Leonardo F. Fontenelle

Early- and late-onset obsessive-compulsive disorder in adult patients: an exploratory clinical and therapeutic study.

It has been suggested that early- and late-onset forms of obsessive-compulsive disorder (OCD) may stem from different neurobiological substrates manifesting themselves through particular phenotypic profiles. Our study aimed to assess the existence of clinical and therapeutic differences between adult patients with early- and late-onset OCD (EOCD and LOCD, respectively). Sixty-six patients with OCD were consecutively recruited among individuals seeking treatment in a university hospital clinic for anxiety and depressive disorders. Patients with EOCD (n=33) and LOCD (n=33) were compared and contrasted with regard to clinical and therapeutic characteristics using the two tailed t test for continuous variables and the Pearsons goodness of fit Chi-square test for categorical ones; Fishers exact test was employed when indicated. We found that, compared to their LOCD counterparts, adult patients with EOCD were characterized by (1) male gender predominance, (2) greater number of clinically significant obsessions and compulsions, (3) higher frequency of rituals repetition, (4) increased severity of obsessive-compulsive symptoms at baseline, and (5) greater number of required therapeutic trials during the follow-up. However, no significant differences between groups were noted in the final treatment outcome. Our results are consistent with previous studies suggesting that EOCD may represent a more severe subtype of this disorder.

Neuropsicologia dos transtornos alimentares: revisão sistemática da literatura

BACKGROUND The pathophysiology of eating disorders is still unknown, with many factors possibly involved. The existence of a central nervous system (CNS) dysfunction is being investigated with particular interest. One of the most employed strategies to reach this goal is the evaluation of cognitive functioning of patients with eating disorders with neuropsychological tests. OBJECTIVE To evaluate the current knowledge about the neuropsychology of ED. METHODS We performed a review of several data bases (including MedLINE, PsychoINFO, LILACS and Cochrane Data Bank), using terms related to main theme of interest. The review comprised articles published up to January, 2004. RESULTS Anorexia Nervosa (AN) was the most studied ED from the neuropsychological point-of-view, with studies tending to elicit attentive, visuo-spatial, and visuo-constructive deficits among such patients. On the other side, patients with Bulimia Nervosa (BN) exhibited deficits in the selective aspects of attention and in executive functions. As yet, there is no study covering the neuropsychological aspects of binge-eating disorder. After successful treatment, individuals show improvement of some cognitive deficits, while other seem to persist. CONCLUSIONS The ED are possibly associated with a certain degree of neuropsychological dysfunction, even though there is no consensus with regard to which function is particularly impaired. The fact that some cognitive dysfunction tend to disappear after treatment argues in favor of the hypothesis that these are functional deficits. Other deficits, however, tend to persist, suggesting that they may precede the development of eating disorders or even contribute to their development or to a worse prognosis. The study of the neuropsychological aspects of ED may help tailoring more selective therapeutic approaches to patients suffering from these disorders.

Altered Functional Brain Connectivity in a Non-Clinical Sample of Young Adults with Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is characterized by symptoms of inattention and hyperactivity/impulsivity that often persist in adulthood. There is a growing consensus that ADHD is associated with abnormal function of diffuse brain networks, but such alterations remain poorly characterized. Using resting-state functional magnetic resonance imaging, we characterized multivariate (complex network measures), bivariate (network-based statistic), and univariate (regional homogeneity) properties of brain networks in a non-clinical, drug-naive sample of high-functioning young men and women with ADHD (nine males, seven females) and a group of matched healthy controls. Data from our sample allowed the isolation of intrinsic functional connectivity alterations specific to ADHD diagnosis and symptoms that are not related to developmental delays, general cognitive dysfunction, or history of medication use. Multivariate results suggested that frontal, temporal, and occipital cortices were abnormally connected locally as well as with the rest of the brain in individuals with ADHD. Results from the network-based statistic support and extend multivariate results by isolating two brain networks comprising regions between which inter-regional connectivity was significantly altered in the ADHD group; namely, a frontal amygdala-occipital network and a frontal temporal-occipital network. Brain behavior correlations further highlighted the key role of altered orbitofrontal-temporal and frontal-amygdala connectivity for symptoms of inattention and hyperactivity/impulsivity. All univariate properties were similar between groups. Taken together, results from this study show that the diagnosis and the two main symptom dimensions of ADHD are related to altered intrinsic connectivity in orbitofrontal-temporal-occipital and fronto-amygdala-occipital networks. Accordingly, our findings highlight the importance of extending the conceptualization of ADHD beyond segregated fronto-striatal alterations.

