Course of OCD
Course of OCD
Twenty years have passed since the landmark National Epidemiology Catchment Area Survey first demonstrated the
prevalence of obsessive-compulsive disorder (OCD) in the
general population to be 50 to 100 times greater than had
been previously believed (1). This unexpected finding was
instrumental in the renewed interest in and rapid growth of
our understanding of the clinical features, pathophysiology,
and treatment of OCD. Epidemiologic studies in different
cultures have confirmed the findings that up to 1% to 2% of
the general population worldwide suffer from the disorder at
any given time (2). Widespread attention in the media, in
addition to growing recognition of the disorder among
health care professionals, has resulted in improvements in
the diagnosis and treatment of large numbers of patients
with OCD who would not even have presented for treatment before 1980.
Knowledge of the clinical features of the disorder has
also expanded significantly in the last 10 years. Treatment
centers specializing in OCD have succeeded in enrolling
large cohorts of patients, so that a more sophisticated analysis of the heterogeneity and comorbidity of OCD and the
relationship of these variables to treatment outcome has
been possible. Prospective observational studies of the longitudinal course of OCD have contributed further insights
into the clinical characteristics and prognosis of the illness
(3). Improvements in methodology, including the development of structured interviews with proven reliability and
validity, the application of survival analysis and other statistical techniques to assess longitudinal variables, and more
sophisticated database management systems, have been instrumental in these advances.
Epidemiologic studies have consistently shown that 2%
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SUBTHRESHOLD SYMPTOMS
DEVELOPMENTAL PSYCHOPATHOLOGY
Brown OC Study
Age of onset in Obsessive Compulsive Disorder
Separation anxiety
Resistance to change or novelty
Risk aversion
Submissiveness (compliance)
Sensitivity
Anacastic
Perfectionism
Hypermorality
Ambivalence
Excess devotion to work
AGE AT ONSET
In most studies of the course of illness, age at onset refers
to the time that symptoms become severe enough that they
meet full DSM criteria for the disorder. The reliability of
retrospective recall is an inescapable problem. It is safe to
assume that reliability decreases as the years between ascertainment and onset increase. In the Brown cohort drawn
from an adult OCD clinic, the mean age at onset of significant OCD symptoms was 20.9 ! 9.6 years, with males
having a significantly earlier onset of illness, 19.5 ! 9.2
years, than females, 22.0 ! 9.8 years (p !.003) (212). The
illness developed before the age of 25 years in 65% of cases,
sometimes as early as 2 years. It developed after age 35
50
Female
Male
40
Number of Probands
excessive morality. The overlap of the developmental antecedents of panic disorder, social phobia, and OCD is consistent with Janets original conception of the psychasthenic
syndrome and adds credibility to the hypothesis that an
element of genetic vulnerability is shared among the anxiety
disorders. The relationship of adult personality characteristics and clinical subtypes to developmental antecedents
awaits further analysis. It appears that some traits are more
commonly seen in particular phenomenologic presentations
(e.g., incompleteness in perfectionism and the need for symmetry and precision; abnormal risk assessment in high levels
of anxiety). It is probable that temperamental factors such
as behavioral inhibition increase the risk for the development of a number of psychiatric syndromes. It would be
informative to determine the relative risk for development
of each of the major anxiety syndromes by following a group
of children with behavioral inhibition longitudinally. The
environmental and genetic factors that predispose a given
individual to the development of a specific anxiety disorder
are unknown. It is also worth noting that a significant minority of patients with OCD do not manifest risk-aversive
tendencies as children. Further prospective study of the developmental antecedents of OCD and prospective longitudinal evaluation of children at risk should be an important
area for future research.
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30
20
10
69
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sive personality disorder were often not made, and obsessions and compulsions occurring in the context of other
disorders (e.g., psychosis, eating disorders) may have been
included as OCD.
Despite these methodologic shortcomings, several more
recent prospective follow-up studies, in which a prospective
design, standardized criteria to assess diagnosis, and structured interviews with direct patient contact were used, have
also shown that most patients continue to meet either all
or some of the criteria for the disorder at follow-up. Relatively few patients experience complete remission. Retrospective and prospective follow-up studies of the course are
reviewed in detail below.
Retrospective Follow-up Studies
In retrospective studies, fluctuations in the severity of psychiatric symptoms and impact on functioning over time are
ascertained primarily on the basis of subjects recall. Results
of these studies are summarized in Table 111.2. In most of
them, patients were selected based on chart review and were
subsequently assessed at the time of the study, either in
person or through questionnaire. In the earliest longitudinal
study of OCD, a relatively good outcome was observed by
Lewis (24), who followed 50 patients with OCD (most of
whom received some psychotherapy) at least 5 years after
initial assessment; 37% were quite well, 14% were much
improved, but 46% were minimally improved, unchanged,
or worse. Only 10% had had an episodic course marked by
later recurrence after remission. Pollitt (25) followed 67
No.
