Degree of insight
|
Pro: As reviewed,2525 . Leckman JF, Denys D, Simpson HB, Mataix-Cols D, Hollander E,
Saxena S, et al. Obsessive-compulsive disorder: a review of the diagnostic
criteria and possible subtypes and dimensional specifiers for DSM-V. Depress
Anxiety. 2010;27:507-27. data show that
people with OCD display a range of insight into the reality
of their obsessive-compulsive beliefs. A small subset of
people show no insight, and are completely convinced that
their obsessive-compulsive beliefs are true. The addition of
such a specifier would help clinicians recognize this range
of insight in OCD patients and potentially prevent some
patients from being incorrectly diagnosed as having a
psychotic disorder that would be erroneously treated with
antipsychotic monotherapy. |
Con: The ability of
clinicians across diverse settings to reliably use such an
insight specifier is unknown. The global applicability of
the concept of insight needs to be studied. |
Tic-related OCD
|
Pro: As reviewed,2525 . Leckman JF, Denys D, Simpson HB, Mataix-Cols D, Hollander E,
Saxena S, et al. Obsessive-compulsive disorder: a review of the diagnostic
criteria and possible subtypes and dimensional specifiers for DSM-V. Depress
Anxiety. 2010;27:507-27. some forms of OCD
have been associated with chronic tic disorders, including
Tourette syndrome, and may be etiologically linked. Data
suggest that those with comorbid tic disorders may respond
better to antipsychotic augmentation of a serotonin reuptake
inhibitor than those without a personal history of tic
disorder.5050 . Bloch MH, Landeros-Weisenberger A, Kelmendi B, Coric V, Bracken
MB, Leckman JF. A systematic review: antipsychotic augmentation with treatment
refractory obsessive-compulsive disorder. Mol Psychiatry.
2006;11:622-32.
Finally, some children with comorbid tic disorders may have
an increased likelihood of remission.5252 . Bloch MH, Craiglow BG, Landeros-Weisenberger A, Dombrowski PA,
Panza KE, Peterson BS, et al. Predictors of early adult outcomes in
pediatric-onset obsessive-compulsive disorder. Pediatrics.
2009;124:1085-93.
|
Con: Not all OCD
patients with comorbid tic disorders differ from those
without comorbid tic disorders; thus, differentiating which
tic disorders are “related” to OCD and which
are not is not necessarily obvious. Moreover, if a comorbid
diagnosis of tic disorder is separately made (as the
diagnostic guideline intends that it should be), then having
this specifier for OCD is redundant. |
Early-onset OCD (i.e., onset before puberty)
|
Pro: As reviewed
elsewhere,2525 . Leckman JF, Denys D, Simpson HB, Mataix-Cols D, Hollander E,
Saxena S, et al. Obsessive-compulsive disorder: a review of the diagnostic
criteria and possible subtypes and dimensional specifiers for DSM-V. Depress
Anxiety. 2010;27:507-27.
early-onset OCD has been found in some studies to present
with a higher rate of OCD among relatives, to differ in
comorbidity and course, and to occur more commonly in
males. |
Con: Studies have
confounded tic-related and early-onset OCD, as well as used
varying definitions of early-onset OCD. Given the variation
in developmental trajectory, choosing a specific age by
which OCD-onset is deemed early is pseudo-precise. At the
same time, using “onset prior to puberty” has
the problem that studies of early-onset OCD did not
typically measure puberty; moreover, it raises the issue of
how clinicians will determine puberty. Finally, it is not
clear that early-onset OCD necessitates different treatment
decisions.5353 . Nakatani E, Krebs G, Micali N, Turner C, Heyman I, Mataix-Cols D.
Children with very early onset obsessive-compulsive disorder: clinical features
and treatment outcome. J Child Psychol Psychiatry.
2011;52:1261-8.
|
Symptom dimensions
|
Pro: As reviewed
elsewhere,2525 . Leckman JF, Denys D, Simpson HB, Mataix-Cols D, Hollander E,
Saxena S, et al. Obsessive-compulsive disorder: a review of the diagnostic
criteria and possible subtypes and dimensional specifiers for DSM-V. Depress
Anxiety. 2010;27:507-27. a
dimensional approach to OCD symptoms may have value in
genetic, biological, and treatment studies. These dimensions
include either four factors (i.e., hoarding,
symmetry/ordering, contamination/cleaning, forbidden
thoughts) or five factors (i.e., the first three factors
[hoarding, symmetry/ordering,
contamination/clearing] with forbidden thoughts divided
into aggressive/sexual/religious obsessions and harm
obsessions with checking compulsions). |
Con: Dimensions are
complex, and using them as a specifier places a burden on
clinicians. Moreover, the strongest evidence is for the
hoarding dimension; however, individuals with predominant
hoarding symptoms will now be given a separate diagnosis of
Hoarding Disorder. Importantly, most individuals with OCD
have symptoms in multiple dimensions, and the symptom
dimensions are not necessarily stable over time.5454 . Rettew DC, Swedo SE, Leonard HL, Lenane MC, Rapoport JL.
