Amsterdam
between 1 July 2006 and 1 July 2008. Diagnosis of psychotic disorders was established
using the Comprehensive Assessment of Symptoms and History schedule. Obsessions
and compulsions were defined in accordance with DSM-III-R criteria and assessed by
clinicians. We analyzed the onset of obsessivecompulsive symptoms and its relation to the
onset of first episode psychosis.
Results: When a strict definition of obsessivecompulsive symptoms is used, 9.3% (n  18)
of patients with schizophrenia or a related disorder exhibited obsessivecompulsive symp-
toms and 1.5% also met criteria for obsessivecompulsive disorder. The onset of obses-
sivecompulsive symptoms occurred before, concurrent with and after onset of first episode
psychosis in the following proportion of patients: 7/18, 3/18, 8/18. We found a prevalence of
20.7% of obsessivecompulsive symptoms in ultra high risk subjects.
Conclusion: Using a strict definition of obsessivecompulsive symptoms, we found rela-
tively low prevalence rates of obsessivecompulsive symptoms and obsessivecompulsive
disorder in patients with schizophrenia or related disorders; the rates are even lower than
known rates of obsessivecompulsive symptoms and obsessivecompulsive disorder in
the general population. Obsessivecompulsive symptoms rates in ultra high risk subjects
are comparable to those in the general population. Further investigation of the predic-
tive validity of obsessivecompulsive symptoms in ultra high risk subjects for developing
psychosis is needed. Obsessivecompulsive symptoms either develop prior, during or after
the onset of first episode psychosis.
Key words: FEP, OCD, onset, schizophrenia, UHR.

Australian and New Zealand Journal of Psychiatry 2011; 45:400406

DOI:10.3109/00048674.2010.533363

Bouke Sterk, Physician Researcher (Correspondence); Kay Lank-
reijer, Medical Intern; Don H Linszen, Psychiatrist; Lieuwe de Haan ,
Psychiatrist
Department of Psychiatry, Academic Medical Centre, University
of Amsterdam Meibergdreef 5, 1105 AZ Amsterdam, Netherlands.
E-mail: b.sterk@amc.nl
Since the early twentieth century it has been noted that
co-occurrence of obsessivecompulsive symptoms
(OCS) and obsessivecompulsive disorder (OCD) is
frequently seen in patients with schizophrenia and related
disorders [1] Recent studies reveal high co-morbidity

