OBSESSIONAL DISORDERS 0193-953X/92 $0.00 + .20 THE EPIDEMIOLOGY AND CLINICAL FEATURES OF OBSESSIVE COMPULSIVE DISORDER Steven A. Rasmussen, MD, and Jane L. Eisen, MD Over the past decade, we have witnessed rapid growth in our understanding of the clinical features, pathophysiology, and treatment of obsessive compulsive disorder (OCD). The recognition by both clinicians and researchers that OCD was much more common than previously believed has led to ever accelerating interest in this most fascinating of psychiatric syndromes. Epidemiologic data have shown that 1% to 2% of the general population suffers from OCD at any given time. This finding has led to what many consider to be the most significant outcome of OCD research over the last decade: the successful treatment of large numbers of OCD patients, who prior to the 1980s, would not have even presented for treatment. Much of the progress in the epidemiology of OCD during the last decade has, been the confirmation of the surprisingly high prevalence rates for OCD that were reported initially in the National Epidemiology Catchment Survey (ECA). Verifica- tion of the ECA figures has come from other studies that have used improved methodology"* and from cross-cultural studies that have confirmed that the widespread prevalence of OCD is a worldwide phenomenon.1°*#4? Knowledge of the clinical features of the disorder also has expanded signifi- cantly in the last 10 years. Treatment centers specializing in OCD have succeeded in enrolling large cohorts of patients, allowing a more sophisticated analysis of the disorder’s heterogeneity, comorbidity, and course of illness, and the relationship of these variables to treatment outcome. Improvements in methodology such as the use of control groups, blind clinical assessments, structured interviews, reliable and valid diagnostic criteria, and more sophisticated and user accessible database management systems have aided these analyses. This article reviews the current From the Department of Psychiatry, Brown University School of Medicine, Butler Hospital, Providence, Rhode Island ooo, PSYCHIATRIC CLINICS OF NORTH AMERICA ‘VOLUME 15 © NUMBER 4 * DECEMBER 1992 743744 | RASMUSSEN & EISEN state of knowledge of the epidemiology and clinical features of OCD. It focuses on the disorder’s phenomenologic heterogeneity and its comorbidity with other Axis I and Axis II syndromes. There is a need to formulate new hypotheses from an analysis of the first generation of descriptive studies that will add to our under- standing of the cause and treatment of the disorder. One such hypothetical model that relates heterogeneity of OCD to the disorder’s comorbidity is presented at the end of the article. EPIDEMIOLOGY Frequency in Psychiatric Populations The impression that OCD was a relatively rare disorder arose from a series of retrospective chart review studies that were completed in the late 1950s and early 1960s. These studies examined the frequency of OCD probands in inpatient and outpatient psychiatric settings. Those with OCD made up only a small minority (1% to 4%) of the total patient pool. This reinforced the only estimate of the prevalence of OCD in the general population, 5 in 10,000 made before the ECA study by Rudin. However, even those investigators felt that Rudin’s figures were probably an underestimate, pointing to the fact that patients often did not come to treatment because of fear or shame. An extensive review of several thousand inpatient charts of hospitals in the Rhode Island area found the frequency of OCD to be 1.6%. (Rasmussen and Tsuang, unpublished data, June 1984). Most previous studies focused on inpatients. A systematic study of the occurrence of OCD in an outpatient psychiatric clinic using DSM-III criteria also was completed in 1984, Our data suggested that as many as 10% of all outpatients who entered a private psychiatric outpatient clinic had significant obsessive compulsive symptoms. Prevalence in the General Population In spite of the fact that only a small percentage of psychiatric inpatients have OCD, most early investigators stressed that the prevalence in the general popula- tion was likely to be significantly higher than the estimate of 0.05% given by Rudin.“ Experienced clinicians are well aware of the secretive nature of these patients as well as their reluctance to reveal their symptoms. The National Epidemiologic Catchment Area Survey (ECA) was funded by the National Institute of Mental Health (NIMH) in the late 1970s. The goals of the study were to determine the lifetime and 6-month prevalence of OCD in the general population, as well as to determine where patients sought treatment. Among the most striking findings to come out of the study was the fact that OCD was 50 to 100 times more common than previously believed, with a 6-month point prevalence of 1.6% and a lifetime prevalence of 2.5%.*? This made it the fourth most common psychiatric disorder, following the phobias, substance abuse, and major depression. The prevalence rate of OCD was double that for panic disorder or schizophrenia.** A Canadian epidemiologic study of 3258 randomly selected residents of Edmonton, using the Diagnostic Interview Schedule to confirm the ECA findings, revealed a lifetime prevalence of OCD of 3.0%” whereas the 6- month point prevalence was 1.6%.