Comorbidity of Pediatric Obsessive–Compulsive Disorder and Anxiety Disorders: Impact on Symptom Severity and Impairment

This study explored the impact of comorbidity on symptom severity and treatment outcome in a sample of 75 pediatric Obsessive–Compulsive Disorder (OCD) patients. Forty received cognitive–behavioral therapy (CBT). Overall, 56% had a comorbid disorder. Results revealed that youth with comorbid disorders (anxiety or otherwise) endorsed significantly more anxiety symptoms than youth with OCD only. Youth with comorbidities instead of or in addition to anxiety exhibited more severe OCD symptoms than youth with OCD alone or an anxiety-only comorbidity. Youth in the comorbidities instead of or in addition to anxiety group had the poorest CBT response relative to the other groups. These results suggest that relative to those with OCD alone or with an anxiety disorder comorbidity, youth with comorbidities instead of or in addition to anxiety have a differing clinical presentation (e.g., more severe symptoms) and worse psychotherapy outcome.

Comorbid anxiety and mood disorders among persons with social anxiety disorder.

Axis I comorbidity is associated with greater severity of social anxiety disorder. However, the differential effects of comorbid mood and anxiety disorders on symptom severity or treatment outcome have not been investigated. We evaluated 69 persons with uncomplicated social anxiety disorder, 39 persons with an additional anxiety disorder, and 33 persons with an additional mood disorder (with or without additional anxiety disorders). Those with comorbid mood disorders reported greater duration of social anxiety than those with uncomplicated social anxiety disorder. They were also judged, before and after 12 weeks of cognitive-behavioral group treatment and at follow-up, to be more severely impaired than those with no comorbid diagnosis. In contrast, persons with comorbid anxiety disorders were rated as more impaired than those with no comorbid diagnosis on only a single measure. Type of comorbid diagnosis did not result in differential rates of improvement of social anxiety disorder.     

Clinical features of tic-related obsessive-compulsive disorder: results from a large multicenter study

OBJECTIVE: To evaluate the clinical features of obsessive-compulsive disorder (OCD) patients with comorbid tic disorders (TD) in a large, multicenter, clinical sample.MethodA cross-sectional study was conducted that included 813 consecutive OCD outpatients from the Brazilian OCD Research Consortium and used several instruments of assessment, including the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, the Yale Global Tic Severity Scale (YGTSS), the USP Sensory Phenomena Scale, and the Structured Clinical Interview for DSM-IV Axis I Disorders. RESULTS: The sample mean current age was 34.9 years old (SE 0.54), and the mean age at obsessive-compulsive symptoms (OCS) onset was 12.8 years old (SE 0.27). Sensory phenomena were reported by 585 individuals (72% of the sample). The general lifetime prevalence of TD was 29.0% (n = 236), with 8.9% (n = 72) presenting Tourette syndrome, 17.3% (n = 141) chronic motor tic disorder, and 2.8% (n = 23) chronic vocal tic disorder. The mean tic severity score, according to the YGTSS, was 27.2 (SE 1.4) in the OCD + TD group. Compared to OCD patients without comorbid TD, those with TD (OCD + TD group, n = 236) were more likely to be males (49.2% vs. 38.5%, p < .005) and to present sensory phenomena and comorbidity with anxiety disorders in general: separation anxiety disorder, social phobia, specific phobia, generalized anxiety disorder, post-traumatic stress disorder, attention-deficit hyperactivity disorder, impulse control disorders in general, and skin picking. Also, the "aggressive," "sexual/religious," and "hoarding" symptom dimensions were more severe in the OCD + TD group.ConclusionTic-related OCD may constitute a particular subgroup of the disorder with specific phenotypical characteristics, but its neurobiological underpinnings remain to be fully disentangled.     