Patients
Mean
Years of
Follow-up
Well
(%)
Minimally
Improved,
Unchanged
or Much
Improved
(%)
50
>5
32
14
44
67
3.4
24
36
37
29
80
100
44
47
88
5.9
1320
5
.5+
622
3.9
7
0
40
8
28
23
21a
24
24
20
26
50
72
76
35
8
46
27
Study (Ref.)
Worse
(%)
Comments
Episodic
course in 10%
Mostly
outpatients
Inpatients
Inpatients
Inpatients
Inpatients
Childhood OCD
Inpatients and
outpatients
diagnostic
heterogeneity
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Study (Ref.)
Treatments
Adults
Orloff et al., 1994 (44)
Eisen et al., 1995
Stekette et al., 1996
a
SSRIs, BT,
psychotherapy,
family therapy
SSRIs, BT
SSRIs, BT
SSRIs, BT
No.
Patients
Mean
Follow-up
(ys)
Remained
in Episode
(%)
Partial
Remission
(%)
Full
Remission
(%)
12
42
17a
54
3.4
43
46
11b
85
51
107
2.1
2
0.55
57
47
31
31
33
12
22
Comment
17% had
compulsive
personality
traits
70% on
medication
at follow-up
mainly
outpatients
Subjects had subclinical OCD at follow-up (i.e., obsessions compulsions were present but not at full criteria).
Three of the six subjects in remission (i.e., symptom-free) were receiving medication.
BT, behavioral therapy; OCD, obsessive-compulsive disorder; SSRIs, selective serotonin reuptake inhibitors; Y-BOCS, YaleBrown
Obsessive-Compulsive Scale.
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1600
1601
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Diagnosis
Major depressive disorder
Simple phobia
Separation anxiety disorder
Social phobia
Eating disorder
Alcohol abuse (dependence)
Panic disorder
Tourette syndrome
Current
Semistructured
(n = 100) (%)
Lifetime
Semistructured
(n = 100) (%)
From SADS
(n = 60) (%)
31
7
11
8
8
6
5
67
22
2
18
17
14
12
7
78
28
17
26
8
16
15
6
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machine and theres a fire? The patients with sexual or aggressive obsessions also worry. What if I do pick up the
knife?
On the opposite side of the spectrum are the patients
with OCD who experience little or no anxiety that something terrible will happen. Janet observed that many patients
with OCD are tormented by an inner sense of imperfection.
Their actions are never completely achieved to their satisfaction. Many of our patients describe an inner drive that is
connected with a wish to have things perfect, absolutely
certain, or completely under control. When they achieve
such perfection, they describe a curious sensation that they
can compare to no other feeling. Janet called it the occasional brief appearance of sublime ecstasy. This absolute
feeling of certainty or perfection is rarely attained, and therefore the patients experience a feeling of incompleteness.
Feelings of going exactly through the middle of a door,
of having both shoelaces tied to exactly the same tension,
of having ones hands perfectly clean, of saying ones prayers
exactly right, or of having ones hair parted precisely down
the middle are clinical examples. Most of us can relate to
the feeling of wanting to have something just so or perfect
and the feeling of accomplishment when we finally get it
that way, and to feelings of frustration and incompleteness
when its not that way. But for the obsessive, this feeling
becomes attached to an action that would hold little significance for most of us, just as most of us do not think about
the one in a million chance that something will go wrong.
Patients with trichotillomania or Tourette syndrome also
describe a feeling of incompleteness with continued tension
until they have finished pulling out an entire patch of hair
or completed a sequence of tics to their satisfaction. Both
say that it is impossible to stop in the middle of a compulsive
action despite the consequences.
The core features appear to relate both to the clinical
features of OCD and to the comorbid disorders. In patients
with abnormal risk assessment, high levels of anxiety are
associated with symptoms. They are also likely to have comorbid axis I generalized anxiety disorder or social phobia,
avoidant and dependent personality features, and a family
history of an anxiety disorder. In contrast, patients with
incompleteness are likely to manifest low levels of anxiety,
comorbid multiple tics or habit disorders (e.g., trichotillomania, onychophagia), and compulsive personality features.