° The ECA study has been criticized on the grounds that it was administered by lay interviewers. This may have led to the overestimation of the prevalence of some disorders, particularly the phobias and OCD. These criticisms were sup- ported by follow-up studies of ECA subjects that used semistructured interviews‘THE EPIDEMIOLOGY AND CLINICAL FEATURES OF OCD 745 conducted by psychiatrists.2"” Both studies found significantly lower prevalence rates of OCD than were reported in the original ECA study. These studies, how- ever, have been criticized because of the small number of subjects interviewed, and because psychiatrists were not using objective rating instruments developed for OCD. Unfortunately, no follow-up study of the OCD subjects from the ECA study has been completed. ‘A carefully designed study of the prevalence of OCD in a population of high school students has supported the ECA results.'? Investigators screened 5000 students with the Leyton Obsessional Inventory.* Students scoring above a prede- termined cut-off on the scale were interviewed by a psychiatrist who was an expert in childhood OCD. Fifteen (0.3%) of the total 5000 students were diag- nosed as meeting DSM-III-R criteria for OCD. The average age of the probands was 15.4 years whereas the average age of onset of the disorder was around age 20 years. When an age correction was applied, the point prevalence estimate for the general population was 1%. Since publication of the ECA data, studies using similar methodology have been completed in diverse cultures including Europe,” Taiwan,” and Africa. Prevalence rates similar to those found in the United States were reported in each study. Some studies have failed to support the ECA findings. The first epidemio- logic prevalence study of psychiatric disorders completed in the United States found that none of the 500 probands interviewed suffered from clinically signifi- cant OCD.” Bebbington reported in the Camberwell Epidemiologic Survey that none of 300 patients interviewed had clinically significant OCD, though several had subthreshold disorder (personal communication, 1991). Unfortunately, no objective measures of OCD severity were used in either of these studies. ‘Additional data from the ECA study suggested that as many as 80% of patients with anxiety disorders present to their primary care physicians rather than mental health professionals.‘ We have found a significant number of obsessive compulsive patients who have not yet sought psychiatric care in the practices of dermatologists, obstetrician/gynecologists, and internists.°4° Demographic Variables The following demographic variables have been examined in both inpatient and outpatient populations: sex, marital status, fertility rate, social class, intelli- gence, parental attitude, occupational status, ordinal position, early parental loss, and cause of death,491218.20.21,262829,30,36424451 Most of these studies were com- pleted prior to 1970. Significant variability exists among them because standard- ized diagnostic criteria were not in use when most of these studies were com- pleted. Sex Ratio Black! tabulated 11 studies of inpatients and outpatients with OCD and found a total of 651 men (48.6%) and 685 women (51.4%). Three hundred and two of 560 patients meeting DSM-II-R criteria for OCD from our own sample were women (53.8%). Adding our figures to two other studies collecting data on sex ratio since that review, we find 969 men and 1071 women, (53% women to 47% men). Hollingsworth et al'® found that 75% of a child and adolescent OCD population (13/17) were male. This male predominance in children has been ronfirmed in the studies of Rapoport* As will be noted, males also have a significantly earlier age of onset than females.746 RASMUSSEN & EISEN Race There is a lower than expected frequency of blacks with OCD who present for treatment. Black respondents in the ECA study reported significantly less lifetime OCD than white respondents. The protective effect of being black, however, was not specific, as the same phenomenon was found for nine other mental disorders. It appears more likely that blacks are less likely to present for treatment because of service delivery issues than because of true genetic differences. Marital Status A higher percentage of patients with OCD remain single compared with age matched controls. Interestingly, the percentage of divorce is lower than one would expect, particularly given the stress that OCD symptoms put on families. It is generally held that there is a significant degree of marital maladjustment in patients with OCD. Coryell,? however, found no significant differences between the marital status of OCD patients compared with a matched group of unipolar depressives. This suggests that marital maladjustment may not be syndrome spe- cific. Rachman and Hodgson” pointed to the distinction between part-time and full-time obsessive compulsives. Full-timers are defined as those patients who are preoccupied for the overwhelming majority of the day with their obsessive com- pulsive symptoms, Part-timers are able to voluntarily control their symptoms more easily, and for the most part, ritualize alone. Severity of illness correlates with marital maladjustment but by no means explains all the variance. Personality factors and family function are also important determinants. Religion Freud" was among the first to point out the relationship of religious practices to obsessive compulsive symptoms. Six percent of our sample presented with primary religious obsessions. There appear to be an overrepresentation of patients with religious symptoms who are brought up in strict religious communities (e.g., Hasidic or fundamentalist Muslim).'