Obsessions and compulsions across time in 79 children and adolescents with
obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry.
1992;31:1050-6.,5555 . Mataix-Cols D, Rauch SL, Baer L, Eisen JL, Shera DM, Goodman WK,
et al. Symptom stability in adult obsessive-compulsive disorder: data from a
naturalistic two-year follow-up study. Am J Psychiatry.
2002;159:263-8. Finally, other than
for Hoarding Disorder itself, different treatment choices
are not currently made for the different dimensions. |
Pediatric autoimmune neuropsychiatric disorders
associated with streptococcal infections (PANDAS)
|
Pro: As reviewed
elsewhere,2525 . Leckman JF, Denys D, Simpson HB, Mataix-Cols D, Hollander E,
Saxena S, et al. Obsessive-compulsive disorder: a review of the diagnostic
criteria and possible subtypes and dimensional specifiers for DSM-V. Depress
Anxiety. 2010;27:507-27. it
has been hypothesized that some susceptible individuals
develop an abrupt and dramatic onset of OCD symptoms and tic
disorders as the result of an autoimmune process following
group A beta-hemolytic streptococcal infection. This
syndrome has been called pediatric autoimmune
neuropsychiatric disorders associated with streptococcal
infections (PANDAS), and may identify a subgroup of children
who might benefit from treatments other than standard
medications and cognitive-behavioral therapy for OCD. |
Con: To date, strong
support for alternative treatments for suspected cases of
PANDAS is lacking.5656 . Swedo SE, Leckman JF, Rose NR. From research subgroup to clinical
syndrome: modifying the PANDAS criteria to describe PANS (Pediatric Acute-onset
Neuropsychiatric Syndrome). Pediatric Therapeut. 2012;2:1-8.
Also, it is unclear whether PANDAS is better conceptualized
as a specifier of OCD (e.g., identifying a subset of OCD
patients with a shared etiology) or a separate disorder (and
therefore an exclusion). Finally, streptococcal infection
may be only one of multiple causes for the abrupt and
dramatic onset of OCD symptoms, which is now being called
pediatric acute-onset neuropsychiatric syndrome (PANS5656 . Swedo SE, Leckman JF, Rose NR. From research subgroup to clinical
syndrome: modifying the PANDAS criteria to describe PANS (Pediatric Acute-onset
Neuropsychiatric Syndrome). Pediatric Therapeut. 2012;2:1-8.) or childhood acute
neuropsychiatric symptoms (CANS3737 . Singer HS, Gilbert DL, Wolf DS, Mink JW, Kurlan R. Moving from
PANDAS to CANS. J Pediatr. 2011;160:725-31.). |
Incomplete versus harm-avoidant
|
Pro: Two core
dimensions of OCD have been proposed: harm avoidance (those
with anxious apprehension and exaggerated avoidance of
potential harm) and incompleteness (those with sensations of
things being incomplete or not “just
right”).5757 . Pietrefesa AS, Coles ME. Moving beyond an exclusive focus on harm
avoidance in obsessive-compulsive disorder: behavioral validation for the
separability of harm avoidance and incompleteness. Behav Ther.
2009;40:251-9.
58 . Rasmussen SA, Eisen JL. The epidemiology and clinical features of
obsessive compulsive disorder. Psychiatr Clin North Am.
1992;15:743-58.-5959 . Summerfeldt LJ. Understanding and treating incompleteness in
obsessive-compulsive disorder. J Clin Psychol. 2004;60:1155-68.
These two dimensions have been associated with different
emotional responses (i.e., anxiety/nervousness and a desire
to prevent harm versus tension/discomfort and a desire to
perform tasks until they are just right), different age of
onset (later onset versus earlier onset), different
comorbidity patterns (e.g., other anxiety disorders versus
comorbid tic disorders and obsessive-compulsive personality
disorder), and, possibly, different treatment outcome
(reviewed in Pietrefesa & Coles5757 . Pietrefesa AS, Coles ME. Moving beyond an exclusive focus on harm
avoidance in obsessive-compulsive disorder: behavioral validation for the
separability of harm avoidance and incompleteness. Behav Ther.