2011 The Royal Australian and New Zealand College of Psychiatrists

 B. STERK, K. LANKREIJER, D. H. LINSZEN, L. DE HAAN
rates for OCS in schizophrenia patients varying from
7.8% to 46.6% [2,3,4]. Prevalence rates for OCD reported
in schizophrenia populations vary from 7.8% to 26%
[2,510]. Estimated prevalence gures for OCS in the
general population are similar (2124%), but clearly
lower for OCD (23%) [11]. The wide range of reported
co-occurrence rates of OCS in schizophrenia patients is
probably due to differences in denitions of obsessive
compulsive features and sample characteristics (i.e. age
of subjects, inpatient-outpatient, stage of illness). An
important challenge facing investigators and clinicians is
differentiating an obsession from a delusion. Obsessions
in OCD have traditionally been distinguished from delu-
sions in psychotic disorders based on the individual rec-
ognition of the compulsions or obsessions as ego-dystonic
phenomena, implying the presence of insight. Earlier
studies concluded that patients with schizophrenia can
develop OCS as a sign of emerging reality testing of
psychotic symptoms and stated that the presence of OCS
could be an indicator of good prognosis [12,13]. How-
ever, subsequent studies reported poorer outcome and
higher levels of positive and negative symptoms in
schizophrenia patients with OCS [3,4,14].
Recently, several hypotheses concerning the associa-
tion of OCS in schizophrenia have been proposed. First,
OCS in schizophrenia might be considered as a subtype
of schizophrenia, with early onset obsessivecompulsive
symptoms representing rst manifestations of the psychi-
atric disorder [3].This subtype can be seen as a separate
category of schizophrenia, by some authors referred to
as schizo-obsessive disorder [15,16]. Second, the occur-
rence of OCS in schizophrenia patients may be associ-
ated with the treatment with second generation
antipsychotic medications [17]. And nally both disor-
ders could be considered as two separate disorders with
a high co-morbidity and both with an onset in adoles-
cence [3,14].
OCS can either begin prior, during or after the rst
episode of psychosis (FEP). If OCS typically occurs prior
to FEP, it would be likely that OCS together with schizo-
phrenia can be seen as a schizophrenia-subtype with
OCS as early symptoms of the psychotic disorder. Since
the mean age at onset of OCS in patients with rst-
episode schizophrenia reported by Poyurovsky et al. [6]
is 16.6 years (SD  8.7) and the mean age at onset of
psychosis is 23.4 (SD  5.9) years, this would also sup-
port the hypothesis that onset of OCS occurs prior to the
onset of psychotic symptoms. Another possible support-
ive argument for the hypothesis that OCS is a subtype of
schizophrenia, is the high incidence of OCS in patients
at ultra high risk (UHR) of developing psychosis [18],
suggesting that OCS could be a part of the prodromal
phase of schizophrenia.
401
However, if OCS occurs mostly after the rst psychotic
episode, the hypothesis that OCS in schizophrenia might
be associated with antipsychotic medication is more
likely. Supporting this argument, Byerly et al. [19] report
in their study that OCS predominantly concurs with, or
develops after the onset of the psychotic disorder in
patients with schizophrenia or a schizoaffective disorder.
To our knowledge there has only been one earlier study
that specically addresses the time of onset of FEP in
relation to the emergence of OCS [19]. Byerly and col-
leagues included only patients that had OCS at the time
of assessment, their study population had a relatively
high age (mean age 47.3 years) and subsequently a long
delay between mean onset of schizophrenia (22.3 years)
and assessment. More recently Devulapalli and col-
leagues performed a meta-analysis on studies concerning
the temporal sequence of clinical manifestations in
schizophrenia with co-morbid OCD and reported that the
onset of OCD precedes schizophrenia; however, this nd-
ing was at a trend level (p  0.066) [20]. To the best of
our knowledge no earlier publication has assessed onset
of OCS and/or OCD in a FEP population.
In the present study, we sought to assess the prevalence
of OCS and OCD among all referrals with a FEP or with
a potential UHR to develop psychosis to a specialized
early psychosis department. When OCS or OCD was
present, we determined the time of onset of OCS related
to the time of onset of FEP: prior, during or after rst-
episode psychosis. Referrals to our specialized early psy-
chosis department were not exclusively from Amsterdam,
and demographic characteristics might differ between
referrals from Amsterdam and from outside this catch-
ment area. The Amsterdam population is known for its
multiethnic background. Because of possible differences
we will assess, gender, ethnicity and referral status
between subjects with OCS and subjects without OCS.
With a consecutively diagnosed young study-sample
with UHR subjects and subjects with recent onset of FEP
and by using a strict denition of OCS (excluding repet-
itive psychotic experiences), our study design is appro-
priate to assess prevalence and disentangle the association
between psychosis and OCS onset.
Materials and methods
Participants
This study was conducted in a specialized early psy-
chosis department for treatment and research of subjects
with FEP and subjects who are at ultra high risk of devel-
oping psychosis, located in the Academic Medical Centre
Amsterdam, the Netherlands. The study was prospective