* One could question whether being brought up in a strict religious environment can lead to the development of OCD. Al- though 66% of our sample is Catholic, this is not significantly different from the general population of Rhode Island which is 69% Catholic. Interestingly, we have found that being brought up with a strict religious upbringing makes it more likely that one will suffer from religious, sexual, or aggressive obsessions. Intelligence Most early studies concluded that OCD patients possess higher than average intelligence.***?93°4 These conclusions, however, were based on clinical impres- sions and not actual data. Three more recent studies however, used the Wechsler Adult Intelligence Scale (WAIS).°2?! Only a small and nonsignificant difference in full-scale IQ between OCD patients and a matched normal comparison group was noted. A small but consistent discrepancy in verbal versus performance IQ scores in OCD patients as well as in neuropsychological tests of frontal lobe function is of more interest. These findings led Flor-Henry et al'* to hypothesize that there may be dominant frontal impairment in OCD. A patient's compulsive- ness and obsessional slowness, however, might interfere with performance of visuospatial tasks, accounting for the differences. This may account for the fact that patients undergoing psychosurgery for relief of OCD actually increase their IQ postoperatively.”‘THE EPIDEMIOLOGY AND CLINICAL FEATURES OF OCD 747 Ordinal Position ‘Three studies have investigated ordinal position in OCD families. In the first, OCD patients showed no significant difference in size of sibship compared with a matched primary unipolar depressive sample.’ In addition, ordinal position and frequency of parental loss before age 15 years were not significantly different between the groups. Obsessive compulsive patients were somewhat more likely to be born first, although this difference did not reach statistical significance. In the second study, 21 of 40 patients with OCD were first born or only children compared with 11 of 40 in the control groups, a highly significant difference.* A third study investigated the birth order of psychiatric inpatients with a wide variety of psychiatric diagnoses.‘* No significant difference in birth order was found between those with OCD and a control population. In a recent analysis of our sample, we found that 115 of 404 (34%) were first born. There was no relationship between ordinal status and clinical course. CLINICAL FEATURES Age of Onset In our cohort, the mean age of onset of significant OCD symptoms was 20.9 + 9.6 with males having a significantly earlier onset of illness, 19.5 + 9.2 for males, 22.0 + 9.8 for females (P < .003). Sixty five percent develop their illness prior to age 25 years, some as eatly as age 2 years. Less than 15% of obsessionals Gevelop the illness after age 35 years (Fig. 1). A significant increase in incidence appears at puberty. Many if not the majority of patients remember having minor OC symptoms that did not significantly interfere with their ability to function and that did not cause significant distress prior to the onset of symptoms that met DSM-IIL-R criteria for the disorder. The average age of onset of minor symptoms was 13.4 + 7.6. Although males noticed minor symptoms earlier than females, the difference did not reach statistical significance. Natural History and Course of Illness Black and Goodwin et al'® reviewed 13 follow-up studies between 1936 and 1970. Few of those studies systematically followed a series of patients with re- peated and reliable measures over time. Most were completed using a retrospective chart review. Relatively little is known through prospective study of the temporal characteristics and patterns of the typical course of OCD, or of the switching of OC symptoms over time, (e.g., washing to checking) or of the patterns of comorbi- dity with other DSMC-III-R disorders over time. Although previous descriptive studies have found that 85% of patients have a chronic waxing and waning course, there has been no attempt in previous studies to subdivide the waxing and waning course into predictable patterns or subtypes.? ‘There is considerable variability in the periodicity, duration, and severity of episodes in patients with OCD. For example, some patients have recurrent epi- sodes of increased symptomatology over a 5-year period whereas others have only one continuous episode during that time. A prospective follow-up study of an OC adolescent cohort concluded that patterns of course were not easily predicted from baseline variables.>* Some patients who were suffering from subthreshold symp- toms at baseline were severely ill at follow-up, whereas others, who at baseline had been classified as severely ill, no longer suffered from clinical levels of symptomatology at follow-up.748 RASMUSSEN é& EISEN 84 © =% PROBANDS a o i ie a % PROBANDS ee ES eee 0 5 10 15 20 25 30 35 40 45 50 55 60 65 AGE of ONSET of MAJOR SXS Figure 1. Age of onset of significant obsessive compulsive disorder symptoms (n = 514). Phenomenologic Subtypes Inevitably, the beginning clinician is struck by the diversity of the clinical presentations of OCD. This initial impression, however, is soon replaced by the realization that the number of types of obsessions and compulsions are remark- ably limited and stereotypic. The basic types and frequencies of OC symptoms have been found to be consistent across cultures and time! Why these particular symptom patterns develop remains unknown. The clinical descriptions of Freud, Bleuler,’ Janet,? Kraeplin,”” and others seem remarkably consistent with the clini- cal presentation of OCD seen today. Over the last 8 years we have characterized the phenomenologic and clinical features of over 500 obsessive compulsives.