Empiric validation of these subgroups may have important
implications for diagnosis and treatment. Some evidence
has already been found that patients with treatment-resistant OCD and tic spectrum disorder are particularly responsive to dopaminergic antagonists. These patients are also
more likely to exhibit incompleteness.
Baer et al. (67) applied principal component analysis to
107 patients with OCD who completed the Y-BOC Symptom Checklist and examined the correlations between the
factor scores and the presence of comorbid tic or personality
disorders. Three factors, symmetry/hoarding, contamina-
tion/cleaning, and pure obsessions, best explained the variance. Only the first factor was significantly related to OCPD
(obsessive-compulsive personality disorder) or a lifetime history of Tourette syndrome.
COMMENT
During the past 15 years, significant advances have revolutionized the way we conceptualize and treat OCD. Epidemiologic studies have confirmed that OCD is an underrecognized common major psychiatric disorder with a lifetime
prevalence of 2% to 3% in the general population, and
they have been instrumental in focusing the attention of
researchers, clinicians, and the media on OCD. Studies of
the clinical features and course of the disorder and associated
comorbid conditions have appeared in the literature since
the turn of the twentieth century and have been the subject
of numerous prospective and retrospective studies of its
course, reviewed here.
Finally, future studies will continue to benefit from further refinement of our thinking about the heterogeneity
and comorbidity of OCD and the search for homogeneous
subtypes. The identification of an OCDtic subtype has
already led to important new genetic and biological studies
and has been directly relevant to treatment. The recent effort to characterize pediatric autoimmune neuropsychiatric
disorders and their relationship to genetic vulnerability to
streptococcal infection offers a promising lead for furthering
our understanding of the pathophysiology of OCD. It is
possible that we will increase our understanding of predictions of remission and relapse related to possible homogeneous subtypes of illness. A review of these studies suggests
that the course of OCD, long thought to be chronic, may
be more episodic than previously believed, particularly in
children and adolescents. It also appears that in some subjects, pharmacologic and behavioral treatments may alter
the natural course of illness. However, a long-term prospective follow-up study of a large number of patients with
OCD is needed to confirm these observations. In addition,
the effectiveness of these treatments in routine practice are
not known.
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incomplete remission that permits normal social functioning. Although the results of studies varied considerably in
regard to the percentage of patients in each category, the
majority of patients in each study were always in the last
group, and the course of about 10% of patients was marked
by progressive deterioration. These figures are consistent
with our own study of patients meeting DSM-III criteria for
OCD (Table 111.3). Although previous descriptive studies
found a chronic waxing and waning course in 85% of patients, no attempt was made in previous studies to subdivide
the waxing and waning course into predictable patterns or
subtypes. More recent studies in which a prospective design
and standardized criteria were used have shown that the
episodic form of this disorder (clear periods of remission
while the patient is off medication) is uncommon. The periodicity, duration, and severity of episodes in patients with
OCD vary considerably. Once established, obsessions and
compulsions usually persist, although the content, intensity,
and frequency of the symptoms change over time.
The introduction of the SSRIs has led to a significantly
improved prognosis for patients with OCD during the last
decade. In a follow-up study by Orloff et al. (44) of a cohort
of 83 OCD patients assessed 1 to 3 years after initial evaluation, 64% had a decrease of more than 50% in Y-BOCS
score, and 33% had a decrease of more than 75% in YBOCS score at follow-up. These results are at odds with
those of two other prospective longitudinal observational
studies of the course of OCD that have recently been initiated at our site. Eisen et al. (38) examined 68 obsessivecompulsive outpatients evaluated at the YaleBrown clinics
and followed them prospectively during a 2-year period. Of
the 51 patients who started the study meeting full criteria,
57% still met full criteria after 2 years. Survival analysis
revealed a 47% probability of achieving at least partial remission during the 2-year study period. In another prospective study, by Steketee et al., 107 clinic patients with OCD
were followed for up to 5 years after intake. The probability
of partial remission for at least a 2-month period was 53%,
and for full remission (no longer meeting criteria) at 5 years
it was 22% (41).
DISCLOSURE
SUMMARY
The prevailing notion that the course of OCD is chronic
and deteriorating has not been consistently borne out by
the evidence, particularly in children followed prospectively.
Furthermore, the natural course of this disorder appears to
have been altered by the availability of effective pharmacologic and behavioral therapy. In their review of follow-up
studies, Goodwin et al. (29) found that the course of OCD
can be categorized as (a) unremitting and chronic, (b) phasic
with periods of complete remission, or (c) episodic with
Dr. Rasmussen receives research support from Solvay Pharmaceuticals and Pfizer.
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