402 OCS IN FIRST EPISODE PSYCHOSIS
and included all patients who were consecutively referred
to the department or to one of our outreaching early inter-
vention for psychosis teams in Amsterdam from 1 July
2006 until 1 July 2008. Patients from Amsterdam repre-
sented a treated incidence sample of FEP patients, while
patients who were referred to our department came also
from regions surrounding Amsterdam. Separate analyses
for these two groups of patients will be presented in the
Results section.
Patients gave their consent that anonymized clinical
data could be used for the purpose of study assessment
and were given the choice to opt out, in which case their
data were not used.
Instruments and procedure
For all patients who entered the study we collected
demographic and psychiatric variables (age, gender, eth-
nicity and urbanicity for determining living in Amster-
dam or outside of Amsterdam, diagnosis). During the
diagnostic procedure, patients were interviewed by a
psychiatrist or a psychologist with extensive clinical
experience. In this approximately 2-h face-to-face inter-
view, subjects were asked about their premorbid history
of complaints, psychotic symptoms, OCS and general
characteristics. Diagnosis of psychotic disorders was
established using the Comprehensive Assessment of
Symptoms and History (CASH) schedule. All residents
and researchers were trained in performing the CASH
interview and supervised by senior psychiatrists of our
department. All cases were discussed in a weekly meet-
ing with three senior psychiatrists and all residents and
researchers involved in our diagnostic facility. Difcul-
ties in assessing symptom status or diagnostic criteria
were discussed and resolved by reaching agreement
between all professionals involved. In 19 cases there
was insufcient information to reach consent on symp-
tom or diagnostic status. In these cases an extra diagnos-
tic interview was held, sometimes including extra
neuropsychological testing. In referrals to the diagnostic
facility of our clinic with no evident psychosis, the
Structured Interview for Prodromal Syndromes (SIPS)
[21] was administered. This semi-structured interview
was used to determine the presence, severity and type of
UHR symptoms. The Scale of Prodromal Symptoms
(SOPS), the rating scale of the SIPS, has four SIPS sub-
scales that include ve positive symptom items, six
negative symptom items, four disorganization symptoms
items and four general symptom items. All symptoms
were rated on a 7-point rating scale rating from 0 (never,
absent) to 6 (severe/extreme and psychotic for the posi-
tive items). The diagnosis of a UHR status is based on
the score on the positive symptoms items. Scores in the
3 to 5 range were considered to be indicative of the
UHR phase. Each SIPS interviewer received a two-
day training workshop by T.J. Miller, one of the SIPS
authors, including a reliability check after approxi-
mately six months. The pair-wise inter-rater reliabil-
ity concordance of the SIPS was 77% and deemed
acceptable by the training team. Patients were also
classified as being UHR when they had a genetic risk
and reduced functioning or brief limited intermittent
psychotic symptoms [22]. Simultaneously, in a sepa-
rate interview the parents or guardians were asked
about the premorbid emergence and presence of
symptoms and signs of the patient. We used informa-
tion of both interviews to assess the presence of OCS
in schizophrenia, schizophrenia-related disorders and
UHR patients.
We used the strict denition of OCS according to the
Structured Clinical Interview for DSM-III-R, patient ver-
sion, as persistent, repetitive, intrusive, and distressful
thoughts, obsessions unrelated to the patients delusions,
or repetitive goal-directed rituals, compulsions, clinically
distinguishable from schizophrenic mannerisms or pos-
turing [23,24]. An example of OCS unrelated to psy-
chotic symptoms: fears of contamination associated with
repetitive hand washing or compulsive behaviours such
as counting, organizing or checking rituals in a patient
with acoustic hallucinations with unrelated content. In
contrast; an example of obsessivecompulsive-like
symptoms related to psychotic symptoms: compulsive
checking behaviours associated with paranoid fears, such
as a need to compulsively check the house for camera or
recording devices [18]. Consequently, patients whose
obsessional thoughts or compulsions are related exclu-
sively to psychotic content of thoughts are not included
in the OCS or OCD group.
We screened all patients for the presence of OCS and
if present, we determined the time of onset of OCS. If
only a year was known, we noted the rst of July of that
year as a date and when there was a month and year
known, we noted the 15th of that month and year. Addi-
tionally, for the patients with OCS who met the DSM-IV
criteria for schizophrenia, schizophreniform or schizoaf-
fective disorder we determined the age of onset of OCS
and assessed whether onset of OCS was prior, during or
after the onset of FEP.
After the diagnostic procedure the presence of OCS
was assessed independently by two of the authors (B.S.,
K.L.), taking longitudinal, clinical, and heteroanamnestic
information into account. They agreed upon the presence
of OCS in (95%) of the cases. In case of uncertainty
(5%), the nal decision on presence of OCS/OCD was
reached in a discussion with a senior psychiatrist (L.H.).
The 5% of cases in which the presence of OCS/OCD was
 B. STERK, K. LANKREIJER, D. H. LINSZEN, L. DE HAAN 403