*? A summary of the types of obsessions and compulsions most commonly found is given in Table 1. The most common obsessions include contamination, pathologic doubt, aggressive, sexual, somatic, and the need for symmetry and precision. The most common rituals were checking, cleaning, and counting compulsions. In what follows, we have attempted to capture the essence of the phenomenologic presen- tation of the most common of the OC subtypes.‘THE EPIDEMIOLOGY AND CLINICAL FEATURES OFOCD 749 Table 1. OC SYMPTOMS ON ADMISSION (n = 560) a Obsessions % Compulsions % Contamination 50 Checking 61 Pathologic doubt 42 Washing 50 Somatic 33 Counting 36 Need for symmetry 32 Need to ask or confess 34 Aggressive 31 ‘Symmetry and precision 28 ‘Sexual 24 Hoarding 18 Multiple obsessions 72 Multiple compulsions 58 Course of IlIness (n = 560) Age of Onset Type % Precipitant % Male 196+93 Continuous 85.0 Not Present 71 Female 22.0+9.8 Deteriorative 10.0 Present 29 Total 20.9496 Episodic 20 Contamination Obsessions Obsessive fear of contamination coupled with handwashing compulsions is the most common phenomenologic presentation of OCD. Although handwashing is the most common compulsion seen in contamination phobics, they will often preferentially use avoidance of contaminated objects over ritualized handwashing or checking if given the opportunity. Of all the obsessive subtypes, their fear structure is linked most closely to the phobias. Both are precipitated by specific external stimuli, both are accompanied by a high level of anxiety, and for both, the coherence of the fear network is high. The most frequently identified contaminant is dirt or germs, but a wide variety of substances (e.g., toxic chemicals, poisons, radiation, or heavy metals) can serve as the contaminant. Although these patients usually are obsessed with external cues or objects, some become morbidly preoc- cupied with cognitive rather than external cues. As is often the case in simple phobias, generalization from fear of a specific object to fear of a more abstract category of objects is frequently seen. The vast majority of contamination obses- sives report anxiety as the dominant affect but the presence of disgust and shame also are commonly seen.'* Shame and disgust are invariably linked to embarrass- ment or guilt. Unlike other phobic patients, contamination obsessives often report that they are more concerned that significant others, rather than themselves, might become ill because of them. Contamination is “magically transmitted” from a dirty object to a clean object merely by coming into contact with it. Objects that have come into contact with the source of contamination, no matter how remote, are often viewed with as much trepidation or disgust as the original contaminant. Pathologic Responsibility or Doubt These patients are characterized by incessant worrisome thoughts that some- thing bad will happen because they have failed to check something thoroughly or completely. This need for certainty is driven by the possibility that something terrible will happen even though they recognize that the possibility is an extremely remote one. They describe an internal conflict between a rational side that knows for example that the door is locked, and an irrational side that feels compelled to check anyway. The rational side is overwhelmed by the strength of the need to check, If checking is postponed, there is a rise in anxiety levels that is impossible for most patients to tolerate for any length of time.750 RASMUSSEN & EISEN The experience of pathologic doubt is present across phenomenologic sub- types, but is seen in its purest form in this subgroup of patients. If one asks these patients, “When are you satisfied that the door is really locked or the faucet is teally off?” many say that if it was not for the fact that they would lose their job or family, they would check all day. One of several strategies is usually adopted in the interest of reducing the amount of time spent checking and maintaining function. The most common is to limit the number of checks by counting. These patients also often develop counting rituals with a system of good numbers and bad numbers. In contrast, some patients report what they describe as the “click phenomena.” In the words of one of our checkers, “I will be checking something over and over and the feeling that it is not totally shut is there until suddenly for no thyme or reason the feeling will no longer be there. It is like clicking a light switch off.” Another is the application of physical force, leading to the snapped off window handles, broken locks, and stripped washers that are often in the homes of these patients. There is a sense of finality or completeness when this occurs, Janet® felt that incompleteness underlies most obsessive and compulsive symp- toms as well as tics. Checkers are usually perfectionist. Rachman®” has noted that they often report having had overly meticulous or overly critical parents. Although usually the fear is centered around making certain that nothing terrible will happen (e.g., a fire or their children being poisoned by medication left unopened