A Multidimensional Model of OCD (Mataix Et Al, 2005)

228 Am J Psychiatry 162:2, February 2005 Reviews and Overviews A Multidimensional Model of Obsessive-Compulsive Disorder David Mataix-Cols, Ph.D. Maria Conceição do Rosario- Campos, M.D. James F. Leckman, M.D. Objective: Obsessive-compulsive disor- der (OCD) is a clinically heterogeneous condition. This heterogeneity can reduce the power and obscure the findings from natural history studies to genome scans, neuroimaging, and clinical trials. The au- thors
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  228  Am J Psychiatry 162:2, February 2005 Reviews and Overviews  A Multidimensional Model of Obsessive-Compulsive Disorder David Mataix-Cols, Ph.D.Maria Conceição do Rosario-Campos, M.D. James F. Leckman, M.D. Objective: Obsessive-compulsive disor-der (OCD) is a clinically heterogeneouscondition. This heterogeneity can reducethe power and obscure the findings fromnatural history studies to genome scans,neuroimaging, and clinical trials. The au-thors review the evidence supporting amultidimensional model of OCD. Method: Computerized and manual lit-erature searches were performed to iden-tify factor-analytic studies of obsessive-compulsive symptoms before data fromdisciplines that bear on the potential use-fulness of these dimensions were consid-ered. Selection criteria included the nov-elty and importance of studies and theirrelevance to outcomes of interest to well-informed mental health professionals. Results: Twelve factor-analytic studiesinvolving more than 2,000 patients wereidentified that consistently extracted atleast four symptom dimensions: symme-try/ordering, hoarding, contamination/cleaning, and obsessions/checking. Thesedimensions were associated with distinctpatterns of comorbidity, genetic transmis-sion, neural substrates, and treatment re-sponse. The evidence supporting thehoarding dimension is particularly robust. Conclusions: The complex clinical pre-sentation of OCD can be summarizedwith a few consistent, temporally stablesymptom dimensions. These can be un-derstood as a spectrum of potentiallyoverlapping syndromes that may 1) coex-ist in any patient, 2) be continuous withnormal obsessive-compulsive phenom-ena, and 3) extend beyond the traditionalnosological boundaries of OCD. Althoughthe dimensional structure of obsessive-compulsive symptoms is imperfect, thisquantitative approach to phenotypictraits has the potential to advance our un-derstanding of OCD and may aid in theidentification of more robust endopheno-types. The need for a dimensional ratingscale and suggestions for future researchaimed at reducing the burden of this dis-order are discussed. (Am J Psychiatry 2005; 162:228–238) The idea of a disease entity is not an objective to bereached, but our most fruitful point of orientation.—Karl Jaspers, 1923 (1) T he symptoms of obsessive-compulsive disorder(OCD) are remarkably heterogeneous to the extent thattwo patients with this diagnosis can display completely dif-ferent nonoverlapping symptom patterns. Despite thisphenotypic heterogeneity, standard nomenclatures (DSM-IV and ICD-10) regard OCD as a unitary nosological entity. While this parsimony has some esthetic appeal, it may bemisleading. Moreover, with the exception of evolutionary-based models (2), most current models of OCD—neuro-biological, developmental, or cognitive behavior—do notaccount for or put enough emphasis on this heterogeneity. Accordingly, most OCD research is based on comparisonsbetween groups of OCD patients and healthy individuals,and global severity rating scales, such as the Yale-BrownObsessive Compulsive Scale (3), are used.Recognizing this heterogeneity, investigators have at-tempted to dissect the phenotype into homogeneous sub-types. For example, Falret made the distinction between  folie du doute   (“madness of doubt”) and délire du toucher  (“delusion of touch”) in 1869 (4). Investigators frequently distinguish “washers” from “checkers” (5) and other symp-tom-based clusters (6–8). Other authors have classified pa-tients into groups that represent extremes of a continuumof, for example, impulsivity (9) or insight (10, 11). Gener-ally, these attempts had limited success in relating theidentified subtypes to biological markers, genetic factors,or treatment response, in part because pure subtypes of patients are rare and the recruitment of sufficient samplesizes of each subtype is difficult and highly impractical.Other putative subtypes have been identified based onclinical characteristics, such as age at onset (12) and co-morbid diagnoses, particularly tic disorders (13). Limita-tions of these