Observed classroom behavior of children with ADHD: relationship to gender and comorbidity

Examined hypothesized gender and comorbidity differences in the observed classroom behavior of children with attention deficit hyperactivity disorder (ADHD). The behavior of 403 boys and 99 girls with ADHD, ages 7–10, was compared (a) to observed, sex-specific classroom behavior norms, (b) by sex, and (c) by comorbid subgroups. Boys and girls with ADHD deviated significantly from classroom norms on 15/16 and 13/16 categories, respectively. Compared to comparison girls, girls with ADHD had relatively high rates of verbal aggression to children. Boys with ADHD engaged in more rule-breaking and externalizing behaviors than did girls with ADHD, but the sexes did not differ on more neutral, unobtrusive behaviors. The sex differences are consistent with notions of why girls with ADHD are identified and referred later than boys. Contrary to hypothesis, the presence of comorbid anxiety disorder (ANX) was not associated with behavioral suppression; yet, as hypothesized, children with a comorbid disruptive behavior disorder (DBD) had higher rates of rule-breaking, and impulsive and aggressive behavior, than did children with ADHD alone and those with ADHD+ANX. Elevated rates of ADHD behaviors were also observed in children with comorbid DBD, indicating that these behaviors are truly present and suggesting that reports of higher ADHD ratings in this subgroup are not simply a consequence of negative halo effects and rater biases.     

Obsessive-compulsive disorder with and without tic disorder: a comparative study from India

Introduction: Evidence from phenomenological, family, genetic, and treatment studies from Western centers have suggested that tic-related obsessive-compulsive disorder (OCD) could be different from non-tic-related OCD. This study from India investigated the differences in OCD with and without tics, with respect to sociodemographics, symptom profile, and comorbidity, including obsessive-compulsive spectrum disorders, to examine whether the clinical profile of tic-related OCD is similar to that reported previously. Methods: Fifty subjects with OCD and tics (chronic motor tics and Tourette syndrome) were compared with 141 OCD subjects without tics. Results: Subjects having OCD with tics tended to be males, and had an earlier onset of illness. They had more of symmetry/aggressive and religious obsessions, and cleaning, ordering/arranging, hoarding, and repeating compulsions and were associated with trichotillomania and hypochondraisis. Stepwise backward (Wald) regression analysis showed that an early age of onset, male gender, aggressive obsessions, cleaning compulsions, and trichotillomania were significantly associated with tic-related OCD. Conclusion: The findings of this study from India are broadly similar to those reported previously from the West indicating the universality of differences in tic- and non-tic-related OCD. Our findings also support the existing evidence that tics contribute to the heterogeneity of OCD.     

The Relation of Severity and Comorbidity to Treatment Outcome with Cognitive Behavioral Therapy for Childhood Anxiety Disorders

The present study investigated the impact of comorbidity over and above the impact of symptom severity on treatment outcome of Cognitive Behavioral Therapy for children with anxiety disorders. Children (aged 8–12, n = 124) diagnosed with an anxiety disorder were treated with a short-term CBT protocol. Severity was assessed with a composite measure of parent-reported behavior problems. Two approaches to comorbidity were examined; “total comorbidity” which differentiated anxiety disordered children with (n = 69) or without (n = 55) a co-occurring disorder and “non-anxiety comorbidity’ which differentiated anxious children with (n = 22) or without a non-anxiety comorbid disorder (n = 102). Treatment outcome was assessed in terms of Recovery, represented by post-treatment diagnostic status, and Reliable Change, a score reflecting changes in pre- to post-treatment symptom levels. Severity contributed to the prediction of (no) Recovery and (more) Reliable Change in parent-reported internalizing and externalizing symptoms and self-reported depressive symptoms. Total and non-anxiety comorbidity added to the prediction of diagnostic recovery. Non-anxiety comorbidity added to the prediction of Reliable Change in parent reported measures by acting as a suppressor variable. Non-anxiety comorbidity operated as a strong predictor that explained all of the variance associated with severity for self-reported depressive symptoms. The results support the need for further research on mechanisms by which treatment gains in children with higher symptom severity and non-anxiety comorbidity can be achieved.     