in the medicine cabinet), this is not always the case. At times these patients are plagued by constant doubts about things that really do not matter; such as, is the refrigerator door totally shut? is the car window totally shut? Although rationally they will tell you that they would almost always rather have the thing that they fear actually happen to them, rather than have to put up with the incessant checking rituals and obsessive thoughts, they are truly incapable of exacting cognitive and motor control over their behavior. Sexual and Aggressive Obsessions These patients suffer from recurrent abhorrent thoughts that they have or may have committed an unacceptable sexual or aggressive thought or act toward others, Janet” noted that thoughts or actions that were the most objectionable that the patient could imagine and that caused them the most horror were the ones that invariably occurred. A very religious man in our clinic was compelled to link the word damn to God everytime he saw, heard, or spoke the word God. A 26-year-old mother was compelled to get rid of all the knives in her house because of the fear she would stab her baby. A 30-year-old stewardess was obsessed with intrusive sexual thoughts and images of Lesbianism and child molestation. A 42-year-old church secretary began having intrusive sexual images of the Virgin Mary when- ever she crossed the threshold of the church. Guilt and anxiety are the dominant affective symptoms. They may think they should be jailed for their thoughts; Partially as a means of protecting them from what they think they might do and partially because they feel they should be punished. The compulsion to ask or confess is frequently present. They are forever telling the therapist, spouse, or close friend some terrible thought or deed that they feel they have committed as a way of seeking reassurance that they are really not capable of doing what they are worried about. They will frequently leave the therapist's office after having sought reassurance for the whole hour, only to call back later in the evening to add some additional meaningless detail that they have worried about, and that they think they have omitted confessing. Distinguishing these patients from paraphiliacs and those with true homicidal impulses is not difficult in most cases. Most have had past histories that follow the typical course‘THE EPIDEMIOLOGY AND CLINICAL FEATURES OF OCD 751 of OCD and have had other types of obsessions and compulsions during their course of illness. Although these patients may worry that they want to do these things, the clinical impression is that they really do spend their time worrying, about it; whereas for paraphiliacs, one is more impressed with the guilt attendent with the thoughts and the anxiety secondary to the guilt. It is the patient’s reaction to the thought or impulse “Oh my God how could I think that’ that leads to the obsessive characteristic of the thought. All of us experience unacceptable sexual or aggressive thoughts, but most of us are able to quickly dismiss them. For this group of patients, the thought becomes labeled with intense negative affect and anxiety and is therefore more likely to be conditionally linked to other neutral stimuli; stored and subsequently replayed with increasing intrusiveness and frequency. Attempts to actively dismiss the thought without dissociation of affect often leads to increasing preoccupation and anxiety. Need for Symmetry and Precision The clinical picture is dominated by an obsession to have objects or events in a certain order or position, to do and undo certain motor actions in an exact fashion, or to have things exactly symmetric or “evened up.” In our experience, these patients usually can be divided into two groups: those with primary obsessive slowness and those with primary magical thinking. These patients take an inordi- nate amount of time to complete even the simplest of tasks. They fall into the group that Rachman®” has labeled primary obsessional slowness. Unlike most OC patients, they do not experience their symptoms as ego-dystonic, Instead, they seem to have lost their goal directiveness in favor of completing a given. subroutine perfectly, MacLean®* has found evidence suggesting that the basal ganglia control motor planning and therefore coordinate motor subroutines as well as what he has termed the master routine. It is tempting to speculate that these patients suffer from some interference in frontolimbic—basal ganglia function that interferes with their goal directedness, making them incapable of distinguishing the importance of subroutines versus overall goal directed behavior. Another characteristic that sepa- rates these patients from other patients with OCD is the subjective feeling that they get when things are not lined up just so or perfectly. It is described as being more a feeling of discontent or tension, than fear or anxiety. It is the preoccupation many of us have with a picture hung crookedly, but magnified many times over In that sense, these patients can be seen as being on the extreme end of the spectrum of compulsive personality where the need for every detail to be perfect or just so is taken to a maximum. The description of rising tension followed by release after the act is phenomenologically more similar to the subjective sensory experience of Tourette's patients* than to the anxiety experienced by other obses- sive compulsives. In contrast to those with primary obsessive slowness, patients