Symptom dimensions, clinical course and comorbidity in men and women with obsessive-compulsive disorder

Abstract

The study aimed to compare male and female patients with obsessive-compulsive disorder (OCD) across symptom dimensions, clinical course and comorbidity. A cross-sectional study was undertaken with 858 adult OCD patients (DSM-IV) from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. Patients were evaluated using structured interviews, including the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) and the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). The sample was composed of 504 women (58.7%) and 354 men (41.3%) with a mean age of 35.4 years-old (range: 18–77). Men were younger, more frequently single and presented more tics, social phobia and alcohol use disorders. Among men, symptom interference occurred earlier and symptoms of the sexual/religious dimension were more common and more severe. Conversely, women were more likely to present symptoms of the aggressive, contamination/cleaning and hoarding dimension and comorbidity with specific phobias, anorexia nervosa, bulimia, trichotillomania, skin picking and “compulsive” buying. In the logistic regression, female gender remained independently associated with the aggressive and contamination/cleaning dimensions. In both genders the aggressive dimension remained associated with comorbid post-traumatic stress disorder, the sexual/religious dimension with major depression and the hoarding dimension with tic disorders. Gender seems to be relevant in the determination of OCD clinical presentation and course and should be considered an important aspect when defining more homogeneous OCD subgroups.

Introduction

Clinical, epidemiological, genetic and intervention studies have consistently demonstrated the heterogeneous nature of obsessive-compulsive disorder (OCD). Efforts have been made by researchers to define more homogeneous subtypes of the disorder (Hounie et al., 2001, De Mathis et al., 2006), which could lead to the identification of specific environmental and genetic risk factors and to the development of more tailored and effective treatments. These include dividing OCD patients according to age of onset, symptom dimensions, comorbid conditions, and gender (Miguel et al., 2005).

Studies conducted in different countries suggest that some OCD gender-related clinical features are fairly universal, including, among male patients, earlier age of OCD onset (Rasmussen and Tsuang, 1986, Minichiello et al., 1990, Noshirvani et al., 1991, Neziroglu et al., 1994, Castle et al., 1995, Bogetto et al., 1999, Fontenelle et al., 2003, Lochner et al., 2004, Tükel et al., 2004, Karadag et al., 2006, Jaissorya et al., 2009, Torresan et al., 2009), with a greater impact on several life domains. A possible indirect indicator of this negative impact is marital status, as men with OCD are less frequently married (Noshirvani et al., 1991, Neziroglu et al., 1994, Castle et al., 1995, Lensi et al., 1996, Bogetto et al., 1999, Sobin et al., 1999, Tükel et al., 2004, Torres et al., 2006, Jaissorya et al., 2009, Torresan et al., 2009). This may also explain the different findings in prevalence of OCD among males and females in community versus clinical samples. In community samples the prevalence of OCD is slightly higher for women, whereas in clinical samples the number of men and women is similar (Karno et al., 1988, Weissman et al., 1994, Torres et al., 2006), suggesting that male sufferers present more interference on functioning and, therefore, seek treatment more often. Some authors have also described more family aggregation among men with OCD, as compared to women (Pauls et al., 1995, Geller et al., 1998, Rosário-Campos et al., 2005).

Regarding comorbidities, men with OCD are more likely than women to present social phobia (Bogetto et al., 1999, Hounie et al., 2001, Tükel et al., 2004, Jaissorya et al., 2009), tic disorders (Hounie et al., 2001, Jaissorya et al., 2009, Torresan et al., 2009) and substance use disorders (Noshirvani et al., 1991, Bogetto et al., 1999, Sobin et al., 1999, Lochner et al., 2004, Torres et al., 2006, Gentil et al., 2009).

Conversely, eating disorders (Noshirvani et al., 1991, Castle et al., 1995, Hantouche et al., 1996, Bogetto et al., 1999, Lochner et al., 2004, Torresan et al., 2009), major depression (Noshirvani et al., 1991, Castle et al., 1995, Sobin et al., 1999, Karadag et al., 2006, Labad et al., 2008) and impulse control disorders (Hantouche et al., 1996, Bogetto et al., 1999, Torresan et al., 2009) have been more frequently described among female patients.

