Toward a New Nosology of Obsessive Compulsive Disorder L. Lee Tynes, Kerrin White, and Gail S. Steketee Obsessive compulsive disorder (OCD) is receiving increasing attention in the clinical research literature. This review briefly summarizes data concerning diagnosis, phenomenology, and epidemiology of OCD and examines other disorders that closely resemble OCD. In addition, the nosological and treatment implications of these data are discussed. We find that OCD is characterized by a focal anxiety point(s) reflected in obsessions and by behavioral or cognitive compulsions. The appearance of these characteristics in other disorders suggests some relation between them and, consequently, the treatment of these disorders may be enhanced by conceptualizing them as OCD “variants.” 0 1990 by W. B. Saunders Company.

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ECENT IMPROVEMENTS in behavioral and pharmacological treatment for obsessive compulsive disorder (OCD) have been responsible, at least in part, for a growing interest in the disorder. Consequently, the research database on OCD is growing ever larger and prompting more intensive investigation of diagnosis, phenomenology, epidemiology, and treatment. This report is an attempt to briefly review and synthesize these data, and to examine more closely the nosological implications of the findings. We begin with a description of OCD symptomatology and epidemiology and then examine differential diagnosis, comorbidity, and “variants” of the disorder. The review of these data, along with our clinical experience, has led us to several general conclusions. First, although there is some uncertainty as to whether OCD is best categorized as an anxiety disorder, a key feature seems to be a focal anxiety point(s) (e.g., germs, contamination, safety, etc.) around which the patient experiences intrusive and repetitive obsessions. A second key feature of the disorder is almost always the presence of behavioral or cognitive compulsions. The latter is often apparent in those patients presenting as “pure” obsessionals. Many disorders closely resemble OCD. Examples include trichotiliomania, hypochondriasis, and bulimia. To the extent symptoms of these disorders include the aforementioned focal anxiety and overt or covert compulsions, they might be conceptualized as subtypes of OCD. As a result, treatments for these disorders may be generated based on those found to be effective for OCD. DESCRIPTION

OF OCD

Svmptomatology According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (Third Edition-Revised),’ the essential features of

From the Departmentof Psychiatry, Harvard Medical School, Cambridge, MA; McLean Hospital Obsessive Compulsive Disorders Clinic. Belmont, MA; and the Department of Social Work, Boston University, Boston, MA. Address reprint requests to L. Lee Tynes, Ph.D.. Psychiatric Clinic. Department of Psychiatry Neurology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112. o 1990 by W.B. Saunders Company. 0010-440x/90/31 05-0010$03.00/0

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OCD are recurrent obsessions or compulsions that are significantly distressing or time-consuming or that cause significant interference with social or occupational functioning. Obsessions are defined as “persistent ideas, thoughts, impulses, or images that are experienced, at least initially, as intrusive and senseless. . . .” (p. 245). The most common of these focus on thoughts of violence, contamination, or doubt. Compulsions are “repetitive, purposeful, and intentional behaviors that are performed in response to an obsession, according to certain rules, or in a stereotyped fashion” and may be “designed to neutralize or to prevent discomfort or some dreaded event or situation” (p. 245). There appears to be general agreement about the categorization of the different types of compulsive behaviors, namely “washing,” “checking,” “repeating,” and more rarely, “ordering.” Conversely, attempts to categorize obsessions have yielded little consensus among investigators. Foa and Steketee* reviewed this issue and produced several relatively exclusive categories, including (1) fear of causing harm to oneself or others, (2) fear of loss of control, (3) pervasive doubts, and (4) sexual and religious fears. The first category of compulsive behaviors (washers) includes patients who are fearful of contaminating themselves or others. Their compulsions revolve around the theme of restoration of cleanliness (e.g., handwashing, frequent showers, repetitive cleaning of objects such as cooking utensils or clothes, etc.). Checking behaviors, the second category, are exhibited by patients who engage in repetitious behaviors in order to assure that a dreaded event or disaster does not occur. These patients may endlessly check and recheck door locks, stove controls, light switches, or electrical outlets in an attempt to prevent burglary, fire, etc. “Repeaters,” whose compulsions usually do not relate logically to the feared disaster, may feel compelled to repeatedly touch an object, say a prayer, or enter a room a certain “magical” number of times in order to prevent harm from befalling themselves, loved ones, or others. Finally, ordering is a relatively less common category of compulsion characterized by the need to arrange objects in relation to one another according to some set of rules. For example, a patient may need to arrange his furniture in a prescribed way (e.g., in a symmetrical fashion, or in such a way that all straight edges are parallel or perpendicular) before he can leave the room. As Steketee and Foa3 point out, traditional classification schemes that define obsessions as cognitive events (e.g., thoughts) and compulsions as behavioral events (e.g., washing) can prove misleading in the actual clinical situation. For instance, consider the patient who performs covert, mental rituals (e.g., silently repeating a prayer) in response to being touched by someone who is “contaminated.” As a result of dilemmas such as these, Foa and Tillmans proposed a different definition of obsessions and compulsions by describing the former as cognitive or behavioral events that produce anxiety, while compulsions are events (whether covert or overt) that alleviate anxiety. Currently, OCD is classified as an anxiety disorder, primarily because of the anxiety induced by the obsessions. In addition, avoidance behavior, often characteristic of anxiety disorders, is frequently observed in OCD patients who avoid stimuli thought to precipitate their particular obsessions or compulsions. It remains to be seen whether OCD is more closely associated with the anxiety disorders than with