Phenomenology of Early Childhood Onset Obsessive Compulsive Disorder

This paper describes the phenomenological features of early childhood onset obsessive compulsive disorder (OCD; defined as children meeting DSM-IV criteria for OCD with age of onset <8 years). Fifty-eight children (ages 4–8) were included in the sample. OCD and comorbid diagnoses were determined by structured interview, and OCD severity was measured using the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Mean age of OCD onset was almost five, and mean age of presentation was between 6 and 7. Mean symptom severity was in the moderately severe range. Comorbidity and family history of OCD were common. Contamination and aggressive/catastrophic obsessions and washing and checking compulsions were endorsed most frequently. Results indicate that early childhood onset OCD may have a lower boy to girl ratio and lower rates of depressive disorders, but may be similar to later childhood onset OCD in terms of OCD symptom presentation and severity.     

Do traumatic events influence the clinical expression of compulsive hoarding?

Traumatic experiences have been posited as one potential catalyst for the abrupt onset of obsessive-compulsive symptoms including compulsive hoarding. To determine whether traumatic life events (TLEs) might influence the expression of compulsive hoarding in obsessive-compulsive disorder (OCD), interview responses to the Posttraumatic Stress Disorder module of the Structured Clinical Interview for DSM-IV (SCID) were examined in 180 individuals with OCD. Compared to individuals with OCD who did not meet criteria for hoarding, participants classified as hoarders (24% of the sample) were significantly more likely to have reported at least one TLE in their lifetime. Patients who met criteria for hoarding and who had also experienced TLEs had significantly greater hoarding symptom severity than those hoarders not exposed to trauma. This association was found to be robust. That is, the relationship between TLEs and hoarding symptom severity was not better accounted for by age, age of OCD onset, depressive symptoms, general OCD symptomatology, or mood and anxiety comorbidity. Closer examination revealed that the clutter factor of compulsive hoarding (and not difficulty discarding or acquisitioning) was most strongly associated with having experienced a traumatic event.     

An investigation of traumatic life events and obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD), like most other psychiatric disorders, is suspected of being influenced by an interaction between life events and genes, both with regard to onset and course of illness. To date, no specific genes have been identified as playing a frequent role, and only a relatively few empirical studies have assessed the association between stressful life events (SLEs) and OCD. The present study builds on past research by examining the potential contributions from traumatic life events (TLEs) on the severity and symptom features in 265 individuals with Structured Clinical Interview for DSM-IV (SCID)-diagnosed OCD. Of these participants 54% endorsed having experienced at least one TLE in their life time. The presence of one or more TLEs was associated with increased OCD symptom severity. This relationship remained significant despite controlling for key variables including age, OCD age-of-onset, comorbidity, and depressive symptoms. In addition, obsessions/checking and symmetry/ordering were two of four symptom factors that were specifically associated with the occurrence of TLEs. These results are generally supportive of a pathoplastic relationship between TLEs and OCD symptomatology and thus suggest the need for greater systematic consideration of life stresses in research focused on the nature and treatment of OCD.     

Psychiatric Comorbidity in Children with Autism Spectrum Disorders: A Comparison with Children with ADHD

The present study was conducted with the aim to identify comorbid psychiatric disorders in children with autism spectrum disorders (ASD) (n = 40) and to compare those comorbidity rates to those in children with attention deficit hyperactivity disorder (ADHD) (n = 40). Participants were clinically referred children aged 7–18 years. DSM-IV classifications were used for the primary diagnosis (ASD/ADHD), while comorbid psychiatric disorders were assessed using a structured diagnostic interview, the structured clinical interview for DSM-IV, childhood diagnoses (KID-SCID). Twenty-three children with ASD (57.5 %) had at least one comorbid disorder, whereas 16 children with ADHD (40.0 %) were classified as having at least one comorbid disorder. No group differences were found with respect to this comorbidity rate or for the rate of comorbid externalizing disorders (ODD and/or CD). However, children with ASD had more comorbid internalizing disorders compared to children with ADHD. More specifically, children with ASD had higher rates of anxiety disorders, but not mood disorders. No associations between comorbidity and age or between comorbidity and the intelligence quotient was found. It is important for clinicians to always be aware of, and screen for, comorbidity, and to consider treatment for these comorbid disorders. In addition, research should focus on establishing valid and reliable screening tools as well as effective treatment options for these comorbid disorders.     