uncertain mainly comprised cases were there was some
doubt about the relation with psychotic content. We used a
minimal uncertainty model, so if there was the slightest
doubt it was discussed with the senior psychiatrist. We only
assessed OCD when DSM-IV criteria were fullled.
To determine ethnicity we used the classication used
by the Dutch Central Bureau of Statistics [25]. If a patient
or one of his or her parents was born in another country,
that patient was assigned to the ethnic group that tted
that foreign country. If the parents were born in different
countries, the country of birth of the mother was used.
Statistical analysis
All statistical analyses were performed using SPSS
16.02 software. By using chi-square tests and logistic
regression we compared different variables (gender, eth-
nicity, living in Amsterdam or not) in patients with OCS
to patients without OCS.
Results
Three hundred and sixty-ve consecutively referred
patients were included in this study. No patients were
rejected and none decided that their anonymized clinical
data could not be used for study purposes. Of these 365
included patients, 297 (81.3%) were male and the mean
age at diagnostic assessment was 21.7 years, (SD 4.5);
197 (54%) patients lived in the catchment area Amster-
dam, 168 (46%) were referred from other parts of the
Netherlands. Regarding ethnic origin, 194 (53.2%)
patients were of Dutch origin and 171 (46.8%) had
another background, e.g. Surinamese (13.1%), Moroccan
(9.9%) or Turkish (3.3%). Of 21 (5.8%) patients we were
not able to identify the ethnic background because there
were not enough reliable data available to determine the
ethnicity. Of the cases included, 154 met DSM-IV criteria
for schizophrenia (120 paranoid type, 21 undifferenti-
ated, 12 disorganized and 1 catatonic), while 20 met
DSM-IV criteria for schizoaffective disorder and 20 met
DSM-IV criteria for schizophreniform disorder; 76 sub-
jects were diagnosed with other DSM-IV psychotic dis-
orders (ve substance-induced psychotic disorder, one
psychotic disorder due to general medical condition, four
mood disorder with psychotic features, eight brief psy-
chotic disorder, 58 psychotic disorder not otherwise
specied); 29 patients met UHR criteria. The remaining
66 participants were referred to our clinic but did not
have a psychotic disorder nor met UHR criteria.
OCS was assessed in 42 of the 365 subjects (11.5%);
18 patients within the group of schizophrenia and related
disorders had OCS (9.3%), 11 patients in the other psy-
chotic disorders group, 14.5%), six in the UHR group
(20.7%) and seen within the group of patients assessed at
our clinic but who did not have a psychotic disorder, nor
met UHR criteria (10.6%). Three patients with schizo-
phrenia, schizophreniform or schizoaffective disorder
also met the DSM-IV criteria for OCD (3/194, 1.5%).
One patient was diagnosed with OCD in the group other
psychotic disorders (1/76, 1.3%) and also one patient
with OCD was found in the UHR group (1/29, 3.4%).
Three patients without a psychotic disorder, nor fullling
UHR criteria had OCD (3/66, 4,5%) (see Table 1).
For further analyses we focused on the group with
schizophrenia and related disorders and the UHR group.
We compared the patients with OCS to the patients with-
out OCS.
Characteristics of patients with schizophrenia or a
related disorder and OCS versus non-OCS
Of the 18 patients with schizophrenia or a related
disorder with OCS, 13 (72.2%) were male, 13 (72.2%)
had a Dutch ethnicity and 12 (66.7%) did not live in
Amsterdam. The mean age at diagnostic assessment