Quality of life and symptom dimensions of patients with obsessive-compulsive disorder

The aim of this study was to evaluate the impact of different dimensions of obsessive-compulsive symptoms, of co-morbid anxious depressive symptoms, and of sociodemographic characteristics on the quality of life of patients with obsessive-compulsive disorder (OCD). We evaluated 53 patients with OCD and 53 age- and gender-matched individuals from the community with a sociodemographic questionnaire, the Structured Clinical Interview for the Diagnosis of Diagnostic and Statistical Manual of Mental Disorders, fourth Edition, (DSM-IV), the Short-Form Health Survey-36 (SF-36), the Saving Inventory-Revised, the Obsessive-Compulsive Inventory-Revised, the Beck Depression Inventory and the Beck Anxiety Inventory. A series of stepwise linear regression analyses were performed, having the SF-36 dimensions as the dependent variables and the sociodemographic and clinical features as the independent ones. Patients with OCD displayed significantly lower levels of quality of life in all dimensions measured by the SF-36, except bodily pain. A model that included depressive symptoms, hoarding and employment status predicted 62% of the variance of the social functioning dimension of the quality of life of patients with OCD. Washing symptoms explained 31% of the variance of limitation due to physical health problems. Further, a series of models that included depressive, but not obsessive-compulsive symptoms, explained the remaining SF-36 dimensions. The severity of depressive and anxiety symptoms seems, therefore, to be powerful determinants of the level of quality of life in patients with OCD.

Obsessive-compulsive disorder, impulse control disorders and drug addiction: common features and potential treatments.

The basic concepts underlying compulsive, impulsive and addictive behaviours overlap, which may help explain why laymen use these expressions interchangeably. Although there has been a large research effort to better characterize and disentangle these behaviours, clinicians and scientists are still unable to clearly differentiate them. Accordingly, obsessive-compulsive disorder (OCD), impulse control disorders (ICD) and substance-related disorders (SUD) overlap on different levels, including phenomenology, co-morbidity, neurocircuitry, neurocognition, neurochemistry and family history. In this review we summarize these issues with particular emphasis on the role of the opioid system in the pathophysiology and treatment of OCD, ICD and SUD. We postulate that with progression and chronicity of OCD, the proportion of the OCD-related behaviours (e.g. checking, washing, ordering and hoarding, among others) that are driven by impulsive ‘rash’ processes increase as involvement of more ventral striatal circuits becomes prominent. In contrast, as SUD and ICD progress, the proportion of the SUD- and ICD-related behaviours that are driven by compulsive ‘habitual’ processes increase as involvement of more dorsal striatal circuits become prominent. We are not arguing that, with time, ICD becomes OCD or vice versa. Instead, we are proposing that these disorders may acquire qualities of the other with time. In other words, while patients with ICD/SUD may develop ‘compulsive impulsions’, patients with OCD may exhibit ‘impulsive compulsions’. There are many potential implications of our model. Theoretically, OCD patients exhibiting impulsive or addictive features could be managed with drugs that address the quality of the underlying drives and the involvement of neural systems. For example, agents for the reduction or prevention of relapse of addiction (e.g. heavy drinking), which modulate the cortico-mesolimbic dopamine system through the opioid (e.g. buprenorphine and naltrexone), glutamate (e.g. topiramate), serotonin (e.g. ondansetron) or g-aminobutyric acid (e.g. baclofen and topiramate) systems, may prove to show some benefit in certain forms of OCD. Based on the available evidence, we suggest that the treatment of patients with these disorders must account for alterations in the underlying motivations and neurobiology of the condition. We provide an initial guide to the specific treatments that future clinical trials might consider in patients with OCD. For example, it might be wise to test naltrexone in patients with co-morbid SUD and ICD, topiramate in patients with co-morbid ICD and eating disorders, and baclofen in patients with co-morbid Tourettes syndrome. These trials could also include scales aimed at assessing underlying impulsivity (e.g. Barratt Impulsiveness Scale) to check whether this construct might predict response to drugs acting on the reward system.

Suicidality in obsessive-compulsive disorder: prevalence and relation to symptom dimensions and comorbid conditions.