The semantic Simon effect in Tourette's syndrome and obsessive-compulsive disorder

Core symptoms of Tourette's syndrome (TS) and obsessive-compulsive disorder (OCD) may be attributed to an impairment in inhibitory control. Neuropsychological studies have addressed inhibition in both disorders, but findings have been inconsistent. The aim of this study was to examine cognitive inhibition, using a semantic Simon effect paradigm, in patients with TS and OCD. Furthermore, to address comorbidity a group of TS+OCD patients was also examined. Results indicated that patients with TS and OCD were affected by the inhibitory components of the task. TS groups performed similarly to controls on simple and choice RT tasks, but were particularly compromised as increasingly complex inhibitory demands were imposed. OCD patients were slower and committed more errors than controls, especially in the more cognitively demanding conditions, and were particularly disadvantaged by incongruent stimulus-response compatibilities. Findings implicate possible fronto-striatal dysfunction, are consistent with previously reported inhibitory deficits in TS and OCD, and support the theory that comorbid TS+OCD is more closely linked to pure TS than OCD.     

Cognitive-Behavior Therapy (CBT) for Panic Disorder: Relationship of Anxiety and Depression Comorbidity with Treatment Outcome

Research evaluating the relationship of comorbidity to treatment outcome for panic disorder has produced mixed results. The current study examined the relationship of comorbid depression and anxiety to treatment outcome in a large-scale, multi-site clinical trial for cognitive-behavior therapy (CBT) for panic disorder. Comorbidity was associated with more severe panic disorder symptoms, although comorbid diagnoses were not associated with treatment response. Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) were not associated with differential improvement on a measure of panic disorder severity, although only rates of comorbid GAD were significantly lower at posttreatment. Treatment responders showed greater reductions on measures of anxiety and depressive symptoms. These data suggest that comorbid anxiety and depression are not an impediment to treatment response, and successful treatment of panic disorder is associated with reductions of comorbid anxiety and depressive symptoms. Implications for treatment specificity and conceptual understandings of comorbidity are discussed.     

Specificity of Reward Sensitivity and Parasympathetic-Based Regulation among Children with Attention-Deficit/Hyperactivity and Disruptive Behavior Disorders

Attention-deficit/hyperactivity disorder (ADHD) is associated with disruptionsin reward sensitivity and regulatory processes. However, it is unclear whether thesedisruptions are better explained by comorbid disruptive behavior disorder (DBD)symptomology. This study sought to examine this question using multiple levels ofanalysis (i.e., behavior, autonomic reactivity). One hundred seventeen children (aged 6 to 12 years; 72.6% male; 69 with ADHD) completed theBalloon-Analogue Risk Task (BART) to assess external reward sensitivity behaviorally.Sympathetic-based internal reward sensitivity and parasympathetic-based regulationwere indexed via cardiac pre-ejection period (PEP) and respiratory sinus arrhythmia(RSA), respectively. Children with ADHD exhibited reduced internal reward sensitivity (i.e.,lengthened PEP; F(1,112)=4.01, p=0.047) compared to healthy controls and werecharacterized by greater parasympathetic-based dysregulation (i.e., reduced RSAaugmentation F(1,112)=10.12, p=0.002). However, follow-up analyses indicated theADHD effect was better accounted for by comorbid DBD diagnoses; that is, childrenwith ADHD and comorbid ODD were characterized by reduced internal rewardsensitivity (i.e., lengthened PEP; t=2.47, p=0.046) and by parasympathetic-baseddysregulation (i.e., reduced RSA augmentation; t=3.51, p=0.002) in response to rewardwhen compared to typically developing youth. Furthermore, children with ADHD and comorbid CD exhibited greater behaviorally-based external reward sensitivity (i.e.,more total pops; F(3,110)= 5.96, p=0.001) compared to children with ADHD only (t=3.87, p=0.001) and children with ADHD and ODD (t=3.56, p=0.003). Results suggest that disruptions in sensitivity to reward may be betteraccounted for, in part, by comorbid DBD.Key Words: attention-deficit/hyperactivity disorder, autonomic nervous system,disruptive behavior disorders, reward sensitivityPowered     