with the need for symmeiry and precision with magical thinking are distinguished by the fact that their obsessions and rituals are all connected with an attempt to ward off an imagined disaster that they think is out of their control, These patients are usually beset with a bewildering variety of doing and undoing rituals, lucky and unlucky numbers, and counting rituals. They are often described as superstitious during childhood by their parents. Their rituals are usually accompanied by severe anxiety. Somatic Obsessions ‘The irrational, persistent fear of developing a serious life threatening illness can be seen across several diagnostic entities including hypochondriasis, major752 RASMUSSEN & EISEN depression with somatic features, panic disorder, and obsessive compulsive dis- order. Somatic obsessions with checking compulsions frequently are seen in ob- sessive compulsive patients at the time of evaluation. Many of our patients with somatic obsessions are indistinguishable from hypochondriacs with the exception that they have multiple other obsessions and compulsions. OC patients with somatic obsessions appear to respond particularly well to the specific serotonergic uptake inhibitors (although there are no controlled trials). There is usually no difficulty in distinguishing these patients from those with somatization disorders. Somatic obsessions most commonly are linked to checking and the need for reassurance rituals. Unlike many OCD patients, those with primary somatic obsessions are concerned primarily with their dying rather than being responsible for harm befalling others. Until recently, cancer, heart attacks, and venereal disease have been the most common fears. Patients with obsessions about AIDS are appearing in rapidly increasing numbers. Hoarding About one fifth of the OCD patients in our clinic have hoarding tendencies. Although the symptom is common, however, it is relatively rare that it dominates the clinical presentation. The only reason most hoarders come to treatment is because of the complaints of family or friends or the fact that the person can no longer function because of the sheer accumulation of material in the house or office. These patients often feel compelled to check their possessions over and over to make certain nothing is missing, or to check their garbage to make certain that they have not inadvertently thrown something valuable out. The ego-syntonic nature of their symptoms makes one wonder if the syndrome should not be seen as part of a compulsive personality instead of OCD. The checking rituals and anxiety attendent with the potential loss of their valued possessions, however, makes it seem more reasonable to classify these patients as suffering from true ocD. Religious Obsessions About 1 in 10 patients in our clinic suffer from religious obsessions. They obsess over the meaning between mortal and venial sins or whether or not they have followed the letter of the religious law. They tend to be overly serious and hypermoral. These patients commonly suffer from the need to confess. Though suffering greatly from their obsessions, some patients see it as a form of religious suffering that God has asked them to endure. These patients are often treatment resistant. It is interesting to note from the perspective of choice of type of OC symptoms, that the frequency of religious OC symptoms appears to be culturally bound. Areas of the world that have religions with strict moral codes are more likely to have higher frequencies of patients with religious obsessions.**”” Also the incidence of religious OC symptoms in OC patients previously described in the literature on scrupulosity, appears to be on the decline in the United States, concurrent with the liberalization of church laws and procedures. This would suggest, however, that the choice of obsession is likely to be environmentally as opposed to genetically determined in some cases. We agree with Greenberg and Chir'* who hypothesized that patients who develop OC symptoms have a pre- existing genotype, and that the development of religious obsessions and compul- sions are dependent on that genotype.‘THE EPIDEMIOLOGY AND CLINICAL FEATURES OF OCD 753, Comorbidity Table 2 summarizes common comorbid Axis I disorders found with OCD. Two thirds of OC patients have a lifetime history of major depression, whereas one third have major depression at the time of first evaluation. The majority (85%) have a mood disorder secondary to their OCD whereas 15% appear to have a concurrent unipolar depression. There is also a significant overlap with the other ‘Axis | anxiety disorders including panic disorder, panic disorder with agoraphobia, social phobia, generalized anxiety disorder, and separation anxiety disorder. Other syndromes with greater comorbidity than one would expect include eating dis- orders, Tourette’s syndrome, and schizophrenia. Comorbid Axis I conditions can influence course of illness and affect choice and order of treatment. Axis II conditions in OCD are covered extensively elsewhere in this issue (see article by Baer and Jenike). The most commonly encountered diagnoses are depen- dent, avoidant, passive aggressive, and compulsive. Schizotypal, paranoid, and borderline personalities are found less commonly in OCD, but appear to be associated with poor outcome. Compulsive personality is covered more fully here because of its relationship to the model that follows. Compulsive Personality Disorder Janet held the view that all