Anish V. Cherian

Impact of age of onset of illness on clinical phenotype in OCD

BACKGROUND This study aims to examine the demographic, clinical and comorbid patterns in a large sample of adult OCD subjects at a specialty OCD clinic in India. METHODS Consecutive patients (n=545) who consulted a specialty OCD Clinic over 5 years at a large psychiatric hospital in India were evaluated with the Mini International Neuropsychiatric Interview, the Yale-Brown Obsessive-Compulsive Scale, and the Clinical Global Impression scale. RESULTS Earlier age onset of OCD (years) was characterized by male preponderance (19.61±7.98 vs. 25.19±10.39, U=23453.5, p=<0.001), positive family history of OCD (19.60±10.02 vs. 22.27±9.20, U=16590.5, p<0.001) and presence of tic disorder (16.28±8.21 vs. 22.01±9.38, OR=0.86, p=0.001). In addition, early age of onset was associated with presence of sexual obsessions (18.92±7.49 vs. 22.88±9.82, OR=0.96, p=0.02), hoarding (19.61±9.32 vs. 22.21±9.36, OR=0.95, p=0.009), repeating rituals (19.76±8.37 vs. 23.29±9.84, OR=0.95, p=0.006) and need to touch compulsions (16.40±7.19 vs. 22.36±9.43, OR=0.89, p<0.001). CONCLUSIONS Our findings from a large sample not only confirm that early onset OCD could be a valid and distinct subtype of OCD but also support the cross-cultural similarity of early onset phenotype.

Impact of depressive and anxiety disorder comorbidity on the clinical expression of obsessive-compulsive disorder.

BACKGROUND The identification of distinct subtypes based on comorbidity offers potential utility in understanding variations in the clinical expression of obsessive-compulsive disorder (OCD). Hence, we examined the hypothesis whether patients with OCD with major depressive disorder (MDD) or anxiety disorder comorbidity would differ from those without in terms of phenomenology. METHODS A total of 545 consecutive patients who consulted a specialty OCD clinic during the period 2004 to 2009 at a psychiatric hospital in India formed the sample. They were evaluated with the Yale-Brown Obsessive-Compulsive Scale (YBOCS), the Mini International Neuropsychiatric Interview, and the Clinical Global Impression scale. RESULTS Among 545 patients, 165 (30%) had current MDD, and 114 (21%) had current anxiety disorder comorbidity. Patients with OCD with MDD were mostly women who had a greater severity of OCD symptoms, more of obsessions (especially religious), greater occurrence of miscellaneous compulsions (need to confess or need to touch), higher suicidal risk, and past suicidal attempts. Patients with OCD with anxiety disorder had an earlier onset of illness that was associated with prior life events, less of compulsions, more of aggressive and hoarding obsessions, pathologic doubts, checking, and cognitive compulsions. CONCLUSIONS Obsessive-compulsive disorder, when comorbid with MDD, is more severe and is associated with higher suicidal risk. On the other hand, anxiety disorder comorbidity seems to influence not so much the morbidity but the phenotypic expression of OCD.

Clinically significant hoarding in obsessive-compulsive disorder: results from an Indian study

BACKGROUND Hoarding is frequently conceptualized as a symptom of obsessive-compulsive disorder (OCD), but recent evidence indicates that, in most cases, hoarding may be better conceptualized as a distinct disorder that can coexist with OCD. Most of the research on hoarding is from the Western countries. This study aimed to provide data on the prevalence and correlates of clinically significant hoarding in a large sample of patients with OCD from the Indian subcontinent. METHODS We examined 200 patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition OCD for clinically significant hoarding using the Saving Inventory-Revised, followed by a clinical interview. RESULTS Twenty patients (10%) had clinically significant hoarding. In all cases, hoarding did not appear to be related or secondary to other OCD symptoms. None of the cases consulted for their hoarding problems. Compared with nonhoarders, hoarders hailed exclusively from an urban background and had a significantly higher frequency of certain obsessions and compulsions, bipolar disorder, generalized anxiety disorder, cluster C personality disorders, and a higher number of lifetime suicidal attempts. They also had a more severe OCD along with poorer global functioning and somewhat poorer insight into obsessive-compulsive symptoms. CONCLUSIONS The results suggest that clinically significant hoarding is relatively prevalent in Indian patients with OCD and that it appears to be largely unrelated to the OCD phenotype. However, the presence of comorbid hoarding is associated with more severe OCD, high comorbidity, more suicidal attempts, and a lower level of functioning. The results contribute to the current nosologic debate around hoarding disorder and provide a unique transcultural perspective.