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other diagnostic groups (e.g., affective disorders, impulse control disorders). As more data become available regarding epidemiology, family history, course, biological correlates, and specific treatment responsiveness, comparative research may reveal relationships between OCD and other disorders that alter the current diagnostic scheme. Epidemiology

Until recently, it was thought that the incidence of OCD in the general population and even among psychiatric patients was quite low. But the tendency of these patients to be secretive about their symptoms, as well as their reluctance to seek treatment, may have compromised the accuracy of these estimates.5 Indeed, recent data gathered in the national Epidemiology Catchment Area (ECA) study of over 18,000 subjects from the general population indicated that anxiety disorders were the most prevalent of all major diagnostic categories and, within this group, OCD was second only to phobic disorders in prevalence. Specifically, the authors reported a l-month OCD prevalence rate of 1.3%, a 6-month prevalence of 1.5%, and a lifetime prevalence of 2.5%~~Other studies7p8are supportive of these conclusions. In a review of the pertinent literature on OCD, Rasmussen and Tsuang’ concluded that patients with the disorder are slightly more often female (1.2: 1.O) and that age of onset is generally around age 20, although some patients trace symptoms back to childhood years and a few report onset after age 35. Rasmussen and Eisen” reported that most of their patients showed a gradual or insidious onset. Approximately 85% of their OCD patients manifested a continuous course of illness, whereas only 15% had either an episodic or deteriorating course. DIFFERENTIAL

DIAGNOSIS

AND COMORBIDITY

For the clinician, an important consideration is that of differential diagnosis and comorbidity in patients presenting with OCD symptoms. Of most concern in this respect are obsessive compulsive personality disorder (OCPD), psychoses, depression, and phobic disorders. For the diagnostician, differential diagnosis and comorbidity data may also hold the key to etiologic or otherwise functional relationships between presumably separate disorders. OCPD

The question of a relationship between obsessive compulsive symptoms and traits has constituted a long-standing controversy. Currently, DSM-III-R defines OCPD as a “pervasive pattern of perfectionism and inflexibility” marked by at least five of the following nine characteristics: perfectionism, preoccupation with details, insistence that others submit to his or her way of doing things, excessive devotion to work, indecisiveness, overconscientiousness, restricted expression of affect, lack of generosity, and inability to discard worthless objects. Some of these traits (e.g., indecision, perfectionism) appear to be characteristic of OCD but encompass a wider range of situations and behaviors than is necessarily typical of OCD. Only the last, inability to discard objects, appears to overlap substantially with symptoms typical of OCD (i.e., hoarding). Insel” notes that the symptoms of OCD are usually ego-dystonic, (that is, they are seen as “out of character,” distressing, unnecessary, etc.). By contrast, the

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pathology of the OCPD patient is ego-syntonic; symptoms (“traits”) are consistent with the character and beliefs of the OCPD patient and are not necessarily seen as distressing in and of themselves, although they may be quite troublesome to others. It was once believed that patients with OCD shared common premorbid obsessive compulsive personality traits.’ The obsessive compulsive symptoms were seen as an extension or exaggeration of the compulsive traits. More recently, investigators have dismissed a one-to-one relationship between predisposing personality traits and OCD, but a significant association does appear to exist between OCPD traits and OCD symptoms in both psychiatric patients and normals.‘2-‘6 Retrospective research has demonstrated a high incidence (72%) of premorbid obsessional traits in obsessional patients (N = 91), but many nonobsessional neurotic patient controls (53% N = 91) also reported such traits. ” The incidence of a diagnosable OCPD occurring in patients with OCD is apparently much lower (4.4%-10.0%).‘6~18 One of the difficulties impeding understanding of the relation between OCD and OCPD has been the lack of consistent diagnostic criteria for obsessive-compulsive personality traits and the consequent difficulty in comparing different studies. In recent years, movement toward more objective and uniform criteria for the diagnosis of mental disorders has improved this situation, DSM-III-R appears to reflect the current research literature by asserting that true obsessions and compulsions are not present in simple OCPD, but that both OCD and OCPD may occur simultaneously and should then be recorded as such. Clearly, these two diagnostic categories (OCD, OCPD) overlap somewhat, yet apparently lack the high degree of association once thought to exist. Schizophrenia

