Original Research

Prevalence of Psychotic Disorders in Patients with ObsessiveCompulsive Disorder

Lieuwe de Haan, MD, PhD, Christine Dudek-Hodge, MD, PhD, Yolanda Verhoeven, MD, and Damiaan Denys, MD, PhD

ABSTRACT
Introduction: The co-occurrence of obsessive-compulsive disorder (OCD) in patients with schizophrenia and related disorders has been increasingly recognized. However, the rate of psychosis comorbidity in OCD patients has yet to be systematically evaluated. Methods: The prevalence of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychotic disorders was evaluated in 757 subjects consecutively referred to a specialised diagnostic and treatment facility for OCD. Demographic and clinical characteristics were assessed. Results: Thirteen OCD patients (1.7%) also met the DSM-IV criteria for a psychotic disorder. We found no significant differences in clinical characteristic between OCD patients with and without a psychotic disorder, although patients with OCD and a psychotic disorder more likely used illicit substances and more likely were male.

FOCUS POINTS

Relatively few patients referred to a specialized obsessive-compulsive disorder (OCD) treatment center suffer from a psychotic disorder. Treatment facilities dedicated to the care of psychotic patients are more likely to be confronted with psychosis and obsessive-compulsive symptoms (OCS) or OCD comorbidity. Research focused on the development of co-morbid OCS and psychotic symptoms is needed. Conclusion: Relatively few patients referred to a specialized treatment OCD center suffer from a psychotic disorder. CNS Spectr. 2009;14(8):415-417

INTRODUCTION
Obsessive-compulsive symptoms (OCS) and obsessive-compulsive disorder (OCD) are a common comorbid condition in patients with schizophrenia with a prevalence between 7% and 40%.1-7 OCS and OCD comorbidity in schizophrenic patients has been the object of extensi ve research in the last 10 years. This research has led to the conclusion that OCS and OCD in

Dr. de Haan is assistant professor in the Department of Psychiatry at Academic Medical Centre in Amsterdam. Dr. Dudek-Hodge is a resident in the Department of Psychiatry at Academic Medical Centre in Amsterdam. Dr. Verhoeven is a resident in the Department of Psychiatry at Academic Medical Centre in Amsterdam. Dr. Denys is professor and head of the Department of Psychiatry at Academic Medical Centre in Amsterdam. Faculty Disclosures: Dr. de Haan has received research/grant support from AstraZeneca and Eli Lilly; has received honoraria from Bristol-Meyers Squibb and Janssen-Cilag. Dr. Dudek-Hodge, Dr. Verhoeven, and Dr. Denys report no affiliation with or financial interests in any organization that may pose a conflict of interest. Submitted for publication: December 24, 2008; Accepted for publication: June 22, 2009. Please direct all correspondence to: Lieuwe de Haan, MD, PhD, Psychiatric Department, Academic Medical Center (AMC), Meibergdreef 5, 1105AZ Amsterdam, The Netherlands; Tel: 31- 20-8913500; Fax: 31-20-8913702; E-mail: l.dehaan@amc.uva.nl.

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schizophrenic patients can be seen as a separate category of schizophrenia, commonly referred to as schizo-obsessive disorder.5,8-10 Surprisingly, little is known about the prevalence of psychotic disorders in patients with recognized OCD. 1,11 In one study, the community prevalence of psychotic disorder in OCS and OCD patients has been found as high as 12%. 12 Identification of psychotic disorders in OCD patients may have prognostic and therapeutic implications.6,13 There are distinct differences in neurocognitive functioning and neurological soft signs between OCD patients, schizo-obsessive patients, and schizophrenia patients.7 In the present study we sought to determine the prevalence of psychotic disorders in patients referred to a specialized diagnostic and treatment facility for OCD.

