A critical evaluation of obsessive–compulsive disorder subtypes: Symptoms versus mechanisms

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Abstract

Recently, experts have suggested that obsessive–compulsive disorder (OCD), a highly heterogeneous condition, is actually composed of distinct subtypes. Research to identify specific subtypes of OCD has focused primarily on symptom presentation. Subtype models have been proposed using factor analyses that yield dimensional systems of symptom categories, but not necessarily distinct subtypes. Other empirical work has considered the role of neuropsychological functioning and comorbidity as part of a comprehensive scheme for subtyping OCD. The identified dimensions from all of these studies have implications for the treatment of OCD. In this article, we review the research on subtypes of OCD, focusing on subtype schemes based upon overt symptom presentation and neuropsychological profiles. We also review research pertinent to alternative subtyping schemes, both conceptually and methodologically. The research is critically examined and implications for treatment are discussed. Recommendations for future investigations are offered.

Section snippets

The empirical status of obsessive–compulsive disorder subtypes

Obsessive–compulsive disorder (OCD) is a heterogeneous condition composed of multiple symptoms. Individuals seeking treatment have clinical presentations associated with many different types of obsessional concerns and compulsive behaviors. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 2000) offers a general definition of OCD that includes obsessions and/or compulsions (either may be present in conjunction with or in the absence of

Categorical approaches to classification

The question of why researchers are interested in identifying subtypes of OCD can be answered by considering why we delineate psychiatric syndromes in the first place. Blashfield and Livesley (1999) observed that this is done to facilitate communication among mental health professionals, develop a basis for theories of psychopathology, predict clinical course, and identify which treatments are most likely to be effective for which patients. Numerous schemes for classifying psychiatric disorders

Identification of subtypes based on symptom theme

The most popular basis for deriving OCD subtypes has been the overt symptom theme. While some authors have attempted to delineate the latent structure of OCD symptom measures via factor analysis, others have aimed to classify patients into distinct symptom-based subgroups using cluster analysis. In this section, we examine research that has used this methodology and summarize the important contributions this work has made to understanding OCD.

Early symptom subtyping approaches characterized OCD

Neuropsychological deficits in symptom-based subtypes

While a variety of etiological models have been proposed to account for the development of OCD, neuropsychiatric models have emerged with technological advances in radiological and neuropsychological domains. Functional and structural imaging (PET, MRI, SPECT, and fMRI) studies have implicated frontal–striatal dysfunction in OCD Greisberg & McKay, 2003, Schwartz, 1998, Saxena et al., 1998, Zald & Kim, 1996, although some researchers have disputed this conclusion (Tallis, Pratt, & Jamani, 1999).

Neuropsychiatric correlates of symptom subtypes

Functional neuroimaging techniques are being used to study neural correlates of OCD in a growing number of studies (for a review, see Whiteside, Port, & Abramowitz, submitted for publication). Whereas most studies have combined patients with different symptom presentations, four investigations addressed the issue of symptom subtypes. Using positron emission tomography (PET), Cottraux, Gerard, Cinotti, & Froment (1996) found that OCD patients with primarily checking rituals evidenced greater

OCD symptom subtypes: implications for treatment outcome evaluations

Ball, Baer, and Otto (1996) examined the prevalence of different OCD symptom subtypes in patient samples across studies of cognitive behavior therapy (CBT) and found that patients with cleaning and/or checking rituals predominated, accounting for 75% of samples. Patients with multiple rituals, or those with exactness, counting, repeating, symmetry, slowness, or hoarding were underrepresented, comprising only 12% of the population which is considerably less than epidemiological estimates. Pure

Symptom-based OCD subtypes: phenomenology and treatment

The section below reviews cognitive and behavioral phenomenology characteristic of the various symptom-based OCD subtypes defined in previous research. Because CBT is a treatment approach involving the use of procedures determined by idiopathic case formulation, we describe therapeutic approaches developed (and in some cases tested) for four of the OCD symptom-based subtypes identified in previous studies (e.g., Abramowitz et al., 2003, Calamari et al., 2004): contamination/washing, harm

Symptom theme-based subtypes: conclusions and future directions

Attempts to identify important subgroups of OCD on the basis of differences in obsessional and compulsive themes have been productive as evidenced by the finding of differential responsiveness to the empirically supported treatments for OCD: behavioral therapy and serotonergic medication. In these initial studies, hoarding symptoms or subgroups were identified as an important OCD subtype. As shown in Table 1, hoarding emerged as a distinct symptom dimension in almost all studies using the

Tic-related versus non-tic-related OCD

In addition to the theme of obsessions and compulsions, researchers have aimed to identify OCD subtypes on the basis of comorbidity with tics and other Axis I and II symptoms. Leckman et al. (2000) proposed a categorical distinction between “tic-related” and “non-tic-related” OCD. Individuals with the tic-related subtype experience symptoms associated with exactness and symmetry, with compulsive urges to carry out rituals that appear similar to tics as in Tourette's syndrome (e.g., touching,

Methodological issues in subtyping

Most researchers and practitioners who have dealt in any serious manner with OCD address the issue of subtypes. As we have discussed above, efforts to document differences between subtypes have been underway for a long time. Washing and checking subtypes have received considerable attention Khanna & Mukherjee, 1992, Steketee et al., 1985, and few doubt the validity of these two groupings within the broader classification of OCD, although multivariate analyses of these symptoms suggests complex

Conclusions

While there have been a number of investigations designed to determine whether subtypes of OCD exist, the current review suggests significant limitations to how subtypes are conceptualized. Studies on the structure of obsessions and compulsions have consistently identified the following subtypes: contamination/washing, checking, hoarding, and symmetry/ordering. Given that these symptom themes have been repeatedly identified, across various statistical methodologies with self-report and

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    The authors are a subgroup of members of the Obsessive–Compulsive Cognitions Workgroup (cochairs: Randy Frost and Gail Steketee). Order of author listing was determined alphabetically following the first two contributors.

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