Another long-standing problem of differential diagnosis has been that of psychosis. Although through most of this century, OCD has been viewed almost invariably as a neurosis (anxiety disorder), it has been observed for years that a small but significant percentage of schizophrenic patients demonstrate obsessive compulsive symptoms.‘9,20 Additionally, in a review of follow-up studies of OCD patients, Insel and Akiska121reported the occurrence of schizophrenia in 0 to 12.3% of OCD study subjects, with most studies citing a 1% to 6% incidence (notably higher than that of the general populatiot?). However, the authors point out that in many of these studies the diagnostic criteria for OCD and for schizophrenia appear to have been quite broad. Thus, many patients classified as schizophrenics would have been diagnosed as affective disorders or paranoid states by current standards. Also, several of the studies reviewed described OCD patients who evidenced a “reactive” or “psychogenic” psychosis, the current diagnostic classification of which is unclear. Since both OCD and psychosis feature intrusive, uncontrollable, and sometimes bizarre thoughts, discrimination is occasionally difficult and patients who by current standards have clear OCD may in the past have incurred diagnoses of schizophrenia for the same symptoms. The distinction between psychotic and nonpsychotic obsessions has traditionally rested on the presence of subjective distress, the realization that the thoughts are senseless and of internal origin, and the provocation of internal resistance, all typical of OCD patients.22V23 However, it is important to note, that the absence of these features also characterizes obsessive compulsive personality traits and overvalued ideas.

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Rachman23 argued that there is little relation between schizophrenia and OCD, since the percentage of OCD patients developing schizophrenia is small and not significantly different from that seen in other neurotic disorders. Insel”*2’ agreed and proposed that OCD be placed on a continuum of severity, the most extreme represented by obsessions that acquire, at least transiently, psychotic proportions. Overvalued Ideation

An examination of the literature on psychotic features in OCD would be incomplete without consideration of the “overvalued idea.” In a recent review of the overvalued idea in psychopathology, McKenna24 paraphrased Wernicke’s original definition as “a solitary belief that came to determine an individual’s actions to a morbid degree, while at the same time being considered justified and a normal expression of his nature” (p. 579). The overvalued idea is further described as being similar to a “passionate conviction” as opposed to a delusion, which is clearly outside the mainstream of normal beliefs. McKenna goes on to distinguish the overvalued idea from an obsession in that the former is “seen as natural rather than intrusive, is acquiesced to without resistance and is not regarded as senseless or even futile” (p. 583). Overvalued ideation may herald failure of behavioral treatment for OCD according to Foa. 25She observed that the subjective anxiety of OCD patients with overvalued ideas did not habituate between sessions as is typical of OCD patients without overvalued ideas. This group of patients appeared to experience a “resensitization” after anxiety had previously habituated during a session of exposure to feared obsessional situations. Foa speculated that this is a function of the closely held belief that still guides behavior between sessions in the absence of a therapist to challenge them. Conversely, the OCD patient without overvalued ideation experiences a long-term habituation to the feared stimuli, presumably as a function of cognitive changes produced by therapist-directed exposure to the feared stimulus. Further research is needed to assess the degree to which OCD patients believe in their obsessional ideas and to determine whether such beliefs are negatively associated with treatment outcome. If Foa’s” observations are substantiated, treatment strategies that can modify such firmly held, irrational beliefs will be needed. In summary, OCPD and schizophrenic disorders were once thought to be more closely related to OCD than current research indicates. Nonetheless, for accurate differential diagnosis, both should be considered (as well as the role of overvalued ideation) in the assessment of these patients, especially since the disorders may coexist. Depression

Depressive symptomatology is very commonly seen in OCD patientsgxz6and may occur either before or following the emergence of OCD pathology. Weiner et a1.27 examined the case records of 150 inpatients demonstrating “indisputable” OCD symptoms. Of 93 patients with both depression and OCD symptoms, 57 (61%) records indicated that the OCD appeared first, 20 (22%) records indicated concurrent onset, and 16 (17%) indicated that the depression arose first.