METHODS
The study was conducted in a specialized academic department dedicated to the diagnosis and treatment of OCD in Utrecht, The Netherlands. All consecutively referred patients underwent an extensive diagnostic protocol. Diagnosis was based on the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders (SCID). Severity of OCD symptoms was assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). 14,15 All clinical assessments were performed by experienced and trained clinicians. The study was approved by the institutional review boards and written informed consent was obtained from the patients after they received full explanations regarding study procedures. Students t test and -square test were used as appropriate.

psychotic disorder group used cannabis and only one used 3,4-methylenedioxymethamphetamine and we found no significant difference in number of alcohol consumptions in the last week between groups. The global assessment of functioning scale (GAF) was rated in all patients to assess overall symptomatic and functional impairment. Mean GAF score was 56.1 (SD=10.4). The severity of OCS was rated for all patients using the Y-BOCS. Mean score on the Y-BOCS was 23.9 (SD=7). No significant differences were found in mean age at OCD onset, Y-BOCS total score, obsessions or compulsions subscale scores, or GAF at admission, between OCD patients with and without comorbid psychotic disorder. We found no significant differences in preceding treatment with antidepressants or cognitive behavioral therapy, although more patients with OCD and a psychotic disorder received an antipsychotic before referral (53.8% versus 13.3%, P=.005).

DISCUSSION
In the present study 1.7% of consecutively referred patients to a specialized treatment OCD center were diagnosed with a psychotic disorder according to DSM-IV. This finding is in contrast with the results of most of the studies examining the rate of OCD in schizophrenia pat ients.1,4,5,11,16,17,18,19 Our results are in concordance with the results from a recent study, 20 but in contrast with earlier research.12 One explanation for the low prevalence of psychotic disorders in OCD patients is that the time between the first OCS and the moment of seeking help is on average 8 years.12 During that time an emerging co morbid psychotic disorder would have led to clinical evaluation and treatment in the majority of the patients. In that case the patient would have been diagnosed with a psychotic disorder and co morbid OCD. The recent focus on early detection of first episode psychosis offers an explanation for the lower prevalence of psychosis in OCD populations in more recent studies.2,4,5,21 Another reason for the low prevalence of psychosis in OCD patients referred for diagnosis and treatment could be that the combination of OCD and psychosis make patients less likely to seek help, due to limited insight in their condition. This would explain why in the community the prevalence of OCD and psychosis has been found as high as 12% 12 while in outpatient and clinical
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RESULTS
Seven hundred fifty-seven subjects referred from January 1, 2000 to January 1, 2006 were included; 463 were female (62.3%). The mean age at OCD onset for the total sample was 21.9 years of age (SD=3.2). Thirteen subjects, five female, were diagnosed with a psychotic disorder (eight with schizophrenia, two with schizoaffective disorder, three with psychotic disorder not otherwise specified). Patients with OCD and a psychotic disorder were more likely to be male (P=.046) and to be a current drug user (P=.036). However, only one patient from the OCD and
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Original Research

setting it has been 0% to 1.7%.20 An explanation of the higher prevalence of OCS and OCD in patients with a primary diagnosis of psychosis could be that treatment of psychosis induces OCS or OCD in some patients. The difference in substance use at admission we found depends more on the relatively low substance use rate of the OCD group (3.8%) than on the high prevalence of substance use (15.4%) in the group with OCD and a psychotic disorder. Contrary to other studies, we did not find significant differences between OCD patients and OCD plus psychosis patients regarding OCD onset, YBOCS total score, obsessions or compulsions ,22,23 subscale scores or GAF scores at admission.7 There are several limitations to our study. Although the study sample contained 757 individuals, the group with co morbid psychosis was small and statistical analysis of between-group differences have to be interpreted with caution. As previously discussed, there is selection bias in our sample. Patients included in the study were referred from other psychiatric treatment facilities to a specialized clinic. It is possible that psychotic disorders are more frequently encountered in patients with OCD in the community. However, we think it is unlikely that the prevalence of psychotic disorders in treated patients with OCD is much higher, since patients with OCD and a psychotic disorder are among the most difficult to treat and therefore, as a group are more likely to be referred to a specialized treatment center.

REFERENCES

CONCLUSION
After systematic diagnostics according to protocol we found that relatively few patients referred to a specialized treatment OCD center suffer from a psychotic disorder. This is in strong contrast to earlier findings of high comorbidity of OCD and psychosis in community studies. CNS