approaches include knowing exactly whenthe obsessive-compulsive symptoms began and the diffi-culty of identifying “hidden” tic-related cases (individuals who have relatives with tic disorders but no tics of theirown).Factor-analytic approaches have been fruitful in the ad-vancement of our understanding of other heterogeneousconditions, such as schizophrenia (14, 15), bipolar disorder   Am J Psychiatry 162:2, February 2005 229 MATAIX-COLS, ROSARIO-CAMPOS, AND LECKMAN  (16), Tourette’s disorder (17), eating disorders (18), andlearning disabilities (19). In OCD, too, recent factor-analyticstudies have reduced its symptoms to a few fairly consistentand clinically meaningful symptom dimensions.In this article, we critically review the evidence support-ing a multidimensional model of OCD. We examine thestudies aimed at identifying the structure of obsessive-compulsive symptoms using a variety of statistical meth-ods before considering data from a range of disciplinesthat bear on the potential usefulness of these dimensions.Such review is timely because various research groupshave begun to search for underlying genes and neuralsubstrates of these symptom dimensions. We will arguethat a dimensional approach can better account for theheterogeneity of OCD and has the potential of explaining a further portion of the variance from previous ap-proaches. Ultimately, we aim to generate new clinical in-terpretations and stimulate further research in this prom-ising field. Method Some definitions may be useful to the reader. In this article, wedistinguish between categorical and dimensional models of OCD.Categorical studies aim at identifying homogeneous and mutu-ally exclusive subgroups of patients (e.g., washers versus check-ers). “Subtype” will be used as a synonym for “subgroup.” In op-position, dimensions derive from factor-analytical studies andare not mutually exclusive because each patient can score on oneor more symptom dimensions at any one time. “Factor” will beused as a synonym for dimension.Keyword-driven PUBMED and PsychINFO searches were per-formed. We also searched the reference sections of the manu-scripts for additional sources. First, we identified studies thatevaluated the structure of obsessive-compulsive symptoms using factor analysis. Only studies that used comprehensive and nonbi-ased instruments to ascertain obsessive-compulsive symptoms were included, such as the Yale-Brown Obsessive CompulsiveScale symptom checklist (3) and the Obsessive-Compulsive In-ventory (20). Other frequently used instruments were excludedbecause their items are heavily biased and are not representativeof the complex phenomenology of OCD. Second, we searched forstudies that examined the various sources of evidence to supportthe predictive validity of the identified symptom dimensions.Topics of interest included natural history, comorbidity (axis Iand axis II), genetics, life-span development, neuroimaging, neu-ropsychology, and predictors of treatment outcome with medica-tions and cognitive behavior therapy. Results In the first factorial study of the Yale-Brown ObsessiveCompulsive Scale symptom checklist, Baer (21) factor-an-alyzed its 13 major symptom categories in a sample of 107patients and identified three factors, accounting for 48%of the variance, that were called “symmetry/hoarding,”“contamination/cleaning,” and “pure obsessions.” SinceBaer’s seminal work, 10 studies corresponding to ninelarge OCD data sets and involving more than 2,000 pa-tients have been identified (4, 20–29). One further study (30) that factor-analyzed the Yale-Brown Obsessive Com-pulsive Scale symptom checklist in a sample of patients with Tourette’s disorder and their first-degree relatives wasalso included (Table 1). Although these studies have useddifferent methods (current versus lifetime symptoms, di-chotomous versus ordinal versus interval scoring, a prioricategories versus item-level analysis, exploratory versusconfirmatory factor analysis) and instruments (Yale-Brown Obsessive Compulsive Scale versus Obsessive-Compulsive Inventory), an inspection of the factor con-tent suggests more similarities than differences. Of note isthat most studies that identified more than three factorsexplained more than 60% of the total variance. The mostconsistent factorial solutions were those of four or five di-mensions. Correlates of OCD Symptom Dimensions Baer (21) reported that patients with high scores on hissymmetry/hoarding factor were more likely to have a co-morbid diagnosis of chronic tics and obsessive-compul-sive personality disorder. Similarly, Leckman et al. (22)found that patients with high