obsessional patients have a premorbid personal- ity that is related causally to pathogenesis of the disorder. As early as 1936, however, Lewis” cautioned against acceptance of the connection between predis- posing personality and emergence of obsessional illness. Despite questions about the validity of current diagnostic criteria for obsessive compulsive personality, there is general agreement that obsessional traits occur in many people who never become mentally ill as well as in those who become mentally ill with conditions other than OCD. Several previous studies have shown that a significant percent- age of patients who have developed obsessive compulsive symptoms do not have premorbid compulsive personalities. In seven studies reviewed by Black,* marked obsessional traits were found in 31% of 254 obsessional patients, moderate traits in 40%, and no obsessional traits in 29%. All these studies were completed prior to the introduction of DSM-III, so that comparisons among studies are difficult because of variations in methodology, terminology, and sample selection. Studies completed after the introduction of DSM-III also have varied regard- Table 2. Coexisting Axis | Diagnoses in Primary OCD (n = 100) Diagnosis Current Lifetime ‘Semistructured ‘Semistructured From SADS (n = 100) (n = 100) (n =60) (%) (%) (%) Major depressive disorder 3 67 78 ‘Simple phobia 7 22 28 ‘Separation anxiety disorder = 2 7 Social phobia WN 18 26 Eating disorder 8 17 8 Alcohol abuse (dependence) 8 14 16 Panic disorder 6 12 15 Tourette's syndrome 5 7 6754 RASMUSSEN & EISEN ing the rates of comorbidity of compulsive personality with OCD. This is in part due to the arbitrary nature of how many of the criteria need to be met to make the diagnosis and the fact that there are considerable variations between DSM-III and DSM-IILR. In spite of these problems, there is no ample evidence from recent studies supporting the discontinuity of obsessive compulsive personality disorder (OCPD) and OCD. The majority of OCD patients do not suffer from compulsive personalities. The classic distinction of the rituals being ego-syntonic in OCPD as opposed to ego-dystonic in OCD is useful but not absolute. Some cleaners, hoarders, as well as those with the need for symmetry and precision or obsessive slowness who strive for perfection or completeness find their rituals ego-syntonic until they begin to impair social and occupational function. Whether these patients should be classified as having OCPD or subthreshold OCD is a subject for further empirical study. The relative validity of each of the criteria also needs further empirical validation. Developmental Psychopathology There has been little systematic study of the developmental antecedents of OCD since Janet.”* In his Obsessions and Psychasthenia, Janet outlines how obses- sions and compulsions are the most severe stage of an underlying stage of psy- chasthenia. He defined psychasthenia as a syndrome consisting of feelings of incompleteness and imperfection. He hypothesized that all patients with obses- sions and compulsions at one time pass through a psychasthenic stage. His clinical descriptions of the temperamental features of psychasthenics coincide remarkably well with our preliminary findings in OCD. His description of the patient who “finds on the stairway, the word that needed to be said in the parlor” is a beautiful clinical description of the independent variable chosen by Kagan et al? to measure behavioral inhibition; that is, speech latency in a novel social situation. It is important to note that Janet includes three of five elements of DSM-III’s compul- sive personality disorder in his description of the psychasthenic state: — perfectionism, restricted emotional expression, and indecisiveness— whereas the orderly and obstinate aspects of our current definition of compulsive personality derive from Freud. Previous studies have shown that a considerable portion if not the majority of patients with OCD do not meet DSM-IILR criteria for obsessive compulsive personality disorder.’ The European diagnostic schema for anacastic personality is more directly related to Janet's original definition of psychasthenia and is consistent with the idea of an obsessive spectrum that ranges from normal obsessional behavior through obsessional personality to OCD. We have conducted a retrospective study of 90 of our OC probands using a semistructured format that was designed to elicit personality traits or tempera- mental factors commonly found in OCD (unpublished observations). During this study, we identified 10 factors that commonly were found in our adult OC probands as children (Table 3 and Fig. 2). These traits tended to be constant throughout development. Table 3. COMMON DEVELOPMENTAL ANTECEDENTS IN ADULT OCD PROBANDS Behavioral Inhibitions Anacastic ‘Separation anxiety Perfectionism Resistance to change or novelty Hypermorali Risk aversion Ambivalence Submissiveness (compliance) Excess devotion to work Sensitivity‘THE EPIDEMIOLOGY AND CLINICAL FEATURES OF OCD 755 RELATED DISORDER Phobias Tourettes A SUBTYPE —_Contamination/Washing <«— Checking —® Need for Symmetry Obsessive Slowness CORE FEATURE Abnormal Risk <—q—— Pathological __~» Incompleteness Assessment Doubt AFFECT High Anxiety <——___________—» Low Anxiety DEVELOPMENTAL Behaviorally Inhibited 9~«————————» Anakastic ANTECEDENT) PERSONALITY TRAITS — Avoidant/Dependent Compulsive Figure 2. Heterogeneity and comorbidity in obsessive compulsive disorders. There