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Estimates of the incidence of depression in patients with OCD vary widely, with Vaughn’* reporting a 17% to 35% incidence and Turner2’ reporting depression in 79% of his OCD sample. Additionally, data were presented from the National Institute of Mental Health Epidemiological Catchment Area studyso that suggested that persons with a major depressive episode are approximately 11 times more likely to experience a diagnosable OCD and that 3 1.7% of OCD subjects met criteria for a diagnosis of major depressive episode.31 The issue of depression in OCD is an important one in that the existence of a concomitant depressive disorder may have important treatment implications. There is some data to suggest that OCD patients with major depression may have a poorer prognosis for behavioral treatments,25’32*33 although recent studies do not support this concern.34-37 The efficacy of serotonergic antidepressants in the treatment of OCD has raised the question of a possible biologic link between OCD and depression. Several recent studies have examined the results of the Dexamethasone Suppression Test (DST, sometimes used as a biological marker for endogenous depression) in both depressed and nondepressed OCD patients. 40-44The results of these studies generally indicated that OCD patients who demonstrate significant affective symptoms also tend to have positive DST results (failure of cortisol to remain fully suppressed). Different interpretations of such results are possible. Insel et a1.41suggested that the DST results may indicate a psychobiological link between OCD and major depression. Conversely, Jenike et a1.,42 Monteiro et a1.,43and Vallejo et a1.44concluded that OCD and major depression are two different disorders, with OCD patients showing biological characteristics of depression only when depression exists as a comorbid disorder. These and other data suggest some biologic commonality between OCD and depression, but the exact nature of the similarity is still unclear. Anxiety Disorders

As one might expect, the incidence of concomitant anxiety disorders in OCD patients is considerable. Rasmussen and Tsuang4’ reported the lifetime incidence of simple phobia in their OCD patients to be 27%; social phobia, 18%; separation anxiety, 18%; panic disorder, 14%; and agoraphobia, 9%. Compatible figures were reported by Rasmussen and Eisen.” Studying 18,000 randomly selected subjects from the ECA study mentioned earlier, Karno et a1.31reported comorbidity of panic disorder and of phobic disorders among persons with OCD to be 13.8% and 46.5%, respectively. Mavissakalian et a1.47emphasized the similarities of OCD patients to panic and agoraphobic patients, including the fear of losing control with subsequent negative consequences. Other researchers in the field have examined the relation between phobic and obsessive compulsive avoidance. Marks4* described OCD as a “type of phobia,” noting the similarities between a phobic’s avoidance of feared stimuli (e.g., a snake, a dog, crowded places, travel routes) and the OCD patient’s avoidance of stimuli that elicit their obsessions or compulsions (e.g., doorknobs). The goal is the same in both cases, namely the minimization of anxiety. However, despite these common features, some differences are evident. Foa et a1.4gpoint out that, whereas the phobic’s feared stimulus may be truly avoidable, the OCD patient’s may not. For example, feared thoughts are often experienced as unpredictable and uncontrollable and thus not avoidable like concrete, external stimuli. Another example can be found in “contamination,” which typically generalizes so broadly as it is “passed”

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from person to place that it can be avoided only with great difficulty if at all. Consequently, rituals are often instituted to reduce anxiety which cannot be contained by avoidance alone. Comorbid depression and anxiety disorders, then, are frequently seen in OCD patients. Indeed, some investigators have cited the data on comorbidity of affective disorders (along with that of biologic marker studies) to support the notion that OCD may not belong with anxiety disorders, but might actually be an affective variant.39,50 Perhaps OCD should be considered an altogether separate diagnostic category, displaying strong relations with both anxiety and depression. VARIANTS

OF OCD

Some psychiatric syndromes present with symptoms that appear to have strong similarities to typical obsessive compulsive symptoms and may constitute a group of “variants” of this disorder. Whether or not these subtypes represent nosologically distinct groups is questionable; however, their identification as possible manifestations of OCD may facilitate clinical appreciation of the variety of OCD patients one may encounter and may suggest treatment alternatives for patients who do not present with OCD as a primary complaint. Impulse Control Disorders

One such group of dysfunctions is that of impulse control disorders (e.g., Tourette’s syndrome, trichotillomania, kleptomania). A history of impulse control difficulties, although not necessarily diagnosable disorders, is sometimes seen in OCD patients. According to Hoehn-Saric and Barksdale,” these patients frequently exhibited childhood disturbances such as learning problems, low frustration tolerance, attention-seeking, and poor relationships. Tourette’s syndrome. One impulse control disorder that has received attention from clinicians and researchers for its relationship to OCD has been Gilles de la Tourette’s syndrome (TS). Patient’s with this disorder typically exhibit motor and vocal tics, which are generally distinguished from compulsions as being involuntary, unintentional, and purposeless. Motor tics, involuntary muscle spasms or jerks, usually involve the head and face, but may include any number of muscle groups of the body. Vocal tics may include grunts and snorts, but may also be more complex as in words or phrases (e.g., coprolalia). The occurrence of obsessive compulsive symptoms in patients with TS has been noted since the initial description of the disorder.52 Recent studies have reported an incidence of OCD in patients with TS of 50% or more.53*54Pauls et al.53 examined 122 first-degree relatives of 32 TS patients and found that the rate of OCD among relatives (22%) was significantly higher than both population estimates and the rates of relatives of adopted TS subjects. Pitman et al.54 found that 63% of their TS subjects (N = 16) also met the diagnostic criteria for OCD. These data certainly suggest a genetic etiologic relationship between TS and OCD despite some obvious dissimilarities between the two disorders. Trichotillomania. Another impulse control disorder that bears resemblance to OCD is trichotillomania, characterized by the habit of or compulsion to pull out hair. The scalp is apparently the most commonly targeted area, though patients may