scores on the obsessions/checking and symmetry/ordering factors were more likely to have tics. Mataix-Cols et al. (25) reported that male butnot female OCD patients with chronic tics scored higherthan patients without tics on the symmetry/ordering di-mension. These results are in accordance with earlier re-ports of elevated frequency of these symptoms in OCD pa-tients with comorbid Tourette’s syndrome or a lifetimehistory of tics (31, 32).Mataix-Cols et al. (33) examined the presence of allDSM-III-R axis II diagnoses and their relation to obses-sive-compulsive symptom dimensions in a sample of 75OCD patients. They found that hoarding symptoms werestrongly related to the presence and number of all person-ality disorders, especially from the anxious-fearful cluster.Similarly, Frost et al. (34) found that hoarding was associ-ated with higher levels of comorbidity, as well as work andsocial disability, compared to nonhoarding OCD andother anxiety disorders. In another study (35), the pres-ence of hoarding was associated with male gender, earlierage at onset, comorbid social phobia, personality disor-ders, and pathological grooming conditions (skin picking,nail biting, and trichotillomania). Although one study (36)found that hoarding was associated with greater overall ill-ness severity (total Yale-Brown Obsessive CompulsiveScale scores), another study did not (37).Taken together, these studies suggest that a symptom-based dimensional approach can integrate previous clas-sification attempts based on age at onset, gender, or pres-ence of comorbid conditions because it has the advan-tages of allowing each patient to have scores in one ormore symptom dimension and of permitting studies thatcut across traditional diagnostic boundaries.  230  Am J Psychiatry 162:2, February 2005 A MODEL OF OCD  Temporal Stability of OCD Symptom Dimensions One potential challenge of the dimensional approach isthe assumption that OCD patients experience drasticsymptom changes over time. For a dimensional approachto be useful, some degree of symptom stability would be ex-pected, but few longitudinal studies examined the evolu-tion of symptoms per se. Rettew et al. (37) assessed the lon-gitudinal course of obsessive-compulsive symptoms in 76children and adolescents with OCD who were followed overa period of 2–7 years with the categories of the Yale-BrownObsessive Compulsive Scale symptom checklist. They found that none of the patients maintained the same con-stellation of symptoms from baseline to follow-up. Never-theless, these authors acknowledged that these changes TABLE 1. Factor-Analytic Studies Using the Yale-Brown Obsessive Compulsive Scale StudyYearScoring a Analysis TechniqueNumber of SubjectsBaer (21)1994Range=0–2Principal-components analysis, current symptoms107 with obsessive-compulsive disorder (OCD)Hantouche and Lancrenon (4)1996Scoring unavailablePrincipal-components analysis, current symptoms615 with OCDLeckman et al. (22)1997Number of symptomsPrincipal-components analysis, lifetime symptoms292 with OCDSummerfeldt et al. (23)1997Range=0–1Principal-components analysis, current symptoms, including miscellaneous obsessions and compulsions203 with OCDSummerfeldt et al. (24) b 1999Range=0–1Confirmatory factor analysis, current symptoms203 with OCDMataix-Cols et al. (25)1999Range=0–2Principal-components analysis, current symptoms354 with OCDTek and Ulug (26)2001Range=0–1Principal-components analysis, current symptoms45 with OCDCavallini et al. (27)2002Range=0–1Principal-components analysis, lifetime symptoms180 with OCDMataix-Cols et al. (28)2002Range=0–1Principal-components analysis, current symptoms153 with OCDLeckman et al. (30)2003Number of symptomsPrincipal-components analysis, lifetime symptoms236 with Tourette’s disorderFoa et al. (20)2002Range=0–4 (Obsessive Compulsive Inventory)Principal-components analysis, confirmatory factor analysis, current symptoms215 with OCDFeinstein et al. (29) c 2003Range=0–1Principal-components analysis, current symptoms160 with OCD a Unless otherwise noted, all scores are on the Yale-Brown Obsessive Compulsive Scale symptom checklist. Score=0–1; investigators assigned ascore of 1 if a symptom category was present and 0 if it was absent. Score=0–2; the most prominent symptom category on the symptom check-list was scored 2 and the remaining domains were scored 1 (present) or 0 (absent). Number of symptoms=the number of symptoms in eachcategory summed, scored 0–4 on a 5-point Likert-type scale evaluating the distress caused by the symptoms in a particular category.   