Andrea Cantisani

Obsessive–Compulsive Disorder Comorbidity: Clinical Assessment and Therapeutic Implications

Obsessive–compulsive disorder (OCD) is a neuropsychiatric disorder affecting approximately 1–3% of the population. OCD is probably an etiologically heterogeneous condition. Individuals with OCD frequently have additional psychiatric disorders concomitantly or at some time during their lifetime. Recently, some authors proposed an OCD sub-classification based on comorbidity. An important issue in assessing comorbidity is the fact that the non-response to treatment often involves the presence of comorbid conditions. Non-responsive patients are more likely to meet criteria for comorbid axis I or axis II disorders and the presence of a specific comorbid condition could be a distinguishing feature in OCD, with influence on the treatment adequacy and outcome.

Anxiety as a core aspect of schizophrenia.

The clinical relevance of anxiety disorders in schizophrenia has been neglected for a long time and has only recently become the subject of a systematic investigation, although its consequences may have a very negative impact on the outcome and considerably worsen the trajectory of the disease. This could be originally related to the hierarchical organization of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and to the lack of assessment instruments. In this article, we will review the most recent literature concerning two of the most impairing anxiety disorders in comorbidity with schizophrenia, such as panic disorder and social anxiety disorder, briefly analyze the role of anxiety in the prodromal phase of psychosis and provide suggestions for the clinical assessment.

Emerging drugs to treat obsessive–compulsive disorder

Introduction: Obsessive–compulsive disorder (OCD) is a chronic and disabling neuropsychiatric disorder with a lifetime prevalence of approximately 1 – 2% and a rate of treatment resistance of 40%. Other disorders have been related to OCD and have been grouped together in a separate DSM-5 chapter, hypothesizing the existence of an ‘OC spectrum’, showing a paradigm shift in the conceptualization of the disorder. Areas covered: A review of the most important and recent neurobiological findings that sustain the hypothesis of a more sophisticated model of the disorder is provided, together with a brief overview of the most relevant pharmacological animal models of OCD and its first-line treatments. Current research goals, new compounds tested and the rationale behind the development of these new pharmacologic agents are then explained and reviewed. Expert opinion: In the past years, no effective novel compounds have emerged for the treatment of OCD, even if many efforts has been made in the study of its neurobiological underpinnings. Relevant changes in the conceptualization of the disorder, suggested by interesting new neurobiological evidences, may result helpful in the development of new treatments.

EEG marker of inhibitory brain activity correlates with resting-state cerebral blood flow in the reward system in major depression.

Frontal alpha band asymmetry (FAA) is a marker of altered reward processing in major depressive disorder (MDD), associated with reduced approach behavior and withdrawal. However, its association with brain metabolism remains unclear. The aim of this study was to investigate FAA and its correlation with resting-state cerebral blood flow (rCBF). We hypothesized an association of FAA with regional rCBF in brain regions relevant to reward processing and motivated behavior, such as the striatum. We enrolled 20 patients and 19 healthy subjects. FAA scores and rCBF were quantified with the use of EEG and arterial spin labeling. Correlations of the two were evaluated, as well as the association with FAA and psychometric assessments of motivated behavior and anhedonia. Patients showed a left-lateralized pattern of frontal alpha activity and a correlation of FAA lateralization with subscores of Hamilton Depression Rating Scale linked to motivated behavior. An association of rCBF and FAA scores was found in clusters in the dorsolateral prefrontal cortex bilaterally (patients), in the left medial frontal gyrus, in the right caudate head and in the right inferior parietal lobule (whole group). No correlations were found in healthy controls. Higher inhibitory right-lateralized alpha power was associated with lower rCBF values in prefrontal and striatal regions, predominantly in the right hemisphere, which are involved in the processing of motivated behavior and reward. Inhibitory brain activity in the reward system may contribute to some of the motivational problems observed in MDD.

Distinct resting-state perfusion patterns underlie psychomotor retardation in unipolar vs. bipolar depression

Psychomotor abnormalities characterize both unipolar (UP) depression and bipolar (BP) depression. We aimed to assess their neurobiological correlates in terms of motor activity (AL) and resting‐state cerebral blood flow (rCBF) and investigate their association in BP, UP, and healthy controls (HC).