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pull hair from other parts of the body (e.g., eyebrows, pubic hair, etc.). Trichotillomania may present itself in the context of obsessive compulsive disorders5 and may be considered, at least in some cases, as a form of 0CD.56 Several investigators have reported anxiety as an accompaniment to trichotillomania.55*56 According to an early review of the literature, hair-pulling served to release “nervous tension” in many cases, and prevention of the compulsion evoked annoyance in many patients.57 Though certainly not definitive, these comments suggest some similarity to the symptomatology of OCD. Recently, Primeau and Fontaine58 presented a case report of a young woman who apparently pulled out her hair to relieve anxiety, particularly that produced by obsessional thoughts of hurting her mother. She responded well to pharmacotherapy with fluoxetine, a drug that has been found effective with OCD symptoms. A study investigating the degree to which compulsive hair-pulling relieves anxiety (as do the compulsions of OCD patients) would be valuable in determining the association of OCD and trichotillomania. Kleptomania. Kleptomania, or compulsive stealing, may also be conceptualized as a variant of OCD, at least in some cases. Similarities between kleptomania and OCD are apparent in the repetitious nature of the impulses to steal, along with the mounting tension and anxiety if the behavior is not emitted and relief of this arousal following an episode of stealing.59-61Separating the two disorders is the inherent pleasurability in the mounting and release of tension reported by most compulsive shoplifters and the lack of purpose of the compulsive behavior (i.e., the shoplifting serves no evident purpose as does the checking, cleaning, etc. of the OCD patient). Commonalities between the two disorders have been noted clinically for years, although only a few case histories have been published involving both kleptomania and 0CD.59@*63 To date, no systematic or experimental studies have been performed to assess OCD symptoms in this population, although McElroy et a1.64 are presently exploring the relationship between these two disorders. A review of recent publications regarding exhibitionism reveals Exhibitionism. a possible link with OCD. Exhibitionism is the exposure of one’s genitals to typically unsuspecting “nonsignificant” others, without further aggression. Snaith65@ outlines several reasons to consider at least some cases of exhibitionism similar to an “obsessional neurosis,” and recommends that obsessive compulsive features be assessed when testing exhibitionists. He points out that patients with this disorder often describe their feelings of being compelled to do something they regard as senseless. Conceptualization of exhibitionism as a variant of OCD might, Snaith suggests, account for several inconsistencies in reports of the disorder, namely “the absence of any single personality type, the engagement in the behavior even when detection and punishment are likely to occur, the occurrence at times when the man is tense, depressed or irritable, [and] the occasional association with depressive illness and with other frank obsessional symptoms” (p. 233).66 With the possible exception of TS, most of the above disorders resemble OCD in that they are characterized by a sense of compulsion to carry out an act that the patient knows to be unreasonable. However, unlike OCD, the acts appear to not merely reduce tension, but to provide pleasure (in most cases). Even those who pull out hair report enjoying what most people consider a mildly painful sensation. Nonetheless, treatments that are effective for OCD (e.g., exposure and response prevention, serotonergic antidepressants) may prove useful in such cases.