Am J Psychiatry 162:2, February 2005 231 MATAIX-COLS, ROSARIO-CAMPOS, AND LECKMAN  could have occurred within rather than between symptomdimensions, although they did not test this hypothesis. In alater study (38), a large sample of adult patients was repeat-edly administered the Yale-Brown Obsessive CompulsiveScale symptom checklist over a period of 2 years. For themost part, the patients maintained their symptoms acrossfollow-up, and the strongest predictor of having a particu-lar symptom was having had that symptom in the past. Forthe symptoms that changed across time, changes oc-curred within rather than between previously identified(25) symptom dimensions, suggesting that the symptomsof adult OCD patients are more stable than it is often as-sumed. Longitudinal studies following up patients fromchildhood to adulthood are needed to further understand Identified Factors(number)Yale-Brown Obsessive Compulsive Scale Symptom Checklist Category a Percent of VarianceExplained1Symmetry and hoarding obsessions; hoarding, ordering, repeating, and counting compulsions20.72Contamination and somatic obsessions; washing and checking compulsions16.03Sexual, religious, and aggressive obsessions11.31Symmetry and hoarding obsessions; repeating, ordering, counting, hoarding, and checking compulsionsUnavailable2Sexual, aggressive, and religious obsessionsUnavailable3Contamination and somatic obsessions; washing compulsionsUnavailable1Aggressive, sexual, religious, and somatic obsessions; checking compulsions30.12Symmetry obsessions; repeating, counting, and ordering compulsions13.83Contamination obsessions; washing compulsions10.24Hoarding obsessions; hoarding compulsions8.51Symmetry, exactness, hoarding obsessions and obsessions of the fear of not saying the right thing; ordering, repeating, hoarding, and excessive list-making compulsions16.62Contamination obsessions; washing compulsions5.43Violent thoughts, images, impulses, sexual, and religious obsessions4.64Superstitious fears, fear of harming self, and lucky/unlucky numbers obsessions; counting compulsions4.15Fear of harming others, doubts, and responsibility obsessions; checking compulsions3.81Aggressive, sexual, religious, and somatic obsessions; checking compulsions— 2Symmetry obsessions; repeating, counting, ordering compulsions— 3Contamination obsessions; washing compulsions— 4Hoarding obsessions; hoarding compulsions— 1Symmetry obsessions; repeating, counting, and ordering compulsions19.02Hoarding obsessions; hoarding compulsions13.83Contamination obsessions; washing compulsions12.74Aggressive obsessions; checking compulsions10.45Sexual and religious obsessions9.71Contamination obsessions; cleaning and repeating compulsions17.82Symmetry and somatic obsessions; ordering compulsions15.23Aggressive obsessions; counting compulsions13.74Sexual and religious obsessions9.75Checking and hoarding compulsions9.21Contamination obsessions; washing compulsions17.02Hoarding obsessions; hoarding compulsions13.03Aggressive, sexual, somatic, and religious obsessions; checking compulsions11.54Symmetry obsessions; ordering compulsions9.55Repeating and counting compulsions8.81Aggressive and religious obsessions; checking, repeating, and counting compulsions23.32Contamination obsessions; washing compulsions13.23Symmetry obsessions; counting and ordering compulsions10.84Hoarding obsessions; hoarding compulsions8.35Sexual and somatic obsessions7.91Aggressive, sexual, religious, and somatic obsessions21.52Symmetry obsessions; counting and ordering compulsions16.73Contamination obsessions; washing, checking, and repeating compulsions21.34Hoarding obsessions; hoarding compulsions13.61Contamination obsessions; washing compulsions40.92Obsessive thoughts10.83Saving obsessions; hoarding compulsions8.84Ordering obsessions; ordering compulsions7.85Checking compulsions6.76Counting, repeating numbers, and good/bad numbers compulsions5.81Symmetry obsessions; ordering, repeating, counting, and touching compulsions14.22Contamination and aggressive obsessions; washing and checking compulsions14.23Hoarding obsessions; hoarding compulsions13.94Sexual and religious obsessions11.8 b This study used the Summerfeldt et al. data set (23) and applied confirmatory factor analysis to examine goodness of fit of the three- andfour-factor solutions proposed by Baer (21) and Leckman et al. (22), respectively. c This study also performed a principal-components analysis at the item level and identified four factors: “responsibility/harm obsessions andchecking,” “disgust with contaminants and washing,” “sexual obsessions,” and “hoarding, symmetry, repeating, counting, and touching.”
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