Table 1. OCS and OCD within four diagnostic categories

Group N OCS OCS OCD

Schizophrenia and related disorders 194 176 (90.7%) 18 (9.3%) 3 (1.5%)

Schizophrenia 154 143 (92.9%) 11 (7.1%) 2 (1.3%)
Schizophreniform 20 17 (85.0%) 3 (15.0%) 1 (5.0%)
Schizoaffective 20 16 (80.0%) 4 (20.0%) 0 (0.0%)
Other psychotic disorders 76 65 (85,5%) 11 (14.5%) 1 (1.3%)
UHR 29 23 (79.3%) 6 (20.7%) 1 (3.4%)
No psychotic disorder, nor UHR 66 59 (89.4%) 7 (10.6%) 3 (4.5%)
Total 365 323 (88.5%) 42 (11.5%) 8 (2.2%)

OCS, no obsessive compulsive symptoms; OCS, obsessive compulsive symptoms present; OCD, obsessive compulsive disorder
fulfilling DSM-IV criteria; UHR, ultra high risk to develop psychosis.
404 OCS IN FIRST EPISODE PSYCHOSIS

Table 2. Demographics and characteristics of patients with schizophrenia or a related disorder

with OCS versus non-OCS

OCS (n  18) OCS (n  176) p value*

Male 13 (72.2%) 148 (84.1%) NS

Dutch ethnicity 13 (72.2%) 75 (42.6%) 0.02
Living outside of Amsterdam 12 (66.7%) 63 (35.8%) 0.01
Mean age at diagnostic 21.9 (SD  3.4) 22.3 (SD  4.1) NS
assessment
Mean age at onset OCS 18.5 (SD  5.6)
Mean age at onset FEP 19.9 (SD  3.7)

OCS, obsessive compulsive symptoms; OCS, no obsessive compulsive symptoms; OCS, obsessive compulsive symptoms
present. *Using chi-square test.