2009;40:251-9.). |
Con: OCD patients can
exhibit both harm avoidance and incompleteness.6060 . Conelea CA, Freeman JB, Garcia AM. Integrating behavioral theory
with OCD assessment using the Y-BOCS/CY-BOCS symptom checklist. J Obsessive
Compuls Relat Disord. 2012;1:112-8. To date, strong
evidence supporting different treatments for these
dimensions is lacking. |
Course
|
Pro: For many
individuals, the course of OCD is chronic, often with waxing
and waning symptoms; at the same time, a subset of
individuals may have an episodic or a deteriorating
course.1919 . Skoog G, Skoog I. A 40-year follow-up of patients with
obsessive-compulsive disorder. Arch Gen Psychiatry.
1999;56:121-7.,3838 . Ravizza L, Maina G, Bogetto F. Episodic and chronic
obsessive-compulsive disorder. Depress Anxiety. 1997;6:154-8. Without treatment,
recovery rates in adults are usually low (e.g., 20% for
those evaluated 40 years later1919 . Skoog G, Skoog I. A 40-year follow-up of patients with
obsessive-compulsive disorder. Arch Gen Psychiatry.
1999;56:121-7.). With treatment, remission rates
vary widely across studies, as do rates of relapse.1717 . Ruscio AM, Stein DJ, Chiu WT, Kessler RC. The epidemiology of
obsessive-compulsive disorder in the National Comorbidity Survey Replication.
Mol Psychiatry. 2010;15:53-63.,2020 . Eisen JL, Sibrava NJ, Boisseau CL, Mancebo MC, Stout RL, Pinto A,
et al. Five-year course of obsessive-compulsive disorder: predictors of
remission and relapse. J Clin Psychiatry. 2013;74:233-9.,5151 . Math SB, Thoduguli J, Janardhan Reddy YC, Manoj PN, Zutshi A,
Rajkumar RP, et al. A 5-year course of predominantly obsessive vs. mixed
subtypes of obsessive-compulsive disorder. Indian J Psychiatry.
2007;49:250-5.,6060 . Conelea CA, Freeman JB, Garcia AM. Integrating behavioral theory
with OCD assessment using the Y-BOCS/CY-BOCS symptom checklist. J Obsessive
Compuls Relat Disord. 2012;1:112-8.
61 . Eisen JL, Pinto A, Mancebo MC, Dyck IR, Orlando ME, Rasmussen SA.
A 2-year prospective follow-up study of the course of obsessive-compulsive
disorder. J Clin Psychiatry. 2010;71:1033-9.
62 . Matsunaga H, Hokari R, Higashiyama M, Kurihara C, Okada Y,
Watanabe C, et al. Cilostazol, a specific PDE-3 inhibitor, ameliorates chronic
ileitis via suppression of interaction of platelets with monocytes. Am J Physiol
Gastrointest Liver Physiol. 2009;297:G1077-84.
63 . Angst J, Gamma A, Endrass J, Goodwin R, Ajdacic V, Eich D, et al.
Obsessive-compulsive severity spectrum in the community: prevalence,
comorbidity, and course. Eur Arch Psychiatry Clin Neurosci.
2004;254:156-64.-6464 . Catapano F, Perris F, Masella M, Rossano F, Cigliano M, Magliano
L, et al. Obsessive-compulsive disorder: a 3-year prospective follow-up study of
patients treated with serotonin reuptake inhibitors OCD follow-up study. J
Psychiatr Res. 2006;40:502-10. In children and
adolescents, 40% may remit by early adulthood.6565 . Stewart SE, Geller DA, Jenike M, Pauls D, Shaw D, Mullin B, et al.
Long-term outcome of pediatric obsessive-compulsive disorder: a meta-analysis
and qualitative review of the literature. Acta Psychiatr Scand.
2004;110:4-13. Thus, a course
specifier (e.g., single episode in remission, episodic, and
chronic course) may have some treatment implications. For
example, in those with a single episode of OCD who remit, an
attempt to taper and stop medications may be appropriate; in
those with chronic symptoms, treatment may have to be
continued for a much longer period or indefinitely. |
Con: The course of OCD
can vary substantially, depending not only on the natural
history of the illness and the type of samples studied,5151 . Math SB, Thoduguli J, Janardhan Reddy YC, Manoj PN, Zutshi A,
Rajkumar RP, et al. A 5-year course of predominantly obsessive vs. mixed
subtypes of obsessive-compulsive disorder. Indian J Psychiatry.
2007;49:250-5.,6262 . Matsunaga H, Hokari R, Higashiyama M, Kurihara C, Okada Y,
Watanabe C, et al. Cilostazol, a specific PDE-3 inhibitor, ameliorates chronic
ileitis via suppression of interaction of platelets with monocytes. Am J Physiol
Gastrointest Liver Physiol. 2009;297:G1077-84.,6363 . Angst J, Gamma A, Endrass J, Goodwin R, Ajdacic V, Eich D, et al.