is a significant overlap of these development antecedents of OCD with the behavioral inhibition syndrome in children that Kagan et al** have described. Four of the developmental traits appear to be shared by adult OCD and panic probands: separation anxiety, resistance to change or novelty, risk aversion, and submissiveness. Four of the traits are more likely to be specific to OCD: perfec- tionism, ambivalence, excess devotion to work, and hypermorality. The overlap of the developmental antecedents of panic disorder and OCD is consistent with Janet's original conception of the psychasthenic syndrome and adds credibility to the hypothesis that there is a shared element of genetic vulnerability among the anxiety disorders. The relationship of adult personality characteristics and clinical subtypes to developmental antecedents awaits further analysis. It appears that some traits are more commonly seen in particular phenomenologic presentations, eg, perfectionism with the need for symmetry and precision or incompleteness, and subtypes with high levels of anxiety with abnormal risk assessment (see Fig. 2), Further prospective study of the developmental antecedents of OCD should be an important area for future research. ‘The Relationship of Heterogeneity to Comorbidity We have become increasingly interested in developing a model for subtyping OCD patients according to what we see as the three core features of the disorder: abnormal risk assessment, pathologic doubt, and incompleteness. These features cut across phenomenologic subtypes such as checking, washing, or the need for symmetry, though some subtypes are associated more closely with one core fea- ture rather than another. Like most phobics, obsessive compulsives are continually worried about the possibility that if there is a one-in-a-million chance that something terrible will happen, it will happen to them. If there is a one-in-a-million chance that the elevator cable will snap, the phobic is certain that it will snap on him. In the same way, many of our OC patients’ thoughts are dominated by the possibility of improbable events that most of us would not think twice about. Many checkers also suffer from What if. What if I didn’t unplug the coffee machine and there's a fire. Patients with aggressive obsessions worry, what if I do pick up the knife?756 RASMUSSEN & EISEN On the opposite side of the spectrum are obsessive compulsives who experi- ence little or no anxiety that something terrible will happen. Janet? observed that many obsessive compulsives were tormented by an inner sense of imperfection. Their actions were never achieved completely to their satisfaction. Many of our patients describe an inner drive that is connected with a wish to have things perfect, absolutely certain, or completely under control. When they achieve this perfection, they describe a curious sensation that they can compare to no other feeling. Janet” called it the occasional brief appearance of sublime ecstasy. This absolute feeling of certainty or perfection rarely is attained, and therefore they experience a feeling of incompleteness. ‘The feeling of going through a door right through the middle, of having both shoelaces tied to exactly the same tension, of having one’s hands perfectly clean, of saying one’s prayers exactly right, or of having one’s hair parted precisely down the middle are clinical examples. Most of us can relate to the feeling of wanting to have something just so or perfect and the feeling of accomplishment when we finally get it that way, as well as the feelings of frustration and incompleteness when it’s not that way. But for the obsessive, it is as if this feeling gets attached to an action that would hold little significance for most of us, just as most of us do not think about the one-in-a-million chance of something going wrong. This feeling of incompleteness also is described by patients with Tourette's syndrome and tricho- tillomania. Both describe a feeling of incompleteness with continued tension until they have finished pulling out an entire patch of hair or until they have completed a sequence of tics to their satisfaction. Both describe the impossibility of stopping in the middle of their compulsive actions, in spite of consequences. The core features appear to relate to both the clinical features of OCD as well as their relationship to comorbid disorders. Patients with abnormalities in risk assessment have high levels of anxiety associated with their symptoms. In addition, they are more likely to have comorbid Axis I panic disorder, generalized anxiety disorder or social phobia, avoidant and dependent personality features, and a family history of an anxiety disorder. In contrast, patients with incompleteness are more likely to manifest low levels of anxiety, to have comorbid multiple tics or habit disorders such as trichotillomania or onchyphagia, and to have compulsive personality features. Empirical validation of these subgroups may have important implications for diagnosis and treatment. There is already some evidence that patients with treatment-resistant OCD and tic spectrum disorder are particularly responsive to dopaminergic antagonists. These patients also are more likely to exhibit incompleteness. References - Akhtar S, Win NN, Varma VK, et al: A phenomenological analysis of symptoms in obsessive compulsive neurosis. 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Rasmussen, MD Butler Hospital 345 Blackstone Boulevard Providence, RI 02906