BACKGROUND Suicidal thoughts and behaviors, also known as suicidality, are a fairly neglected area of study in patients with obsessive-compulsive disorder (OCD). OBJECTIVE To evaluate several aspects of suicidality in a large multicenter sample of OCD patients and to compare those with and without suicidal ideation, plans, and attempts according to demographic and clinical variables, including symptom dimensions and comorbid disorders. METHOD This cross-sectional study included 582 outpatients with primary OCD (DSM-IV) recruited between August 2003 and March 2008 from 7 centers of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. The following assessment instruments were used: the Yale-Brown Obsessive Compulsive Scale, the Dimensional Yale-Brown Obsessive Compulsive Scale, the Beck Depression and Anxiety Inventories, the Structured Clinical Interview for DSM-IV Axis I Disorders, and 6 specific questions to investigate suicidality. After univariate analyses, logistic regression analyses were performed to adjust the associations between the dependent and explanatory variables for possible confounders. RESULTS Thirty-six percent of the patients reported lifetime suicidal thoughts, 20% had made suicidal plans, 11% had already attempted suicide, and 10% presented current suicidal thoughts. In the logistic regression, only lifetime major depressive disorder and posttraumatic stress disorder (PTSD) remained independently associated with all aspects of suicidal behaviors. The sexual/religious dimension and comorbid substance use disorders remained associated with suicidal thoughts and plans, while impulse-control disorders were associated with current suicidal thoughts and with suicide plans and attempts. CONCLUSIONS The risk of suicidal behaviors must be carefully investigated in OCD patients, particularly those with symptoms of the sexual/religious dimension and comorbid major depressive disorder, PTSD, substance use disorders, and impulse-control disorders.

Impulse control disorders in patients with obsessive-compulsive disorder.

Abstract  The purpose of the present paper was to identify the rate of prevalence of impulse control disorders (ICD) in patients with obsessive–compulsive disorder (OCD) and to compare patients with OCD with and without ICD with regard to sociodemographic, clinical and prognostic characteristics. Forty‐five patients with OCD were assessed by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th edn, DSM‐IV) plus additional modules for the assessment of ICD and examined using the Yale–Brown Obsessive–Compulsive Scale, the Clinical Global Impression, the Beck Depression Inventory, the Hamilton Depression Rating Scale, and the Global Assessment of Functioning. These patients were treated with serotonin re‐uptake inhibitors (SRI) and followed for a variable period of time. Individuals with ICD (here defined as including not only the impulse control disorders not elsewhere classified of the DSM‐IV, but also other disorders in which impulse control is a prominent feature such as alcohol and drug dependence, paraphilias and bulimia nervosa/binge eating disorder) were compared to those without ICD using the Mann–Whitney U‐test and the Pearsons goodness of fit χ2 test. Sixteen patients with OCD (35.5%) displayed comorbid ICD. Patients with ICD were characterized by a significantly earlier age at OCD onset (P = 0.04), a more insidious appearance of OCD symptoms (P = 0.04), a higher rate of comorbid anxiety disorders (P = 0.03), a greater number (P = 0.02) and severity of compulsive symptoms (P = 0.04), an increased rate of counting compulsions (P = 0.02), and a higher number of required SRI trials (P = 0.01). When OCD is found in association with ICD, the clinical picture is characterized by a greater severity of the obsessive–compulsive symptoms at presentation and by the requirement of a greater number of therapeutic attempts during follow up.

Topiramate use in obese patients with binge eating disorder: An open study

Objective: To assess topiramates efficacy and tolerability in a group of obese binge eaters with no neuropsychiatric comorbidity. Method: We consecutively selected 8 obese patients with binge eating disorder (BED) and no medical or psychiatric comorbidity from individuals seeking treatment for obesity. Treatment with topiramate at 150 mg daily was administered over a 16-week period. To assesss outcome, we employed the days with binge episodes per week (DBE), the Binge Eating Scale (BES), the Beck Depression Inventory (BDI), and body weight evaluation. Results: Of the 6 patients who completed the trial, all showed reduced binge eating. Four patients presented a total remission, and 2 had a marked reduction in binge eating frequency. The mean DBE decreased significantly from 4.3 to 1.1 (P = 0.03), as did the BES scores, which fell from 31.8 to 15.3 (P = 0.04). Moreover, there was a statistically significant weight loss (mean 4.1 kg, P = 0.04). The most frequent side effects were paresthesias, fatigue, and somnolence. Conclusion: Topiramate may be an effective and well-tolerated agent in the treatment of BED in obese patients.

Impulse control disorders and “behavioural addictions” in the ICD-11

Psychiatric classifications have traditionally recognized a number of conditions as representing impulse control disorders. These have included pathological gambling, intermittent explosive disorder, kleptomania, pyromania, and trichotillomania.

Psychiatric comorbidity in a Brazilian sample of patients with binge-eating disorder

We compared sociodemographic characteristics and psychiatric status in obese Brazilian patients who did (n=32) and did not (n=33) meet DSM-IV criteria for binge-eating disorder (BED). The samples mean age was 35.0 years (+/-10.5), with 92.3% of individuals being female and 41.5% having some higher education. Obese binge eaters (OBE) were significantly more likely than obese non-binge eaters to meet criteria for a current diagnosis of any axis I disorder, any mood disorder and any anxiety disorder. Specifically, OBE patients were characterized by significantly higher rates of current and lifetime histories of major depressive disorder. Similar to patients from developed countries, Brazilian patients with BED display increased rates of psychiatric comorbidity, particularly mood and anxiety disorders.