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Hypochondriasis

Perhaps even more closely associated with OCD than the above disorders is hypochondriasis, which is characterized by preoccupation with or fear of having a serious illness, despite negative medical evaluations and reassurance from physicians. Hypochondriacal patients experience such anxiety over bodily symptoms that they suffer from intrusive thoughts about health and disease and are motivated by this distress to repeatedly seek physician reassurance. In a study of 5 12 patients with a primary or secondary diagnosis of hypochondriasis, OCD was not listed as one of the concomitant psychiatric diagnoses frequently present.67 Interestingly, of 295 inpatients for whom data were available, 22.8% of the primary hypochondriacal patients and 28.2% of the secondary hypochondriacs exhibited premorbid “obsessional” traits. More recently, Rasmussen and Tsuang45 reported that 34 of their 100 OCD clinic patients had somatic obsessions that compelled them to undergo repetitive examinations to reassure themselves that they had no serious illness. However, they did not report that hypochondriasis was among the concomitant axis I diagnoses. This lack of a dual diagnosis of OCD and hypochondriasis in both of these studies may simply reflect an artifact of the diagnostic procedure employed. For instance, DSM-III discouraged the diagnostician from giving a patient both diagnoses simultaneously (unless the hypochondriacal symptoms were not “due to” the OCD, an arguably difficult decision to make3’), while DSM-III-R instructs the reader to give both diagnoses if the criteria for both are met. Salkovskis and Warwick” draw a parallel between hypochondriacal patients and those with OCD. Specifically, they point to the anxiety about illness and the consequent intrusive, catastrophic cognitions followed by the seeking of medical reassurance as being typologically similar to the obsessions and compulsions of OCD. However, unlike the obsessions of OCD, preoccupation with illness is typically ego-syntonic. Nonetheless, the authors present data suggesting that the physician’s reassurance negatively reinforces the hypochondriac’s reassuranceseeking behavior (that is, it reduces anxiety) in much the same way as an OCD patient’s compulsions are negatively reinforced. The authors recommend an exposure and response prevention paradigm for treatment of these patients and present two case histories in which such an intervention was successfully employed. Body Dysmorphic Disorder

Resembling hypochondriasis to some extent is body dysmorphic disorder, the essential feature of which is a subjective concern and preoccupation with a particular physical “defect” in a person whose appearance is essentially normal. For instance, a patient may believe that his nose is disproportionately large and should be corrected with surgery when, in actuality, his nose appears unremarkable to others. DSM-III-R has changed the name of this disorder from dysmorphophobia to body dysmorphic disorder, stating that phobic avoidance is not involved and emphasizing that patients with this diagnosis are not delusional in their belief (though this may be difficult to assess). There is apparently little reliable data published concerning this diagnostic entity, probably due to its relative rarity in the general population and, to some extent, the fact that it was not included in American diagnostic manuals until the publication of the DSM-III.

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The results of a study by Hardy and Cotteril69 showed that dysmorphophobic patients (N = 12) had significantly higher scores on three of the four factors of the Leyton Obsessional Inventory (LOI) when compared with normal controls (N = 12), but were not significantly different on these variables from psoriatic control patients (N = 11). Additionally, some anecdotal evidence suggests that these patients tend to have obsessional personality traits.70’71Hollander et al.” recently reported five cases of body dysmorphic disorder that responded preferentially to serotonergic antidepressants. The authors expressed their clinical impression that this disorder may be closely related to OCD, but did not examine their hypothesis in any systematic way. More rigorous research is needed, but there is some suggestion at this point that commonalities may exist between at least some cases of body dysmorphic disorder and OCD. Anorexia/Bulimia

The relationship of eating disorders such as anorexia nervosa and bulimia nervosa to OCD has been studied by several investigators. Based on chart review data and clinical experience, Rothenberg73 recently suggested that both anorexia and bulimia are “modern” syndromes of OCD. Research data appear to support this hypothesis for at least some cases. For example, Kasvikis et a1.74 reported that 16 of 151 (10.6%) female OCD patients had a history of anorexia, compared with none of 149 male OCD patients and 100 agoraphobic patients. Smart et a1,75administered the LO1 to 22 female anorexic patients. They found that all four subscale scores were significantly higher than those of normals, but three of the four scores for anorexics were significantly lower than those of “obsessional patients.“” Similarly, Solyom, et a1.76compared 15 female anorexics with 14 age-matched female obsessives on a variety of psychometric tests. Both groups scored similarly on the LOI, although the obsessives scored consistently higher on all measures; only one of the four subscales significantly differentiated the groups. Additionally, about half of the anorexic sample qualified for a diagnosis of “obsessive neurosis” on nonfood and body-related obsessions alone. The authors speculated that intense ambivalence and obsessive personality traits constitute common factors between the two disorders worthy of further investigation. Although these studies point to commonalities between anorexia and OCD, many investigators believe that another eating disorder, bulimia, even more closely resembles OCD. This contention has found support in epidemiologic data, theoretical analysis, and treatment research. The lifetime prevalence of OCD in bulimics has been found to be as high as one third to two thirds of such patient samples.77T7* The “anxiety disorder” model of bulimia79 suggests that the anxiety caused by weight gain (a feared stimulus) is reduced by vomiting, which acts as a negative reinforcer in much the same way as a ritual reduces the anxiety invoked by exposure to a feared stimulus in OCD patients. This model also suggests that exposure and response prevention would be a viable treatment strategy for this group of patients and, indeed, several treatment outcome studies support the efficacy of this intervention either alone or in combination with other strategies.79W83 Additionally, there is evidence suggesting that bulimics respond positively to serotonergic antidepressants, as do OCD patients, although they also may respond to other nonserotonergic antidepressants.50

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Morbid Jealousy and Morbid Infatuation