Psychomotor retardation is linked to frontal alpha asymmetry in major depression

BACKGROUND Psychomotor disturbances are a main clinical feature of major depressive disorder (MDD) but little is known about their EEG signature. One of the most replicated EEG findings in MDD is resting frontal asymmetry in the alpha band (FAA), which is thought to be a correlate of withdrawal behavior and reduced approach motivation. The purpose of this study was to assess psychomotor alterations, alpha band power, FAA and investigate the association between them. METHODS 20 MDD patients and 19 healthy subjects were enrolled. Alpha power and FAA scores were calculated from a resting state EEG. Wrist actigraphy was recorded from the non-dominant arm for 24 h and activity level scores (AL) were extrapolated from the wakeful periods. RESULTS MDD patients had a left-lateralized frontal alpha activity and lower AL scores when compared to healthy subjects. A significant correlation was found between mean FAA and AL scores. A negative covariance between power in the lower alpha range and AL scores over the motor cortex bilaterally was detected. LIMITATIONS Relatively small sample size. Patients were pharmacologically treated with antidepressants. CONCLUSIONS This study replicates the finding of left-lateralized FAA and lower AL scores in MDD patients, and establishes the first evidence of significant correlations between alpha power, FAA scores and measures of motor activity, which may be interpreted as an expression of impaired motivational drive in MDD.

Hypochondriasis and obsessive-compulsive disorder in schizophrenic patients treated with clozapine vs other atypical antipsychotics.

OBJECTIVE The aim of the study was to investigate the prevalence rates of obsessive-compulsive disorder (OCD) and hypochondriasis in schizophrenic patients treated with atypical antipsychotics (AAPs) and to investigate the different comorbidity rates of OCD and hypochondriasis between clozapine-treated patients and patients treated with other AAPs. METHODS We therefore recruited 60 schizophrenic patients treated with clozapine or other AAPs. We assessed the prevalence rates of OCD or OC symptoms and hypochondriasis or hypochondriac symptoms in the whole group of patients and in clozapine-treated patients versus patients treated with other AAPs. RESULTS Schizophrenic patients had a higher comorbidity rate of OCD (26.6% vs 1-3%) and hypochondriasis (20% vs 1%) than the general population. These comorbidities were more frequent in schizophrenic patients treated with clozapine versus patients treated with other AAPs (36.7% vs 16.7% and 33.3% vs 6.7%). Clozapine-treated patients showed a higher mean Y-BOCS and HY-BOCS score when compared to patients treated with other AAPs (10.90 vs 5.90, p = .099; 15.40 vs 8.93, p = .166). A statistical significant correlation was found between the Y-BOCS and HY-BOCS scores of the whole group (r = .378, p = 0.03). Furthermore, we found an inverse correlation between the global level of functioning and the diagnosis of hypochondriasis (p = .048) and the severity of hypochondriac symptoms (p = .047). CONCLUSIONS Hypochondriasis could represent an important clinical feature of schizophrenic patients treated with atypical antipsychotics, and further research is needed in this field.

The Treatment of Obsessive-Compulsive Disorder and the Approaches to Treatment Resistance

Obsessive-compulsive disorder (OCD) is characterized by recurrent intrusive ideas, impulses, or urges (obsessions) along with overt or covert behaviors (compulsions) aimed at reducing the distress (DSM-IV-TR). Patients have either obsessions, compulsions, or, most commonly, both. Obsessions are defined as recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and cause anxiety. The obsessions are not simply excessive worries about real-life problems and the affected individual usually recognizes that these thoughts, impulses or images are excessive, unreasonable and a product of their own mind (DSM-IV-TR). In order to naturalize the obsessions, other thoughts or actions are performed (compulsions). Examples of obsessions include, among others, contamination (concern with dirt or germs, fear of blood) symmetry (concern about order, exactness), obsessions about safety and harm (fear of harm due to carelessness, fear of being responsible for terrible events) hoarding, pathological doubt (after completing a routine activity the affected individual wonders whether he or she performed it correctly or did it at all), numbers with special significance, etc. Compulsions are repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that patients with OCD feel compelled to do in response to an obsession, or according to rules which must be applied rigidly (e.g. checking that a light switch is turned off by switching it on and off without any interruption). The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors are either not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly unreasonable or excessive. Examples of compulsive activities are washing hands until they are raw, repeatedly checking the locked door, arranging and rearranging items in a set order, counting, asking, repeating reassurance questions etc. The diagnosis is made by clinical interview, with a specific and detailed focus on OCD. To diagnose the disorder according to the DSM-IV criteria, the patient must suffer from either obsessions or compulsions that cause great distress, are time-consuming (more then 1 hour

Psychotropic treatment of Autism

The therapy for autism and other pervasive developmental disorders is based on a multimodal intervention that includes not only pharmacological approaches but also nonmedical treatments such as rehabi