Obsessive-compulsive severity spectrum in the community: prevalence,
comorbidity, and course. Eur Arch Psychiatry Clin Neurosci.
2004;254:156-64. but also on the
presence of comorbidity, the nature of the treatment
received, and the length of follow-up.6666 . Marcks BA, Weisberg RB, Dyck I, Keller MB. Longitudinal course of
obsessive-compulsive disorder in patients with anxiety disorders: a 15-year
prospective follow-up study. Compr Psychiatry. 2011;52:670-7. Definitions of course (e.g.,
response, remission, relapse) have also varied across
studies.6767 . Simpson HB, Huppert JD, Petkova E, Foa EB, Liebowitz MR. Response
versus remission in obsessive-compulsive disorder. J Clin Psychiatry.
2006;67:269-76.,6868 . Simpson HB, Franklin ME, Cheng J, Foa EB, Liebowitz MR. Standard
criteria for relapse are needed in obsessive-compulsive disorder. Depress
Anxiety. 2005;21:1-8. Given these
complexities, it is hard to generalize about course in OCD.
In addition, there are little data to support different
treatment recommendations for those with different courses.
As a result, it not clear that a course specifier has
clinical utility or can be used reliably. |
Severity
|
Pro: Some studies have
shown that greater symptom severity is associated with
poorer treatment response and outcome.2020 . Eisen JL, Sibrava NJ, Boisseau CL, Mancebo MC, Stout RL, Pinto A,
et al. Five-year course of obsessive-compulsive disorder: predictors of
remission and relapse. J Clin Psychiatry. 2013;74:233-9.,6464 . Catapano F, Perris F, Masella M, Rossano F, Cigliano M, Magliano
L, et al. Obsessive-compulsive disorder: a 3-year prospective follow-up study of
patients treated with serotonin reuptake inhibitors OCD follow-up study. J
Psychiatr Res. 2006;40:502-10.,6969 . Steketee G, Eisen J, Dyck I, Warshaw M, Rasmussen S. Predictors of
course in obsessive-compulsive disorder. Psychiatry Res.
1999;89:229-38.
Classifying OCD into mild, moderate, and severe subtypes may
have treatment and prognostic implications. |
Con: Not all treatment
studies find that severity predicts outcome.7070 . Eisen J, Steketee G. Course of illness in obsessive-compulsive
disorder. In: Dickstein LJ, Riba MB, editors. American psychiatric press review
of psychiatry. Washington: American Psychiatric Association; 1997. p.
III-73-III-95.,7171 . Foa EB, Franklin ME. Psychotherapies for obsessive-compulsive
disorder: a review. In: Maj M, Sartorius N, Okasha A, Zohar J, editors.
Obsessive-compulsive disorder. 2nd edition. Chichester: Wiley; 2002. p.
93-115. Thus, the clinical
utility of severity is not clear. Moreover, poor outcome may
be related to a particular symptom dimension, such as
washing7272 . Alarcon RD, Libb JW, Spitler D. A predictive study of
obsessive-compulsive disorder response to clomipramine. J Clin Psychopharmacol.
1993;13:210-3.
73 . Ravizza L, Barzega G, Bellino S, Bogetto F, Maina G. Predictors of
drug treatment response in obsessive-compulsive disorder. J Clin Psychiatry.
1995;56:368-73.-7474 . Shetti CN, Reddy YC, Kandavel T, Kashyap K, Singisetti S, Hiremath
AS, et al. Clinical predictors of drug nonresponse in obsessive-compulsive
disorder. J Clin Psychiatry. 2005;66:1517-23. or hoarding.2020 . Eisen JL, Sibrava NJ, Boisseau CL, Mancebo MC, Stout RL, Pinto A,
et al. Five-year course of obsessive-compulsive disorder: predictors of
remission and relapse. J Clin Psychiatry. 2013;74:233-9.,5252 . Bloch MH, Craiglow BG, Landeros-Weisenberger A, Dombrowski PA,
Panza KE, Peterson BS, et al. Predictors of early adult outcomes in
pediatric-onset obsessive-compulsive disorder. Pediatrics.
2009;124:1085-93. Whether severity of
OCD irrespective of the principal symptom dimension predicts
outcome of OCD is unclear. Finally, categorizing OCD
severity into mild, moderate, and severe requires giving
clinicians simple and reliable tools for doing so. Studies
that examined the relation between OCD severity and outcome
used validated measures like the Yale-Brown Obsessive
Compulsive Scale,7575 . Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill
CL, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and
reliability. Arch Gen Psychiatry. 1989;46:1006-11.
which is a continuous variable. However, most clinicians do
not use structured scales such as this one before initiating
treatment. |