Jealousy is generally a negative emotion and, when extreme, can lead to pathological behavior. “Morbid jealousy” has been compared with OCD symptoms by several investigators.84-s6 In parallel to OCD, these patients appear to obsess about their loved ones’ sexual and emotional commitment and may engage in compulsive behaviors such as repeatedly checking on them or questioning them excessively to relieve their concerns. Cobb and Marks!’ successfully treated three of four OCD patients with chronic morbid jealousy and accompanying compulsions using behavior therapy. Similar cases of morbid infatuation are occasionally seen in clinical practice. Most appear to be males who experience unreasonable infatuation with particular women to whom they feel attracted emotionally and physically, but who do not wish or encourage (and may actively discourage) their attentions. Their infatuation appears to fit the criteria for an obsession in that it is experienced as intrusive and inappropriate. However, unlike most obsessions, it involves some content (e.g., sexual fantasy) that is experienced as pleasurable. In this sense, obsessive infatuation resembles some of the impulse control disorders (trichotillomania, gambling) discussed above. Compulsions typically take the form of seeking verbal reassurance of approval and mental checking of interactions. The occasional attention received appears to reassure the patient periodically, to reduce tension and thereby to maintain the compulsive behavior. Hoarding

Another “variant” of OCD is compulsive hoarding in which patients collect and save excessive amounts of unneeded objects such as newspapers, books, cans, old mail, trash paper, bottles, etc. Generally, the rationale for not disposing of the items is that they might be useful someday. The corresponding obsessional fear is that something useful or essential will be discarded. Although these symptoms may appear as part of a more general picture of OCD, OCPD, or other disorder such as bulimia/anorexia, it apparently can also exist as a circumscribed and distinct disorder. Greenberg 88described several cases in the latter category and concluded that these patients had “(1) onset in their 20s (2) preoccupation with hoarding to the exclusion of work and family, (3) diminished insight, (4) little interest in treatment, [and] (5) no attempt to curb their compulsion.” Although the author distinguished these cases from “classical obsessive compulsive disorder,” he nonetheless suggested that, generally, hoarding would be best categorized as a subtype of OCD. Obsessional Slowness

Obsessional slowness is often a symptom of OCD and usually results from rituals involved in morning preparations, leaving one place for another, or traveling rituals. However, Rachman” asserted that, albeit rare, primary obsessional slowness exists in some patients as a distinct entity. He presented data from 10 such patients whose slowness persisted even apart from ritualistic checking. These patients were also characterized by an “obsessional personality” that may be linked in some way to the etiology of the dysfunction. However, unlike true OCD, primary obsessional slowness does not typically demonstrate focal anxiety or relief of that anxiety via

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rituals. Further, treatment strategies are different, requiring a gradual reduction of the time period allowed for each slow activity, rather than the exposure and response prevention required for 0CD.89 Primary obsessional slowness, then, may not be an OCD “variant.” CONCLUSION

As OCD is better understood, nosologic and diagnostic considerations become more important. This is particularly true for new research and in the assimilation of data presented by many different investigators. Additionally, to the extent that obsessive symptoms appear routinely as part of the clinical picture of other disorders, the effective treatment of those disorders may be enhanced by conceptualizing them as OCD “variants.” Thus, in this report, we have taken a closer look at the symptoms of OCD, differential diagnoses, comorbid disorders, and other disorders that might, at least in some cases, be similar to OCD in presentation. We propose that the two key features of OCD are (1) a focal anxiety point or points around which the patient experiences repetitious, intrusive thoughts and (2) cognitive or behavioral compulsions that reduce the anxiety associated with the obsessions. To the extent that other disorders exhibit these two elements, clinicians and researchers may do well to consider exposure and response prevention treatment techniques or pharmacotherapy with serotonergic antidepressants. Indeed, such research has already taken place in some of the disorders reviewed above, including bulimia and, to a lesser extent, hypochondriasis, kleptomania, and body dysmorphic disorder. We certainly believe that sufficient evidence exists to warrant further investigation of the extent of the relationship between “typical” OCD and these OCD “variants,” both phenomenologically and in treatment responsiveness to therapies used successfully for OCD. The final product of these types of investigations may be a more widely applicable definition of “obsessive compulsiveness” and the conceptualization of OCD as a symptom configuration that may occur alone or intertwined with the symptoms of a related disorder. Moreover, researchers interested in the assessment and treatment of disorders that sometimes present with an OCD symptom configuration may find that this subset of their population is phenomenologically distinct from those that do not appear “OCD-like.” They may also detect differential treatment response between subgroups. Our initial goal for this report was to investigate the possibility of a new, more useful classification of OCD and the disorders that share some of its central features. In the final analysis, we have concluded that a meaningful restructuring of diagnostic guidelines for OCD, although conceptually appealing, is probably not possible at this point. There are simply too many dimensions along which these patients may vary. Examples of these dimensions include the degree of overvalued ideation, psychotic thought process, anxiety or depressive symptoms, pleasurable sensation produced by the compulsive behavior, and others. Ultimately, the most accurate description of a patient with OCD or an OCD-like symptom configuration will rest, as mentioned above, in the specification of the focal anxiety point or points around which the patient obsesses and the covert or overt compulsive behaviors that alleviate this anxiety. Specific treatment goals and target behaviors of patients with