was 21.9 years (SD  3.4). The mean age at onset of
FEP was 19.9 years (SD  3.7). The mean age at onset
of OCS was 18.5 years (SD  5.6). Of the 176 patients
with schizophrenia or a related disorder without OCS,
148 (84.1%) were male, 75 (42.6%) were Dutch and 63
(35.8%) did not live in Amsterdam. The mean age at
diagnostic assessment was 22.3 years (SD  4.1). By
using chi-square tests, we found that having a Dutch
ethnicity or living outside of Amsterdam was related to
prevalence of OCS. However, when we tted these two
variables in a logistic regression model, only living out-
side of Amsterdam seemed to predict OCS (odds ratio
3.6, CI 1.210.0, p-value 0.01), whereas adding ethnic-
ity did not improve the model (see Table 2).
The onset of OCS occurred before, concurrent with,
and after the onset of rst-episode psychosis in the fol-
lowing proportion of patients: 38.9% (7/18), 16.7%
(3/18) 44.4% (8/18) (see Table 3). OCS onset would
therefore be as likely to occur before as after the onset
of schizophrenia or related disorders.
Characteristics of UHR patients
Of the 29 patients fullling UHR criteria, 26 (89.7%)
were male. Their mean age at diagnostic assessment was
Table 3. Time of onset of OCS prior, during or
after time of onset of FEP
N rates for OCS and OCD in schizophrenia and related
Onset OCS prior to FEP 7 (38.9%)
Onset OCS during FEP 3 (16.7%)
Onset OCS after FEP 8 (44.4%)
Total 18 (100%)
OCS, obsessive compulsive symptoms; FEP, first episode
psychosis.
19.1 years (SD  3.4). Eleven (37.9%) patients lived in
Amsterdam and 18 (62.1%) were referred from other
parts of the Netherlands 20 (69%) had a Dutch back-
ground; the remaining nine (31%) had an ethnic back-
ground other than Dutch.
Characteristics of UHR patients with OCS
versus non-OCS
Of the six patients who fullled UHR criteria, with
OCS, three (50%) were male, four (66.7%) had a Dutch
ethnicity and three (50%) lived in Amsterdam. The mean
age at intake was 18.3 years (SD  2.5). The mean age
at onset of OCS was 13.9 years (SD  3.7). Of the 23
patients who met UHR criteria without OCS, 23 (100%)
were male, 16 (69.6%) were Dutch and eight (34.8%)
lived in Amsterdam. The mean age at intake was 19.3
years (SD  3.6).
Discussion
In this study 9.3% of the patients with recent onset
schizophrenia, schizophreniform or schizoaffective dis-
order had OCS, when a strict denition of OCS used.
1.5% also met the criteria for OCD. These prevalence
gures for OCS and OCD are not as high as reported
prevalence rates in other recent studies that examined
OCS and OCD in schizophrenia and related disorders
[210]. In contrast with the relatively low prevalence
disorders in our sample, we did nd relatively high rates
of OCS (20.7%) and OCD (3.4%) in UHR patients,
although this nding should be interpreted with caution,
since the sample size of this UHR group was reasonably
small (N  29) and predominantly male.
The onset of OCS occurred before, concurrent with,
and after the onset of rst-episode psychosis. Unlike
 B. STERK, K. LANKREIJER, D. H. LINSZEN, L. DE HAAN
Byerly et al. [19], we found no signicant difference
between the time of onset of OCS prior to or after the
time of onset of rst-episode psychosis. Also we did not
conrm the nding that OCD precedes the onset of
schizophrenia in co-morbid patients as found at a trend
level in the meta-analysis by Devulapalli and colleagues
[20]. An explanation of these differences might be the
heterogeneity and possible selection bias (i.e. chronically
ill and older age at assessment) in the study samples
included in this meta-analysis. We specically studied a
young, recent-onset population.
The equal distribution of the time of onset of OCS
related to the time of onset of rst-episode psychosis
suggests that OCS and schizophrenia are two separate
disorders which have their onset in adolescence. How-
ever, it could still be that both hypotheses, OCS as a
schizophrenia-subtype and OCS induced by antipsychotic
medication, are true. It is not ruled out that maybe a
small number of the patients with OCS occurrence prior
to FEP suffer from a schizo-obsessive disorder, and
possibly another subgroup of patients with OCS occur-
rence after FEP, developed OCS associated with the
effects of antipsychotic medication.
We found prevalence rates of OCS and OCD in patients
with schizophrenia that are almost the same, or even
lower, as the rates of OCS and OCD found in the general
population. More importantly, these ndings show lower
prevalence rates of OCS and OCD in schizophrenia than
many other studies. This difference might be caused by
several reasons:
1. Our criteria for dening OCS were strict:
obsessivecompulsive symptoms needed to be
unrelated to the psychotic content. By narrow-
ing our denition of OCS, we aimed at reducing
the risk of over-reporting OCS.
