Prevalence of psychotic disorders in patients with obsessive-compulsive disorder.
ABSTRACT 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.
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.
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.
Relatively few patients referred to a specialized treatment OCD center suffer from a psychotic disorder.
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ABSTRACT: Epidemiological studies have found that obsessive-compulsive disorder (OCD) is estimated to occur in up to 12% of patients with schizophrenia. Furthermore, several etiopathogenic mechanisms have been postulated for understanding this co-occurrence. Whether this subgroup of "schizo-obsessive" patients may be posed as a clinical entity with a distinct psychopathological and functioning profile remains unclear. A sample of adult patients who met DSM-IV criteria for both schizophrenia/schizoaffective disorder and OCD (n=30) was compared with a "non-OCD schizophrenic" group (n=37) and another subset of "non-schizophrenic OCD" patients (n=30). The Positive and Negative Syndrome Scale (PANSS), the Scale to Assess Unawareness of Mental Disorder (SUMD), the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Brown Assessment of Beliefs Scale (BABS), the Clinical Global Severity scale (CGI), the Quality of Life Scale (QLS), and the Beck's Depression Inventory (BDI) were used. We found that "schizo-obsessive" subjects did not show significant differences in any outcome measures when compared to the "non-OCD schizophrenic" group. Furthermore, statistical analyses also revealed that the "non-schizophrenic OCD" group tended to have lower severity of psychopathology as well as greater quality of life than both psychotic groups. These findings indicate that comorbidity between schizophrenia/schizoaffective disorder and OCD does not comprise a distinct clinical entity, particularly when compared to "non-OCD schizophrenia" disorder. Discrepancies among previous studies may be justified by methodological divergences.Comprehensive psychiatry 03/2014; · 2.08 Impact Factor
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ABSTRACT: A large subgroup of schizophrenic patients develops obsessive-compulsive symptoms (OCS) during treatment with second-generation antipsychotics (SGA). A genetic risk factor for these secondary OCS was recently described in the gene SLC1A1 encoding the neuronal glutamate transporter excitatory amino acid carrier 1. The aim of this study was to replicate these findings in a European sample. A total of 103 schizophrenic patients treated with SGAs were included. Three single nucleotide polymorphisms in SLC1A1 (rs2228622, rs3780412 and rs3780413), which had been associated with SGA-induced OCS, were investigated. Single marker and haplotype analyses were tested with logistic regressions using age, sex and medication type as covariates. Treatment with markedly antiserotonergic SGAs such as clozapine was more prevalent in the subgroup of patients with comorbid OCS (P<0.001). The dosage and duration of clozapine treatment correlated significantly with the severity of OCS. In contrast to the Asian sample, no genetic associations were found with OCS. Larger samples are necessary to unravel the interplay of pharmacological and genetic risk factors for OCS in schizophrenia.Psychiatric genetics 04/2012; 22(5):245-52. · 2.33 Impact Factor
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ABSTRACT: A large subgroup of around 25% of schizophrenia patients suffers from obsessive-compulsive symptoms (OCS) and about 12% fulfill the diagnostic criteria of an obsessive-compulsive disorder (OCD). The additional occurrence of OCS is associated with high subjective burden of disease, additional neurocognitive impairment, poorer social and vocational functioning, greater service utilization and high levels of anxiety and depression. Comorbid patients can be assigned to heterogeneous subgroups. One hypothesis assumes that second generation antipsychotics (SGAs), most importantly clozapine, might aggravate or even induce second-onset OCS. Several arguments support this assumption, most importantly the observed chronological order of first psychotic manifestation, start of treatment with clozapine and onset of OCS. In addition, correlations between OCS-severity and dose and serum levels and duration of clozapine treatment hint toward a dose-dependent side effect. It has been hypothesized that genetic risk-factors dispose patients with schizophrenia to develop OCS. One study in a South Korean sample reported associations with polymorphisms in the gene SLC1A1 (solute carrier family 1A1) and SGA-induced OCS. However, this finding could not be replicated in European patients. Preliminary results also suggest an involvement of polymorphisms in the BDNF gene (brain-derived neurotrophic factor) and an interaction between markers of SLC1A1 and the gene DLGAP3 (disc large associated protein 3) as well as GRIN2B (N-methyl-D-aspartate receptor subunit 2B). Further research of well-defined samples, in particular studies investigating possible interactions of genetic risk-constellations and pharmacodynamic properties, are needed to clarify the assumed development of SGA-induced OCS. Results might improve pathogenic concepts and facilitate the definition of at risk populations, early detection and monitoring of OCS as well as multimodal therapeutic interventions.Frontiers in Pharmacology 01/2013; 4:99.
