David Baxter PhD
Late Founder
Unraveling the Mystery of OCD
by Norman Sussman, MD, DFAPA
Psychiatry Weekly, Volume 3, Issue 37, on November 17, 2008
November 17, 2008
The diverse clinical presentations of obsessive-compulsive disorder (OCD) often lead to confusion when diagnosing patients with OCD-like symptoms. The dimensions of OCD, broadly defined, include
Three recent studies1-3 provide important new insights into the underlying brain circuits involved in OCD, and how these correlate with clinical presentations.
Menzies and colleagues1 found that adult patients with OCD and unaffected first-degree relatives showed white matter changes, including a significant increase in fractional anisotropy in a right medial frontal region and significantly reduced fractional anisotropy in a large region of the right inferior parietal white matter. The majority of patients had either prominent contamination obsessions, washing compulsions, or prominent checking compulsions, suggesting that these white matter findings are closely related to a specific OCD symptom dimension.
Szeszko and colleagues2 indicated that, in addition to white matter changes, some pediatric patients with OCD have structural changes in regions comprising cortical-striatal-thalamic-cortical circuits. Patients with either predominant contamination/cleaning or aggressive/checking symptoms have significantly more gray matter bilaterally in both the putamen and orbital frontal cortex, suggesting that these structures may contribute to the circuitry that supports these OCD symptom dimensions.
Purtusa and colleagues,3 found that compulsive hoarding appears to be a syndrome separate from OCD in most individuals. Yet in other individuals, compulsive hoarding seems to be a symptom of OCD. Reconciling these findings is clearly a challenge for those drafting the DSM-V. Prominent hoarding symptoms differ from nonhoarding OCD patients across many important respects, including an earlier onset but later presentation for treatment, according to the authors. Hoarding symptoms are consistently associated with poor response to cognitive-behavioral therapy and pharmacological inventions.
In an accompanying editorial, Leckman and Bloch4 say it is likely that the answers to some of the uncertainties about how to define and categorize OCD will come from genetic research. They posit that genes are specific to certain subtypes or dimensions, while others are ?generalist? genes that influence the expression of OCD and closely related disorders. These related disorders might include major depression, body dysmorphic disorder, trichotillomania, tic disorders, and compulsive hoarding. The task of researchers will be to determine which networks produce normal and dysfunctional obsessive-compulsive phenomena and then develop appropriate interventions.
References
by Norman Sussman, MD, DFAPA
Psychiatry Weekly, Volume 3, Issue 37, on November 17, 2008
November 17, 2008
The diverse clinical presentations of obsessive-compulsive disorder (OCD) often lead to confusion when diagnosing patients with OCD-like symptoms. The dimensions of OCD, broadly defined, include
- forbidden thoughts;
- obsessions with symmetry and exactness and related ordering and arranging rituals, as well as counting and repeating rituals;
- contamination obsessions and washing compulsions;
- hoarding obsessions and compulsions.
Three recent studies1-3 provide important new insights into the underlying brain circuits involved in OCD, and how these correlate with clinical presentations.
Menzies and colleagues1 found that adult patients with OCD and unaffected first-degree relatives showed white matter changes, including a significant increase in fractional anisotropy in a right medial frontal region and significantly reduced fractional anisotropy in a large region of the right inferior parietal white matter. The majority of patients had either prominent contamination obsessions, washing compulsions, or prominent checking compulsions, suggesting that these white matter findings are closely related to a specific OCD symptom dimension.
Szeszko and colleagues2 indicated that, in addition to white matter changes, some pediatric patients with OCD have structural changes in regions comprising cortical-striatal-thalamic-cortical circuits. Patients with either predominant contamination/cleaning or aggressive/checking symptoms have significantly more gray matter bilaterally in both the putamen and orbital frontal cortex, suggesting that these structures may contribute to the circuitry that supports these OCD symptom dimensions.
Purtusa and colleagues,3 found that compulsive hoarding appears to be a syndrome separate from OCD in most individuals. Yet in other individuals, compulsive hoarding seems to be a symptom of OCD. Reconciling these findings is clearly a challenge for those drafting the DSM-V. Prominent hoarding symptoms differ from nonhoarding OCD patients across many important respects, including an earlier onset but later presentation for treatment, according to the authors. Hoarding symptoms are consistently associated with poor response to cognitive-behavioral therapy and pharmacological inventions.
In an accompanying editorial, Leckman and Bloch4 say it is likely that the answers to some of the uncertainties about how to define and categorize OCD will come from genetic research. They posit that genes are specific to certain subtypes or dimensions, while others are ?generalist? genes that influence the expression of OCD and closely related disorders. These related disorders might include major depression, body dysmorphic disorder, trichotillomania, tic disorders, and compulsive hoarding. The task of researchers will be to determine which networks produce normal and dysfunctional obsessive-compulsive phenomena and then develop appropriate interventions.
References
- Menzies L, Williams GB, Chamberlain SR, et al. White matter abnormalities in patients with obsessive-compulsive disorder and their first-degree relatives. Am J Psychiatry. 2008;165(10):1308-1315.
- Szeszko PR, Christian C, MacMaster F, et al. Gray matter structural alterations in psychotropic drug-naive pediatric obsessive-compulsive disorder: an optimized voxel-based morphometry study. Am J Psychiatry. 2008;165(10):1299-1307.
- Pertusa A, Fullana MA, Singh S, et al. Compulsive hoarding: OCD symptom, distinct clinical syndrome, or both? Am J Psychiatry. 2008;165(10):1289-1298.
- Leckman JF, Bloch MH. A developmental and evolutionary perspective on obsessive-compulsive disorder: whence and whither compulsive hoarding? Am J Psychiatry. 2008;165(10):1229-1233.