Obsessive-compulsive disorder with comorbid major depression: what is the role of cognitive factors?

Individuals with obsessive-compulsive disorder (OCD) commonly experience comorbid mood disturbances such as major depressive disorder (MDD). Previous studies that have compared OCD patients with and without MDD have revealed differences in demographic characteristics, clinical severity, and symptom presentation between these two patient groups. Previous studies have not, however, examined whether there are differences with respect to cognitive processes. The present study therefore aimed to address this gap in the literature. Eighty patients with OCD and no unipolar mood disorders were compared with 34 OCD patients with comorbid major depression on measures of OCD symptoms, cognitions, and insight, as well as on measures of depression and functional impairment. Whereas depressed OCD patients evidenced higher scores than non-depressed OCD patients on semi-idiographic measures of OCD symptoms and cognitions, this was not the case for nomothetic measures. Functional impairment and the tendency to misinterpret innocuous intrusive thoughts as significant emerged as unique predictors of depression within the entire sample of OCD patients. Results are discussed in terms of (a) the importance of semi-idiographic assessment of OCD, (b) possible explanations for the relationship between OCD symptoms, depression, and cognitive processes, and (c) the psychological treatment of comorbid OCD and MDD.     

Cognitive biases and obsessive-compulsive symptoms in children: examining the role of maternal cognitive bias and child age

Objective: Multiple cognitive biases associated with adult obsessive-compulsive disorder (OCD) were tested in a clinical sample of children (ages 7-11) and adolescents (12-17) and their mothers. This study examined (a) the associations between child cognitive biases and OCD severity, (b) maternal cognitive biases and child OCD severity, and (c) maternal cognitive bias and child cognitive bias. It was hypothesized that age would significantly moderate these relationships, with stronger associations with OCD severity for cognitive bias in adolescents (relative to children), and maternal cognitive bias in younger children (relative to adolescents). Method: Forty-six children and adolescents diagnosed with OCD and their mothers completed questionnaires assessing responsibility bias, thought-action fusion (TAF), thought suppression, and metacognitive beliefs. OCD symptoms were assessed using structured diagnostic interviews and semistructured symptom interviews. Results: As predicted, age significantly moderated associations between (a) child cognitive variables and OCD severity-specifically between child responsibility and child metacognition, which were associated with OCD severity for adolescents only; (b) maternal cognitive biases and child OCD severity-specifically for maternal responsibility and thought suppression, which were significantly and positively associated with child OCD severity but not adolescent OCD severity; and (c) maternal cognitive biases and child cognitive bias-such that significant associations were evident only in the younger child sample, and only between maternal TAF self and metacognition, with child suppression and child TAF moral, respectively. Conclusion: Maternal cognitive biases are more consistently linked to greater OCD severity among younger children, whereas personal cognitive biases are associated with greater OCD symptoms in adolescents. Treatments for pediatric OCD are likely to be improved by age-specific considerations for the role of maternal and child cognitive biases associated with OCD.     

Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls

Hoarding is a symptom of obsessive compulsive disorder (OCD), as well as a diagnostic criterion for obsessive compulsive personality disorder (OCPD). One recent study suggests that people who suffer from compulsive hoarding report more general psychopathology than people who do not [Frost, R.O., Krause, M.S., & Steketee, G. (1996). Hoarding and obsessive compulsive symptoms. Behavior Modification, 20, 116-132]. The present study addressed whether persons with OCD hoarding exhibit more depression, anxiety, OCD and personality disorders symptoms than community controls, OCD nonhoarders, or other anxiety disorder patients. Disability was also examined. Hoarding subjects were older than the other three groups, but age did not account for any of the differences observed among the groups. Compared to controls, OCD hoarding, nonhoarding OCD and anxiety disorder patients showed elevated YBOCS scores, as well as higher scores on depression, anxiety, family and social disability. Compared to nonhoarding OCD and anxiety disorder patients, OCD hoarding patients scored higher on anxiety, depression, family and social disability. Hoarding subjects had greater personality disorder symptoms than controls. However, OCD hoarding subjects differed from OCD nonhoarding and anxiety disorder subjects only on dependent and schizotypal personality disorder symptoms. The findings suggest that hoarding is associated with significant comorbidity and impairment compared to nonhoarding OCD and other anxiety disorders.     

Patterns of neural response to emotive stimuli distinguish the different symptom dimensions of obsessive-compulsive disorder

Despite its heterogeneous symptomatology, obsessive-compulsive disorder (OCD) is currently conceptualized as a unitary diagnostic entity. Recent factor-analytic studies have identified several OCD symptom dimensions that are associated with different demographic variables, comorbidity, patterns of genetic transmission, and treatment response. Functional abnormalities in neural systems important for emotion perception, including the orbitofrontal cortex, lateral prefrontal cortex, anterior cingulate gyrus, and limbic regions, have been reported in OCD. In this review, we discuss the extent to which neurobiological markers may distinguish these different symptom dimensions and whether specific symptom dimensions, such as contamination/washing, are associated with abnormalities in emotion and, in particular, disgust, perception in OCD. Also discussed are findings that indicate that anxiety can be induced in healthy volunteers in response to OCD symptom-related material, and that associated increases in activity within neural systems important for emotion perception occur to washing- and hoarding-related material in particular in these subjects. Further examination of neural responses during provocation of different symptom dimensions in OCD patients will help determine the extent to which specific abnormalities in neural systems underlying emotion perception are associated with different symptom dimensions and predict treatment response in OCD.     

Does comorbid attention-deficit/hyperactivity disorder impact the clinical expression of pediatric obsessive-compulsive disorder?

What is the impact of attention-deficit/hyperactivity disorder (ADHD) on the phenotypic expression of pediatric obsessive-compulsive disorder (OCD). We examined phenotypic features, and functional and clinical correlates in youths with OCD, with and without comorbid ADHD, from a large sample of consecutively referred pediatric psychiatry patients. Although comorbid ADHD had no meaningful impact on the phenotypic expression or clinical correlates of OCD, it was associated with higher rates of compromised educational functioning compared with other OCD youths. Our findings suggest that the OCD phenotype runs true and is not impacted by comorbid ADHD in youths diagnosed with both OCD and ADHD. In such affected youths, both disorders contribute to morbid dysfunction and require treatment. More work is needed to determine whether OCD plus ADHD represents a developmentally and etiologically distinct form of the OCD syndrome.     

Neurochemistry in the comorbidity of conduct disorder with other disorders of childhood and adolescence: Implications for counselling

Conduct disorder (CD) is comorbid with other child and adolescent disorders with a frequency that is significantly greater than chance. Findings of studies on neurochemical abnormalities and treatment provide tentative empirical evidence for a neurochemical diathesis in children and adolescents with CD with others disorders. Counsellors of children and adolescents with CD and comorbid conditions with a greater appreciation of the medical and psychosocial aspects of comorbidity are likely to be more effective.