1. Eisen JL, Beer DA, Pato MT, Venditto TA, Rasmussen SA. Obsessive-compulsive disorder in patients with schizophrenia or schizoaffective disorder. Am J Psychiatry. 1997;154:271-273. 2. Porto L, Bermanzohn P, Pollack S, et al. A profile of obsessive compulsive symptoms in schizophrenia. CNS Spectr. 1997;2:21-25. 3. Fabisch K, Fabisch H, Langs G, Huber HP, Zapotoczky HG. Incidence of obsessivecompulsive phenomena in the course of acute schizophrenia and schizoaffective disorder. Eur Psychiatry. 2001;16:336-341. 4. Poyurovsky M, Fuchs C, Weizman A. Obsessive-compulsive disorder in patients with first episode schizophrenia. Am J Psychiatry. 1999;156:1998-2000. 5. Poyurovsky M, Hramenkov S, Isakov V, e al. Obsessive-compulsive disorder in hospitalized patients with chronic schizophrenia. Psychiatry Res. 2001;102:49-57. 6. Tibbo P, Kroetsch M, Chue P, Warneke L. Obsessive-compulsive disorder in schizophrenia. J Psychiatr Res. 2000;34:139-146. 7. Sevincok L, Akoglu A, Arslantas H: Schizo-obsessive and obsessive compulsive disorder: Comparison of clinical characteristics and neurological soft signs. Psychiatry Res. 2006;145:241-248. 8. Rajkumar R, Reddy J, Kandavel T. Clinical profile of schizo-obsessive disorder: a comparative study. Compr Psychiatry. 2008;49:262-268. 9. Poyurovsky M, Kriss V, Weismann G, et al. Comparison of clinical characteristics and comorbidity in schizophrenia patients with and without obsessive compulsive disorder: schizophrenic and OC symptoms in schizophrenia. J Clin Psychiatry. 2003;64:1300-1307. 10. Poyurovsky M, Faragian S, Pashinian A et al. Clinical characteristics of schizotypical related obsessivecompulsive disorder. Psychiatry Res. 2008;159:254-258. 11. Ganesan V, Kumar TC, Khanna S. Obsessive-compulsive disorder and psychosis. Can J Psychiatry. 2001;46:750-754. 12. Karno M, Golding JM, Sorenson SB, Burnam MA. The epidemiology of obsessive-compulsive disorder in five US communities. Arch Gen Psychiatry. 1988;45:1094-1099. 13. Fenton WS, McGlashan TH. The prognostic significance of obsessive-compulsive symptoms in schizophrenia. Am J Psychiatry. 1986;143:437-441. 14. Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale, II: validity. Arch Gen Psychiatry. 1989;46:10121016. 15. de Haan L, Hoogenboom 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;39:25-30. 16. de Haan L, Linszen DH, Gorsira R. Clozapine and obsessions in patients with recent onset schizophrenia and other psychotic disorders. J Clin Psychiatry. 1999;60:364-365. 17. Van Nimwegen L, De Haan L, van Beveren N, et al. Obsessive-Compulsive Symptoms in a Randomized, Double-Blind Study With Olanzapine or Risperidone in Young Patients With Early Psychosis. J Clin Psychopharmacol. 2008;28:214-218. 18. De Haan L, Oekeneva A, Van Amelsvoort T, Linszen D. Obsessive-Compulsive Disorder and treatment with clozapine in 200 patients with recent-onset schizophrenia or related disorders. Eur Psychiatry. 2004;19:524. 19. De Haan L, Beuk N, Hoogenboom B, Dingemans P, Linszen D. Obsessive-Compulsive Symptoms during treatment with olanzapine and risperidone, a prospective study of 113 patients with recent-onset schizophrenia or related disorders. J Clin Psychiatry. 2002;63:104-107. 20. Reddy Y, Reddy P, Srinath S, Khanna S, Sheshadri SP, Girimaji SC. Comorbidity in juvenile obsessive-compulsive disorder: A report from India. Can J Psychiatry. 2000;45:274-278. 21. Pigott T, LHeureux F, Dubbert B, Berstein S, Murphy DL. Obsessive compulsive disorder: comorbid conditions. J Clin Psychiatry. 1994;55(suppl):15-27. 22. Poyurovsky M, Fuchs C, Faragian S. Prefential aggregation of obsessive-compulsive spectrum disorders in schizophrenia patients with obsessive-compulsive disorder. Can J Psychiatry. 2006;51:746-754. 23. Whitney K, Fastenau P, Evans J, Lysaker PH. Comparative neuropsychological function in obsessive-compulsive disorder and schizophrenia with and without obsessive-compulsive symptoms. Schizophr Res. 2004;69:75-83.

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