Prevalence of Psychotic Disorders
in Patients with Obsessive-
Lieuwe de Haan, MD, PhD, Christine Dudek-Hodge, MD, PhD, Yolanda Verhoeven, MD,
and Damiaan Denys, MD, PhD
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: email@example.com.
CNS Spectr 14:8 © MBL Communications Inc.
Introduction: The co-occurrence of obses-
sive-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 evalu-
ated in 757 subjects consecutively referred to a
specialised diagnostic and treatment facility for
OCD. Demographic and clinical characteristics
Results: Thirteen OCD patients (1.7%) also met
the DSM-IV criteria for a psychotic disorder. We
found no significant differences in clinical char-
acteristic between OCD patients with and with-
out a psychotic disorder, although patients with
OCD and a psychotic disorder more likely used
illicit substances and more likely were male.
• 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 psy-
chotic patients are more likely to be confronted
with psychosis and obsessive-compulsive symp-
toms (OCS) or OCD comorbidity.
• Research focused on the development of co-mor-
bid OCS and psychotic symptoms is needed.
Conclusion: Relatively few patients referred to
a specialized treatment OCD center suffer from a
CNS Spectr. 2009;14(8):415-417
Obsessive-compulsive symptoms (OCS) and
obsessive-compulsive disorder (OCD) are a
common comorbid condition in patients with
schizophrenia with a prevalence between 7%
OCS and OCD comorbidity in schizophrenic
patients has been the object of extensive
research in the last 10 years. This research
has led to the conclusion that OCS and OCD in
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 preva-
lence of psychotic disorders in patients with rec-
ognized 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.
The study was conducted in a specialized
academic department dedicated to the diag-
nosis 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 writ-
ten informed consent was obtained from the
patients after they received full explanations
regarding study procedures. Student’s t test and
χ-square test were used as appropriate.
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 disor-
der (eight with schizophrenia, two with schizoaf-
fective 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
psychotic disorder group used cannabis and
only one used 3,4-methylenedioxymethamphet-
amine 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 signifi-
cant differences were found in mean age at OCD
onset, Y-BOCS total score, obsessions or com-
pulsions subscale scores, or GAF at admission,
between OCD patients with and without comorbid
We found no significant differences in preceding
treatment with antidepressants or cognitive behav-
ioral therapy, although more patients with OCD
and a psychotic disorder received an antipsychotic
before referral (53.8% versus 13.3%, P=.005).
In the present study 1.7% of consecutively
referred patients to a specialized treatment OCD
center were diagnosed with a psychotic dis-
order 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 dis-
order 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 epi-
sode psychosis offers an explanation for the
lower prevalence of psychosis in OCD popula-
tions in more recent studies.2,4,5,21 Another rea-
son for the low prevalence of psychosis in OCD
patients referred for diagnosis and treatment
could be that the combination of OCD and psy-
chosis make patients less likely to seek help,
due to limited insight in their condition. This
would explain why in the community the preva-
lence of OCD and psychosis has been found as
high as 12%12 while in outpatient and clinical
CNS Spectr 14:8 © MBL Communications Inc. August 2009
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 sig-
nificant differences between OCD patients and
OCD plus psychosis patients regarding OCD onset,
YBOCS total score, obsessions or compulsions
subscale scores or GAF scores at admission.7 ,22,23
There are several limitations to our study.
Although the study sample contained 757 indi-
viduals, 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 selec-
tion 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 fre-
quently 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.
After systematic diagnostics according to
protocol we found that relatively few patients
referred to a specialized treatment OCD cen-
ter suffer from a psychotic disorder. This is
in strong contrast to earlier findings of high
comorbidity of OCD and psychosis in commu-
nity 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.
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 obsessive-
compulsive 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 schizo-
phrenia. J Psychiatr Res. 2000;34:139-146.
7. Sevincok L, Akoglu A, Arslantas H: Schizo-obsessive and obsessive compulsive dis-
order: Comparison of clinical characteristics and neurological soft signs. Psychiatry
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.
10. Poyurovsky M, Faragian S, Pashinian A et al. Clinical characteristics of schizotypical
related obsessive–compulsive 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-com-
pulsive 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;46:1012–1016.
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 schizo-
phrenia 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 schizo-
phrenia 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.
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, L’Heureux 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 func-
tion in obsessive-compulsive disorder and schizophrenia with and without obses-
sive-compulsive symptoms. Schizophr Res. 2004;69:75-83.
CNS Spectr 14:8 © MBL Communications Inc. August 2009