Concerning OCD symptoms, some studies have reported that women are more likely to present contamination obsessions and/or cleaning rituals (Minichiello et al., 1990, Noshirvani et al., 1991, Ratnasuriya et al., 1991, Bogetto et al., 1999, Tükel et al., 2004, Karadag et al., 2006, Stein et al., 2007, Labad et al., 2008, Jaissorya et al., 2009, Li et al., 2009), while men have a greater likelihood of presenting sexual and/or religious obsessions and related compulsions (Ratnasuriya et al., 1991, Hantouche et al., 1996, Lensi et al., 1996, Bogetto et al., 1999, Sobin et al., 1999, Tükel et al., 2004, Karadag et al., 2006, Labad et al., 2008, Jaissorya et al., 2009, Torresan et al., 2009), and symmetry/ordering manifestations (Hantouche et al., 1996, Leckman et al., 1997, Karadag et al., 2006, Stein et al., 2007, Jaissorya et al., 2009, Li et al., 2009, Torresan et al., 2009). Some authors have also described more hoarding symptoms (Fischer et al., 1996/1997, Samuels et al., 2002, Stein et al., 2007) and aggressive obsessions (Hantouche et al., 1996, Lochner et al., 2004, Tükel et al., 2004) among male patients.

Recently, a dimensional approach for the evaluation of obsessive-compulsive symptoms (OCS) was proposed (Rosário-Campos et al., 2006). The importance of this approach has been supported by genetic and neuroimaging studies that showed relevant differences among the OCD dimensions (Mataix-Cols et al., 2004, Pujol et al., 2004, Gilbert et al., 2008, van Grootheest et al., 2008). To our knowledge, only one previous study with 186 patients (Labad et al., 2008) has used the dimensional approach to study OCD gender differences. A positive association was verified among females with the contamination–cleaning dimension and, among males, with the sexual–religious dimension. This study, however, was limited by the fact that symptom dimensions were derived from the Y-BOCS checklist and not directly assessed with a dimensional instrument.

The aim of this study was to compare male and female patients with OCD across symptom dimensions, clinical course and Axis I comorbidity. Based on the literature, our main hypotheses were that, compared to women, men would be more likely to be single (Noshirvani et al., 1991, Neziroglu et al., 1994, Castle et al., 1995, Lensi et al., 1996, Bogetto et al., 1999, Sobin et al., 1999, Tükel et al., 2004, Torres et al., 2006, Jaissorya et al., 2009, Torresan et al., 2009), to present family history of obsessive-compulsive symptoms or disorder (Pauls et al., 1995, Geller et al., 1998, Rosário-Campos et al., 2005), earlier OCD onset (Rasmussen and Tsuang, 1986, Minichiello et al., 1990, Noshirvani et al., 1991, Neziroglu et al., 1994, Castle et al., 1995, Bogetto et al., 1999, Fontenelle et al., 2003, Lochner et al., 2004, Tükel et al., 2004, Karadag et al., 2006, Jaissorya et al., 2009, Torresan et al., 2009), more sexual–religious (Ratnasuriya et al., 1991, Hantouche et al., 1996, Lensi et al., 1996, Bogetto et al., 1999, Sobin et al., 1999, Tükel et al., 2004, Karadag et al., 2006, Labad et al., 2008, Jaissorya et al., 2009, Torresan et al., 2009) and symmetry-ordering symptoms (Hantouche et al., 1996, Leckman et al., 1997, Karadag et al., 2006, Stein et al., 2007, Jaissorya et al., 2009, Li et al., 2009, Torresan et al., 2009), and more comorbidity with social phobia (Bogetto et al., 1999, Hounie et al., 2001, Tükel et al., 2004, Jaissorya et al., 2009), tic disorders (Hounie et al., 2001, Jaissorya et al., 2009, Torresan et al., 2009) and substance use disorders (Noshirvani et al., 1991, Bogetto et al., 1999, Sobin et al., 1999, Lochner et al., 2004, Torres et al., 2006, Gentil et al., 2009). Conversely, we expected women to be more frequently married, to have children, to report later OCD onset, to present more contamination–cleaning symptoms (Minichiello et al., 1990, Noshirvani et al., 1991, Ratnasuriya et al., 1991, Bogetto et al., 1999, Tükel et al., 2004, Karadag et al., 2006, Stein et al., 2007, Labad et al., 2008, Jaissorya et al., 2009, Li et al., 2009) and more comorbid major depression (Noshirvani et al., 1991, Castle et al., 1995, Sobin et al., 1999, Karadag et al., 2006, Labad et al., 2008), eating (Noshirvani et al., 1991, Castle et al., 1995, Hantouche et al., 1996, Bogetto et al., 1999, Lochner et al., 2004, Torresan et al., 2009) and impulse control disorders (Hantouche et al., 1996, Bogetto et al., 1999, Torresan et al., 2009). No specific hypotheses were raised regarding aspects never investigated in previous studies on OCD gender differences (e.g. severity of symptom dimensions and suicidality).