Plasma cytokine abnormalities in drug-naïve, comorbidity-free obsessive–compulsive disorder

Growing evidence in the last decade suggest significant role of immune alterations in the pathogenesis of obsessive-compulsive disorder (OCD). Cytokines, mediators of inflammation, alter the neurotransmitter concentration and result in a hyposerotonergic and hyperglutamatergic state implicated in pathogenesis of OCD. However, only few studies have examined cytokine abnormalities in OCD with inconsistent results possibly due to confounding effects of medications and comorbid anxiety-depression. We examined 20 comorbidity free, drug free OCD patients and 20 age and sex matched healthy controls. Clinical severity was assessed using Yale Brown Obsessive Compulsive Scale, Hamilton anxiety rating scale, Hamilton depression rating scale and Clinical Global Impression. Levels of different cytokines, Interleukin (IL)-2, IL-4, IL-6, IL-10, Tumor necrosis factor (TNF)-α and Interferon (IFN)-γ were assessed using Cytometric Bead Array. OCD patients had significantly greater plasma levels of IL-2, IL-4, IL-6, IL-10 and TNF-α levels than controls but not IFN-γ. Reanalysis of data with only drug naïve patients (excluding 4 drug free patients) did not alter the results. Presence of these abnormalities in drug-naïve patients suggests the possible role of cytokines in the pathogenesis of OCD. Study findings have potential clinical utility in development of novel therapeutic options targeting cytokine aberrations in OCD.

Does insight have specific correlation with symptom dimensions in OCD

OBJECTIVE To study relationship between insight and clinical characteristics in subjects with obsessive-compulsive disorder (OCD). METHOD Sample included 545 consecutive patients with a primary diagnosis of DSM-IV OCD who consulted a specialty OCD Clinic at a tertiary psychiatric hospital in India between January 2004 and December 2009. They had been evaluated with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) symptom checklist, severity rating scale and the item 11 for insight, the Mini International Neuropsychiatric Interview (MINI) and the Clinical Global Impression scale (CGI). Regression analyses were performed to identify predictors of insight. RESULTS The sample had 498 (91%) subjects with good insight (score≤2) and 47 (9%) subjects with poor insight (score>2) as per the Y-BOCS item11. Poor insight group had a significantly higher score on the Y-BOCS compulsions (p<0.001) and total score (p=0.001), the CGI-Severity (p=0.001) and a higher rate of contamination fears (p<0.001) and washing compulsions (p<0.001). Good insight group had a significantly higher frequency of aggressive obsessions (p<0.001). In linear regression, contamination dimension (p=0.007) and Y-BOCS total score (p<0.001) predicted poorer insight and presence of forbidden thoughts (p=0.006) predicted better insight. LIMITATIONS Study sample is from a specialty OCD clinic of a major psychiatric hospital in India and therefore, generalizability to other clinical settings may be limited. CONCLUSION Poor insight is associated with severe form of OCD, and is associated with contamination dimension. That degree of insight has specific correlation with certain symptom dimensions adds to the growing knowledge on the dimensional aspect of OCD. Insight has to be systematically assessed in all OCD subjects particularly in those with contamination fears. Failure to systematically assess insight may have treatment implications.

Family accommodation of obsessional symptoms and naturalistic outcome of obsessive–compulsive disorder

Accommodation of symptoms by families and expressed emotion (EE) may have a negative impact on the outcome of obsessive-compulsive disorder (OCD). The study examines the effect of family accommodation (FA) and EE on the 1-year naturalistic outcome of OCD. Patients with OCD who met the criteria for the Diagnostic and Statistical Manual of Mental Disorders-IV, text revision (DSM-IV TR; N=94) were followed up for 1 year and assessed every 3 months. Assessments included measurement of symptom severity, FA, EE and family burden. By the 12th month, the cumulative probability of remission was 58%. Non-remitters compared with remitters had a significantly higher FA, EE and family burden at the baseline and did not report significant reductions on any of the family variables over the year. In a Cox proportional hazard regression analysis, a higher FA at the baseline significantly predicted time to remission. FA of symptoms has a significant negative impact on the naturalistic outcome of OCD. This emphasises the need to design specific interventions to reduce FA for a better outcome.

