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Obsessive-Compulsive Spectrum Disorders Andrea Allen, Phd; Audrey King, Phd; Eric Hollander, MD

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Obsessive-Compulsive Spectrum Disorders Andrea Allen, Phd; Audrey King, Phd; Eric Hollander, MD Clinical research Obsessive-compulsive spectrum disorders Andrea Allen, PhD; Audrey King, PhD; Eric Hollander, MD O bsessive-compulsive disorder (OCD) is char- acterized by obsessions and compulsions, but it has become clear that there are a significant number of other disorders that have core obsessive and compulsive fea- tures. Disorders that include such features cross several diagnostic categories and can be grouped according to the focus of the symptoms: bodily preoccupation, impulse control, or neurological disorders (Table I). In addition to having obsessive and compulsive symptoms, all of these disorders also have some similarities in patient characteristics, course, comorbidities, neurobiology, or The obsessive-compulsive spectrum is an important con- treatment response.Thus, an obsessive-compulsive (OC) cept referring to a number of disorders drawn from sev- spectrum has been proposed, for which all of these dis- eral diagnostic categories that share core obsessive-com- orders are candidates.1-4 Each of these disorders can often pulsive features. These disorders can be grouped by the be chronic and devastating in terms of the suffering focus of their symptoms: bodily preoccupation, impulse caused, the interference with functioning in important control, or neurological disorders. Although the disorders areas of life, and the economic toll to individuals and are clearly distinct from one another, they have intriguing society. similarities in phenomenology, etiology, pathophysiology, Individuals with these disorders exhibit repetitive behav- patient characteristics, and treatment response. In com- iors because they have a defect in the mechanism that bination with the knowledge gained through many years enables them to inhibit acting.2 The disorders vary in the of research on obsessive-compulsive disorder (OCD), the extent to which they are characterized by compulsivity concept of a spectrum has generated much fruitful versus impulsivity, and this difference is often discussed in research on the spectrum disorders. It has become appar- terms of a compulsive-impulsive spectrum.2-4 They vary in ent that these disorders can also be viewed as being on a numerous ways beginning with the phenomenology of continuum of compulsivity to impulsivity, characterized by this inability to resist acting. Compulsive disorders include harm avoidance at the compulsive end and risk seeking at OCD, body dysmorphic disorder (BDD), hypochondria- the impulsive end. The compulsive and impulsive disorders sis, and anorexia nervosa. Individuals who act compul- differ in systematic ways that are just beginning to be sively are avoiding risk and seeking safety; these individ- understood. Here, we review these concepts and several uals appear to have an exaggerated sense of harm and are representative obsessive-compulsive spectrum disorders driven to avoid harm or reduce anxiety and distress by including both compulsive and impulsive disorders, as well performing the compulsive behaviors. The impulsive dis- as the three different symptom clusters: OCD, body dys- morphic disorder, pathological gambling, sexual compul- Author affiliations: Department of Psychiatry, Mount Sinai School of sivity, and autism spectrum disorders. Medicine, New York, NY, USA © 2003, LLS SAS Dialogues Clin Neurosci. 2003;5:259-271. Address for correspondence: Andrea Allen, PhD, Department of Psychiatry, Mount Sinai School of Medicine, Box 1230, One Gustave L. Levy Place, New Keywords: obsessive-compulsive disorder; body dysmorphic disorder; patholog- York, NY 10029-6574, USA ical gambling; sexual compulsivity; autism; Asperger’s disorder; impulsivity (e-mail: [email protected]) Copyright © 2003 LLS SAS. All rights reserved 259 www.dialogues-cns.org Clinical research Selected abbreviations and acronyms involve risk taking rather than risk avoidance.The seem- ASD autism spectrum disorder ingly opposing drives of compulsivity and impulsivity can BDD body dysmorphic disorder exist at the same time in one individual or appear at dif- CBT cognitive behavioral therapy ferent times during the course of a disorder. OCD obsessive-compulsive disorder Baxter and his colleagues have suggested that OC spec- OC obsessive-compulsive (spectrum) trum disorders as a whole may involve corticostriatal dys- PG pathological gambling function with the specific disorders having different areas PRD paraphilia-related disorder of dysfunction within this system.5,6 Structural imaging SC sexual compulsivity supports this hypothesis; studies have shown volumetric SNRI serotonin and norepinephrine reuptake inhibitor abnormalities in these structures in numerous OC