2. The symptoms of schizophrenia or related disor-
ders in our patients were probably not as severe
as chronic schizophrenia patients as described in
other studies.
3. Most patients were not using antipsychotic
medication yet or had only recently started
antipsychotic medication. Therefore, the sug-
gested inducing effect of antipsychotic medi-
cation could have not yet been in force. There
are indications that OCS might develop dur-
ing long-term use of antipsychotic medication
[26,27].The patients in our sample generally had
a short duration of treatment with antipsychotic
medication; this may have reduced the occur-
rence of OCS and OCD in our sample.
4. It has been suggested by other authors that the
use of low dose of antipsychotic medication may
405
reduce OCS in schizophrenia and schizophrenia
related disorders [26]. Because giving low doses
of antipsychotic medication is common in recent-
onset psychotic disorders this may also have been
a factor related to the relatively low prevalence of
OCS in our sample.
Some limitations to the present study need to be
acknowledged. First, although we assessed the largest
group to date of recent-onset schizophrenia and related
disorder patients in respect to OCS occurrence, the sam-
ple size might be still insufcient to comprehensively
evaluate the prevalence of OCS and OCD and the asso-
ciation of occurring OCS with the onset of rst-episode
psychosis. Hence, replication with a larger group and a
strict catchment area is required to substantiate our nd-
ings. By including all patients who were consecutively
referred to the department and all patients who were
referred to one of our outreaching early intervention for
psychosis teams in Amsterdam, we do not think we have
missed FEP patients who are willing to participate in a
diagnostic interview or willing to receive treatment in
Amsterdam during the study period. However, we miss
information on FEP patients not in contact with mental
health care professionals. Included subjects with an UHR
were help seeking. Many subjects with UHR may not
have come to our attention, because they were not help
seeking or were not referred to our diagnostic facility. All
referrals with UHR were given a second chance if they
missed their rst appointment. However, 26 subjects
(from the 121 potential UHR subjects referred) did not
present themselves at the second appointment and infor-
mation on their clinical characteristics is missed. Second,
there might be a reporting bias: although psychiatrists and
psychologists involved with the diagnostic procedure
were instructed to focus on obsessivecompulsive symp-
toms, our strict OCS denition may have induced under-
reporting of OCS. However, since patients were also
asked to ll in questionnaires about OCS we suppose that
OCS with a certain severity is detected in our study. Third,
on the other hand, OCS might have been over reported
due to the possible presence of referral bias: patients
referred to our specialized clinic from outside Amsterdam
might suffer from a more severe disorder, thus may have
more symptoms, including obsessivecompulsive symp-
toms. This might have affected our ndings in this group.
Fourth, although we suppose that we were able to include
almost all FEP in contact with mental health care in
Amsterdam, we probably have missed several cases.
However, a systematic bias in occurrence or severity of
OCS, between patients included and those not, is not
likely. Fifth, the relatively small sample of UHR subjects
precludes more denitive conclusions to be drawn.
406 OCS IN FIRST EPISODE PSYCHOSIS
In conclusion, we found a relatively low prevalence of
OCS and OCD in a large consecutively diagnosed cohort
of patients with a rst episode of schizophrenia or related
disorder. OCS either developed prior, during, or after the
onset of FEP, which may have implications for understand-
ing the relationship of the two conditions and their asso-
ciation with each other. We found a relatively high incidence
of OCS in subjects who met UHR criteria, possibly
prodromal for FEP, suggesting that OCS might be a part of
the prodromal phase of rst-episode psychosis. The predic-
tive validity of OCS for transition to psychosis in UHR
subjects warrants further investigation. Prospective, long-
term follow-up studies are needed to fully characterize the
occurrence, development and impact of OCS in subjects at
UHR for psychosis and patients with recent onset schizo-
phrenia, schizophreniform or schizoaffective disorder.
Declaration of interest: Funding for this study was pro-
vided by ZonMw (the Netherlands Organization for
Health Research and Development), Grant no. 63300020;
ZonMw had no further role in the study design, in the
collection, analysis and interpretation of data, in the writ-
ing of the report, and in the decision to submit the paper