Is Familial Obsessive-Compulsive Disorder Different from Sporadic Obsessive-Compulsive Disorder? A Comparison of Clinical Characteristics, Comorbidity and Treatment Response

Background: Familial and sporadic subtypes of obsessive-compulsive disorder (OCD) have been proposed, but have not been well studied. The aim of the study was to compare the clinical characteristics, comorbidity and treatment response of familial OCD with sporadic OCD. Sampling and Methods: We reviewed the clinical records of 84 familial OCD patients and 80 randomly selected sporadic OCD patients from a specialty OCD clinic in India. All the subjects had been evaluated using the specially devised topical OCD evaluation proforma, the Yale-Brown Obsessive Compulsive Scale and the Clinical Global Impression scale. A diagnosis of OCD was made according to the DSM-IV criteria. Results: Familial OCD was associated with earlier age at onset, a greater duration of untreated illness and more compulsions, particularly ordering and cognitive types. It was also associated with greater comorbidity, especially depression and other anxiety disorders, and treatment non-response. The sporadic group had more sexual obsessions and predominant obsession subtypes of OCD. In regression analysis, ordering compulsions, cognitive compulsions, absence of sexual obsessions, lifetime comorbidity of major depression and anxiety disorders and a greater duration of untreated illness predicted familial OCD. Conclusions: Our findings support the observation that familial OCD could be phenotypically different from sporadic forms of OCD and therefore a putative subtype of OCD.

A 5-year prospective follow-up study of patients with obsessive-compulsive disorder treated with serotonin reuptake inhibitors.

BACKGROUND Although obsessive-compulsive disorder is usually regarded as a chronic illness, there is limited data on the naturalistic long-term outcome of the disorder and on predictors of remission and relapse. The study examines the 5-year course prospectively in outpatients with the primary diagnosis of DSM-IV OCD who were mostly treated with serotonin reuptake inhibitors (SRIs). METHOD 106 of 115 subjects recruited over a period of 2 years from the outpatient services of an OCD clinic in India were followed periodically up to 5 years. RESULTS Subjects were moderately ill, mostly self-referred (89%), and less than a half was treatment-naive. Cumulative probability of at least partial remission and full remission at 5 years was 93% and 65% respectively. Most achieved remission by 2 years. In those who achieved either partial or full remission, cumulative probability of relapse by 5 years was 36%. Percentage of time on treatment and treatment-naive status at intake predicted at least partial remission, whereas only percentage of time on treatment predicted full remission. Full remission and doubts/checking dimension predicted lesser likelihood of a relapse. LIMITATIONS Patients were recruited from a specialty OCD clinic and treatment was not controlled during the follow-up period. CONCLUSIONS The outcome of OCD seems to be better than generally assumed, at least in moderately ill outpatients. Regular treatment over extended period may enhance likelihood of remission. Full remission should be the goal of treatment since it is associated with lesser propensity for relapse. Most patients remit in the first 2 years of treatment; therefore, early detection and intervention may improve the outcome.

Gender differences in the psychological impact of tsunami

Aim: The aim of this observational study was to explore gender-related differences in psychiatric morbidity during the initial three months following the December 2004 earthquake and tsunami involving the Andaman and Nicobar Islands, India. Methods: There were 12,784 survivors sheltered across 74 relief camps with 4,684 displaced survivors in Port Blair and 8,100 non-displaced survivors in Car-Nicobar Island. All persons who accessed mental health assistance within the camps constituted the study sample. Diagnoses were made by qualified psychiatrists using the ICD-10. There were 475 patients: 188 (40%) men and 287 (60%) women. Results: There were significant gender differences in terms of displacement. There were significantly higher levels of panic disorder, unspecified anxiety disorder and somatic complaints in the displaced women while the non-displaced population showed more adjustment disorder. Conclusions: Displacement was a significant factor in the manifestations of observed pathology. Displaced women had greater psychiatric morbidity. In addition, the fact that adjustment disorder (a self-limiting disorder form of psychopathology) was more prevalent in the non-displaced group may be a reflection of the findings of overall lesser morbidity in non-displaced women. Hence, women may have to be rehabilitated in their own habitats after major disasters.

Sexual Crime in India: Is it Influenced by Pornography?

Purpose: Studies on whether pornography poses a greater risk for sexually aggressive behavior have revealed conflicting results. This study aims to examine the relationship between the consumption of pornography and the subsequent increase in sexual violence, thus testing the hypothesis that increase in consumption of pornography is related to increased sexual crime, in the Indian scenario. Materials and Methods: The current study explored the association between reported incidence of crime over a period of four decades - 1971-2008 (time periods being divided into: Pre-liberalization and post-liberation - India adopted liberalization policy in 1992) and availability of pornography over internet with a particular focus on crime against women (such as rape, sexual harassment, and crime against women). Results: Comparison of pre-liberalization and post-liberalization growth of rape rates was not significant. Though there were statistically significant positive correlations between the number of internet users and sexual crime rates, the association was non-significant after controlling for the effects of population growth using regression analysis. Conclusion: Results presented needs to be interpreted with extreme care and caution. Nevertheless, the results from this study suggest that easy access to pornography did not have a significant impact on rape rates and crime rate against women.