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an obsessive-compulsive symptom configuration would be implicit in this type of description. OCD is a disorder that, until recently, was thought to be relatively rare. As more data become available, it is increasingly clear that, not only is OCD not rare, it may actually be one of the more common psychiatric disorders found in the general population. If treatment and research efforts are to be more efficient, diagnostic and nosologic issues must be addressed. It is toward the end of improved classification and, ultimately, improved treatment that we submit this review and encourage further investigation of this complex disorder and the diverse group of syndromes that appear to share with it some common symptomatic and perhaps etiologic links. REFERENCES 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3, revised). Washington, DC, APA, 1987 2. Foa EB, Steketee GS: Obsessive-compulsives: Conceptual issues and treatment interventions, in Hersen M, Eisler RM, Miller PM (eds): Progress in Behavior Modification, vol 8. San Diego, CA, Academic, 1979 3. Steketee G, Foa EB: Obsessive-compulsive disorder, in Barlow D (ed): Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual. New York, NY, Guilford, 1985 4. Foa EB, Tillmanns A: The treatment of obsessive-compulsive neurosis, in Goldstein A, Foa EB (eds): Handbook of Behavioral Interventions: A Clinical Guide. New York, NY, Wiley, 1980 5. Turns DM: Epidemiology of phobic and obsessive-compulsive disorders among adults, Am J Psychother 34:360-370, 1985 6. Regier DA, Boyd JH, Burke JD, et al: One-month prevalence of mental disorders in the United States. Arch Gen Psychiatry 45977-986, 1988 7. Rapoport JL: The biology of obsessions and compulsions. Scientific Am 83-89, 1989 8. Henderson JG, Pollard A: Three types of obsessive compulsive disorder in a community sample. J Ciin Psycho1 44:747-752, 1988 9. Rasmussen SA, Tsuang MT: Epidemiology and clinical features of obsessive-compulsive disorder, in Jenike MA, Baer L, Minichiello WE (eds): Obsessive-Compulsive Disorders: Theory and Management. Littleton, MA, PSG, l986a, pp 23-24 10. Rasmussen SA, Eisen JL: Clinical features and phenomenology of obsessive compulsive disorder. Psychiatr Ann 19:67-73, 1989 11. Insel TR: Obsessive-compulsive disorder: The clinical picture, in Insel TR (ed): New Findings in Obsessive-Compulsive Disorder. Washington, DC, American Psychiatric Press, 1984 12. Cooper JE: The Leyton Obsessional Inventory. Psycho1 Med 1:48-64, 1970 13. Dijkema S: Een psychometrische evaluatie van de D-schaal van Zung, de Leyton Obsessional Inventory en de Fear Survey Schedule. University of Griiningen, The Netherlands, 1978 (unpublished manuscript) 14. Fontana D: Some standardization data for the Sandier-Hazari Obsessionality Inventory. Br J Med Psycho] 53:267-275,198O 15. Kendell RE, Discipio WJ: Obsessional symptoms and obsessional personality traits in patients with depressive illness. Psycho1 Med 1:65-72, 1970 16. Steketee G: Personality traits and disorders in obsessive-compulsive patients. Presented at the Annual Meeting of the World Congress of Behavior Therapy, Edinburgh, Scotland, September, 1988 17. Kringlen E: Obsessional neurotics: A long term follow-up. Br J Psychiatry 111:709-722, 1965 18. Joffe RT, Swinson RP, Regan JJ: Personality features of obsessive-compulsive disorder. Am J Psychiatry 145:1127-l 129, 1988 19. Jahrreiss W: Uber Zwangsvorstellungen im Verlant der Schizophrenic. Arch Psychiatr Nervenkr 77:740-789, 1925 20. Rosen I: The clinical significance of obsessions in schizophrenia. J Ment Sci 103:773-786, 1957 21. Insel TR, Akiskal HS: Obsessive-compulsive disorder with psychotic features: A phenomenologic analysis. Am J Psychiatry 143:1527-1533, 1986 22. Jacob RG, Ford RR, Turner SM: Obsessive-compulsive disorder, in Hersen M (ed): Practice of Inpatient Behavior Therapy. Philadelphia, PA, Grune & Stratton, 1985, pp 61-91

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