for publication. The authors alone are responsible for the
content and writing of the paper.
References
1. Gordon A. Obsessions in their relation to psychosis. Am J
Psychiatry 1926; 82:647659.
2. Eisen JL, Beer DA, Pato MT, Venditto TA, Rasmussen SA.
Obsessivecompulsive disorder in patients with schizophrenia or
schizoaffective disorder. Am J Psychiatry 1997; 154:271273.
3. Fenton WS, McGlashan TH. The prognostic signicance of
obsessivecompulsive symptoms in schizophrenia. Am J Psychia-
try 1986; 143:437441.
4. Berman I, Merson A, Viegner B, Losonczy MF, Pappas D,
Green AI. Obsessions and compulsions as a distinct cluster of
symptoms in schizophrenia: a neuropsychological study. J Nerv
Ment Dis 1998; 186:150156.
5. Poyurovsky M, Hramenkov S, Isakov V et al. Obsessivecompul-
sive disorder in hospitalized patients with chronic schizophrenia.
Psychiatry Res 2001; 102:4957.
6. Poyurovsky MD, Fuchs C, Weizman A. Obsessivecompulsive
disorder in patients with rst-episode schizophrenia. Am J Psy-
chiatry 1999; 156:19982000.
7. Tibbo P, Kroetsch M, Chue P, Warneke L. Obsessivecompulsive
disorder in schizophrenia. J Psychiatr Res 2000; 34:139146.
8. Ohta M, Kokai M, Morita Y. Features of obsessivecompulsive
disorder in patients primarily diagnosed with schizophrenia.
Psychiatry Clin Neurosci. 2003; 57:6774.
9. Nechmad A, Ratzoni G, Poyurovsky M et al. Obsessivecompulsive
disorder in adolescent schizophrenia patients. Am J Psychiatry
2003; 160:10021004.
10. Kruger S, Braunig P, Hofer J, Shugar G, Brner I, Langkrr J.
Prevalence of obsessivecompulsive disorder in schizophrenia and
signicance of motor symptoms. J Neuropsychiatry Clin Neurosci
2000; 12:1624.
11. Fullana M, Mataix-Cols D, Caspi A et al. Obsessions and compul-
sions in the community: prevalence, interference, help-seeking,
developmental stability, and co-occurring psychiatric conditions.
Am J Psychiatry 2009; 166:329336.
12. Rosen I. The clinical signicance of obsessions in schizophrenia.
J Ment Sci 1957; 103:773785.
13. Stengel E. A study on some clinical aspects of the relationship
between obsessional neurosis and psychotic reaction types. J Ment
Sci 1945; 91:166187.
14. Cunill R, Castells X, Simeon D. Relationships between obsessive
compulsive symptomatology and severity of psychosis in schizo-
phrenia: a systematic review and meta-analysis. J Clin Psychiatry
2009; 70:7082.
15. Hwang MY, Hollander E. Schizo-obsessive disorders. Psychiatr
Ann 1993; 23:396401.
16. Zohar J. Is there room for a new diagnostic subtype: the schizo-
obsessive subtype? CNS Spectr 1997; 2:4950.
17. Tibbo P, Warneke L. Obsessivecompulsive disorder in schizophre-
nia: epidemiologic and biologic overlap. J Psychiatry Neurosci
1999; 24:1524.
18. Niendam TA, Berzak J, Cannon TD, Bearden CE. Obsessive
compulsive symptoms in the psychosis prodrome: correlates of
clinical and functional outcome. Schizophr Res 2009; 108:170175.
19. Byerly M, Goodman W, Acholonu W, Bugno R, Rush AJ. Obsessive
compulsive symptoms in schizophrenia: frequency and clinical
features. Schizophr Res 2005; 76:309316.
20. Devulapalli KK, Welge JA, Nasrallah HA. Temporal sequence of
clinical manifestation in schizophrenia with co-morbid OCD:
review and meta-analysis. Psychiatry Res 2008; 161:105108.
21. Miller TJ, McGlashan TH, Rosen JL et al. Prospective diagnosis
of the initial prodrome for schizophrenia based on the structured
interview for prodromal syndromes: preliminary evidence of inter-
rater reliability and predictive validity. Am J Psychiatry 2002;
159:863865.
22. Yung AR, Phillips LJ, Yuen HP, Francey SM, McFarlane CA,
Hallgren M, McGorry PD. Psychosis prediction: 12-month follow
up of a high risk (prodromal) group. Schizophr Res 2003; 60:
2132.
23. Spitzer RL, Williams JBW, Gibbon M, First MB. Structured clinical
interview for DSM-III-R (SCID) - Patient edition. Washington:
American Psychiatric Press, 1990.
24. de Haan L, Hoogeboom B, Beuk N, Wouters L, Dingemans PM,
Linszen DH. Reliability and validity of the Yale-Brown Obsessive
Compulsive Scale in schizophrenia patients. Psychopharmacol
Bull 2006; 39:2530.
25. CBS: Central Bureau of Statistics, key gures 2009. Available from
URL: http://www.cbs.nl/en-GB/menu/cijfers/kerncijfers/.
26. van Nimwegen L, de Haan L, van Beveren N, Laan W, van den
Brink W, Linszen D. Obsessivecompulsive symptoms in a rando-
mized, double-blind study with olanzapine or risperidone in young
patients with early psychosis. J Clin Psychopharmacol 2008;
28:214218.
27. de Haan de L, Beuk N, Hoogenboom B, Dingemans P, Linszen D.
Obsessivecompulsive symptoms during treatment with olanzapine
and risperidone: a prospective study of 113 patients with recent-
onset schizophrenia or related disorders. J Clin Psychiatry 2002;
63:104107.
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