Obsessive compulsive symptoms in the psychosis prodrome: Correlates of clinical and functional outcome

doi:10.1016/j.schres.2008.11.023

Schizophrenia Research

Volume 108, Issues 1–3, March 2009, Pages 170-175

https://doi.org/10.1016/j.schres.2008.11.023 Get rights and content

Abstract

Objectives:

Obsessive–Compulsive Disorder (OCD) is a common co-morbid condition in schizophrenia, associated with poor prognosis. However, the prevalence of obsessive compulsive symptomatology (OCS) and its relationship to outcome has not been evaluated in adolescents at ultra high-risk for psychosis (UHR).

Methods:

Sixty-four UHR and 26 non-prodromal comparison (NPC) youth were ascertained using the Structured Interview for Prodromal Syndromes (SIPS). Participants completed diagnostic interviews and the Padua Inventory (Sanavio, E., 1988. Obsessions and compulsions: the Padua Inventory. Behav. Res. Ther. 26, 169–177.), a self-report measure of OCS.

Results:

UHR youth reported significantly higher rates of OCS on the Padua Inventory compared to NPC youth. Clinical diagnosis of OCD (20% of sample) was associated with lower risk of conversion to psychosis over the follow-up period, but was unrelated to clinical severity or psychosocial functioning. However, dimensional ratings of OCS were significantly associated with positive symptom severity, self-reported depression, and a trend toward increased suicidal ideation within the UHR sample.

Conclusions:

OCS rates in UHR youth are well above estimated prevalence rates in normal populations, and commensurate with rates of comorbidity observed in schizophrenia. Although clinical diagnosis of OCD was not associated with later conversion to psychosis, OCS severity in UHR youth was associated with more acute symptomatic presentation, including more severe depression and suicidality.

Introduction

The link between obsessive–compulsive symptomatology and psychosis has been noted since the early 20th century (Gordon, 1926, Stengel, 1945). Prevalence rates for obsessive–compulsive disorder (OCD) as high as 30% have been reported in schizophrenia populations (Byerly et al., 2005), as compared to 1.2–2.4% in the normal population (Foa et al., 1995). Further, a substantial proportion of individuals with schizophrenia report clinically significant obsessive or compulsive symptoms (Bermanzohn, 1999), which may appear early in the developmental course of the illness (Eisen et al., 1997).

Persistent obsessive–compulsive symptoms (OCS) also appear to be a powerful predictor of poorer course and outcome in individuals with psychotic illness (Fenton and McGlashan, 1986). OCS in schizophrenia have been associated with poorer cognitive functioning, particularly on measures tapping prefrontal cortical integrity (Berman et al., 1998), as well as increased levels of depression (Poyurovsky et al., 2001), more severe negative symptoms (Nechmad et al., 2003), poorer social functioning (Poyurovsky et al., 2001), and higher rates of hospitalization (Samuel et al., 1993).

There are several possible explanations as to why OCD and schizophrenia might be integrally related. For example, one disorder could present as a prodrome of the other or one disorder might cause the other (Bottas et al., 2005). Additionally, some researchers (Tibbo and Warneke, 1999) have postulated that the development of OCS in schizophrenia may be associated with effects of atypical antipsychotic medications on serotonergic sites associated with basal ganglia functioning, suggesting that OCS may be the consequence of treatment for some individuals with schizophrenia rather than an aspect of the disorder itself.

In order to explore the potential role of OC symptoms in the developmental period preceding psychosis onset, this study aims to investigate the presentation and effects of OCS on clinical course in youth who are putatively prodromal for psychosis. The prevalence of OC symptoms in this sample and their relationship to diagnostic outcome were explored both categorically, using the Structured Clinical Interview for DSM-IV Axis I Disorders (First et al., 2002), as well as dimensionally, using a quantitative self-report measure of OC symptom severity, the Padua Inventory (Sanavio, 1988). The associations between OC symptomatology, clinical symptom severity, psychosocial functioning, and medication treatment history were examined to determine if OCS have a notable impact upon clinical course in UHR youth or affect subsequent diagnostic outcome. Finally, we describe OC symptoms that have been observed within this adolescent sample in order to illustrate the manner in which such symptoms may manifest during the prodromal period.

Section snippets

Participants

Participants were 64 UHR youth and 26 non-prodromal comparison (NPC) youth, between the ages of 12–22, enrolled in an ongoing investigation of adolescents at high clinical risk for developing psychosis. UHR youth were referred by local mental health providers or school staff, or were self-referred in response to advertisements or the CAPPS website. NPC youth were recruited from a community sample via advertising and were age matched to the UHR sample. Participants completed follow-up

Results

Sixty-four UHR and 26 NPC youth completed the SCID interview. Forty-nine (77%) of the UHR and 21 (81%) of the NPC youth completed the Padua Inventory. While 4% of PI non-completers discontinued the study before finishing their questionnaires, 18% of non-completers failed to complete the Padua despite completion of other study procedures. However, completers and non-completers of the Padua Inventory did not differ on any demographic variables. The rates of Padua non-completion did not differ

Discussion

Consistent with prior studies of first-episode and chronic schizophrenia, this study reveals a high rate of obsessive–compulsive disorder in UHR youth (14–20%), when compared to the prevalence of 1–2% in the general population. Previous studies have suggested that OC symptoms may precede the onset of psychosis (Eisen et al., 1997), and our findings highlight that significant obsessive–compulsive symptoms can present as part of the prodromal picture in youth that are at clinical high-risk for

Role of funding source

This research was supported by the following grants: NIMH MH65079, NIMH P50 MH066286, NIMH MH14584 (Ruth L. Kirschstein National Research Service Award Post-doctoral Fellowship to T.A.N), NARSAD Young Investigator Award (Maxine and Jack Zarrow Investigator Award to C.E.B.), National Science Foundation Graduate Fellowship, as well as donations from the Rutherford Charitable Foundation and Staglin Music Festival for Mental Health. These funding sources had no further role in the study design, in

Contributors

Tyrone D. Cannon, Ph.D., designed the overall CAPPS study; the protocol was written and conceptualized by Tyrone D. Cannon, Ph.D., and Carrie Bearden, Ph.D. Tara Niendam, Ph.D., developed this investigation, conducted the literature searches, conducted the statistical analyses, developed the first draft of the manuscript, and created the figures and tables. Jodi Berzak assisted in the data collection, developed the data set, and assisted in data analysis. Carrie Bearden Ph.D., and Tyrone

Conflict of interest

All other authors declare that they have no conflicts of interest.

Acknowledgements

The authors would like to thank the following individuals for their contributions to this project: Cindy Akin, M.A., Rachel Loewy, Ph.D., Sabrina Lux, Stephanie Meyer, Ph.D., Jennifer Johnson, Ph.D., Adrienne Gallet, Sandra DeSilva, Ph.D., and Jamie Zinberg, M.A.

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