spec- SRI serotonin reuptake inhibitor trum disorders.6 In addition, the different ends of the SSRI selective serotonin reuptake inhibitor compulsive-impulsive spectrum seem to differ systemat- ically in their pathophysiology and thus differ somewhat orders include, for example, pathological gambling (PG) in their treatment response.2,7 Indications are that com- and sexual compulsivity (SC).Those who act impulsively pulsive disorders are characterized by increased frontal are risk takers, who underestimate the likelihood or sever- lobe activity and increased sensitivity of specific sero- ity of possible harm; they are seeking pleasure, arousal, or tonin receptor subsystems, while impulsive disorders are gratification; their actions may also be aggressive and are characterized by decreased frontal lobe activity and often accompanied by feelings of loss of control. The decreased presynaptic serotonergic function.2 impulsive disorders are also often discussed as addictions, We will first outline the characteristics of OCD, the pro- and treatment programs modeled after those used for totypical OC spectrum disorder, and then compare it substance abuse have arisen to treat them. These disor- with several OC spectrum disorders drawn from differ- ders have many similarities to addictions, but differ from ent symptom categories and from different ends of the traditional addictions in numerous ways, most notably in compulsive-impulsive spectrum. that they do not involve the intake of psychoactive sub- stances. They are also sometimes considered as compul- Obsessive-compulsive disorder sive disorders, but are differentiated from compulsive dis- orders in our conceptualization for several reasons. For OCD is characterized by obsessions and compulsions. example, at least in the initial stages of the disorder, the The obsessions are recurrent thoughts, impulses, or repetitive behaviors are sought for pleasure and they images, which are intrusive and ego dystonic; they are related to basic fears or urges that are distressing to the Category Representative disorders individual, such as contamination, aggression, sex, reli- Bodily preoccupation Body dysmorphic disorder (BDD) gion/scrupulosity, order/symmetry, hoarding, or patho- Hypochondriasis logical doubt. The compulsions are repetitive behaviors, Eating disorders including mental acts that the individual feels compelled Depersonalization disorder to perform to reduce the anxiety created by the obses- Impulse control Pathological gambling (PG) sions. The compulsions are often performed in specific Sexual compulsivity (SC) ways, and can result in elaborate rituals. Kleptomania With the exception of children, individuals with OCD Trichotillomania recognize at some point in time that their obsessions are Intermittent explosive disorder excessive or unreasonable.This insight can vary over time Borderline personality disorder and from situation to situation. It is not unusual for an Antisocial personality disorder individual to have insight when not in an OCD-provok- Neurological disorders Autism ing situation, but to have insight disappear when faced Asperger disorder with an OCD fear and thus feel compelled to perform a Tourette syndrome ritual. Sydenham chorea The obsessions and compulsions are intrusive, preoccu- Table I. Obsessive-compulsive disorders. pying, and distressing. The obsessions interfere with 260 Obsessive-compulsive spectrum disorder - Allen et al Dialogues in Clinical Neuroscience - Vol 5 . No. 3 . 2003 attention and concentration, thus interfering with cogni- ment of selective serotonin reuptake inhibitors (SSRIs) tive tasks and often social interactions. The obsessions greatly expanded the options for treatment of OCD.The and compulsions can be very time-consuming: they inter- SSRIs have more favorable side-effect profiles than fere with functioning because of the time they occupy, clomipramine, and have become the first-line treatments and because patients with OCD often develop patterns for OCD.They include citalopram, escitalopram, fluoxe- of avoidance of situations or things that provoke their tine, fluvoxamine, paroxetine, and sertraline.Venlafaxine, obsessions or compulsions. a newer SNRI, is also used to treat OCD. Most have been OCD typically begins in late adolescence or early established as effective in OCD through large controlled adulthood with an earlier age of onset for males than trials: citalopram,22 clomipramine,23 fluoxetine,24,25 fluvox- females.8-10 In adult clinical samples, OCD is equally amine,26,27 paroxetine,28 and sertraline.29,30 In addition, common in females as in males,11 but, due to a higher there is evidence for the efficacy of venlafaxine in treat- incidence of childhood-onset OCD in males, younger ment-resistant OCD.31 The SRIs (including all the SSRIs samples have more males than females.12 Compared and the SNRIs clomipramine and venlafaxine) are
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