Elsevier

Psychiatry Research

Volume 226, Issue 1, 30 March 2015, Pages 368-375
Psychiatry Research

Associations of obsessive–compulsive symptoms with clinical and neurocognitive features in schizophrenia according to stage of illness

https://doi.org/10.1016/j.psychres.2015.01.021Get rights and content

Highlights

  • Patients with obsessive–compulsive symptoms had more severe psychotic symptoms.

  • They had more severe depressive symptoms and poorer quality of life.

  • Comorbid obsessive–compulsive symptoms were associated with higher learning ability.

Abstract

This study aimed to investigate the association of obsessive–compulsive symptoms with clinical and neurocognitive features in patients with schizophrenia. This study enrolled 163 people with schizophrenia who were receiving risperidone monotherapy. Comorbid obsessive–compulsive symptoms were assessed using the Yale–Brown Obsessive–Compulsive Scale, and subjects with a score≥10 constituted the obsessive–compulsive symptom group (n=30, 18.4%). The learning index was significantly higher in patients with obsessive–compulsive symptoms than in those without such symptoms after adjusting for age, stage (early and chronic), duration of illness, and CDSS score. However, there was no significant interaction between obsessive–compulsive symptoms and stage of illness. Scores on Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, and Beck Depression Inventory were significantly higher in the obsessive–compulsive symptom group. In addition, the Subjective Well-being under Neuroleptic Treatment score was significantly lower in the obsessive–compulsive symptom group. In conclusion, comorbid obsessive–compulsive symptoms in patients with schizophrenia were associated with a higher learning ability without a significant interaction with stage of illness. However, schizophrenia patients with obsessive–compulsive symptoms had more severe psychotic and depressive symptoms and poorer quality of life.

Introduction

The prevalence and burden of comorbid obsessive–compulsive symptoms in patients with schizophrenia has long been recognized but its associations with the clinical and neuropsychological profiles of those with schizophrenia remains poorly understood.

The prevalence of obsessive–compulsive disorder (OCD) in schizophrenia has been estimated to be 12.3%, which is higher than that in the general population (Achim et al., 2011, Swets et al., 2014) and obsessive–compulsive symptoms, not restricted to diagnostic criteria, have been reported to be even more prevalent (30.7%). Obsessive–compulsive symptoms develop either prior to, during, or after the onset of the first episode of psychosis (Hwang and Opler, 1994, Sterk et al., 2011, Kim et al., 2013). Critically, current evidence suggests that the prevalence of OCD or obsessive–compulsive symptoms varies according to the stages of schizophrenic illness. Recent reports indicate that the prevalence of OCD (3.5–14%) and obsessive–compulsive symptoms (20%) in patients at ultra-high risk (UHR) for psychosis exceeds that in the general population (Niendam et al., 2009, Fontenelle et al., 2011, Sterk et al., 2011). But, the patients with chronic schizophrenia have a higher prevalence rate for comorbid OCD than the first-episode schizophrenia (Craig et al., 2002, Achim et al., 2011, Swets et al., 2014). This difference suggests an increase in the obsessive–compulsive comorbidity with the chronicity of the schizophrenia and the use of antipsychotic medications.

The prevalence of obsessive–compulsive symptoms has been reported to differ according to the type of antipsychotic prescribed. It has been generally reported that the obsessive–compulsive symptoms are significantly more frequent in patients taking atypical antipsychotics than in those taking typical antipsychotic medications, suggesting that atypical antipsychotics may induce obsessive–compulsive symptoms (Lykouras et al., 2003, Lim et al., 2007, Schirmbeck et al., 2011, Üçok et al., 2011). In particular, clozapine treatment has been most commonly associated with the emergence of de novo obsessive–compulsive symptoms (Allen and Tejera, 1994, Lim et al., 2007, Schirmbeck et al., 2011, Scheltema Beduin et al., 2012, Schirmbeck and Zink, 2012). De novo emergence of obsessive–compulsive symptoms with atypical antipsychotics is thought to be related to their antagonist effect on 5-HT2 receptors, whereas the dopamine receptor-blocking activity of antipsychotics is thought to be related to their anti-obsessional effect (Kim et al., 2008, Kim et al., 2009a, Schirmbeck et al., 2011).

Several previous studies have investigated the relationships between comorbid obsessive–compulsive symptoms and clinical outcome, including neurocognitive functioning in schizophrenia. The findings have been inconsistent and the impact of comorbid obsessive–compulsive symptoms on the psychotic symptoms and neurocognitive functioning in schizophrenia is unclear. While some studies reported a negative impact of comorbid obsessive–compulsive symptoms on clinical outcomes in schizophrenia (Berman et al., 1998, Hwang et al., 2000, Cunill et al., 2009, Lysaker et al., 2009, Patel et al., 2010, Üçok et al., 2011), others found no association (Whitney et al., 2004, Ongur and Goff, 2005, Tumkaya et al., 2009, Tiryaki and Ozkorumak, 2010). A few studies even reported less severe psychotic symptoms or cognitive impairment in schizophrenia patients with comorbid obsessive–compulsive symptoms, particularly at the early stage of illness (Poyurovsky et al., 1999, Borkowska et al., 2003, Bottas et al., 2005, Lee et al., 2009). These different findings may be related to the varying study population and the diverse nature of obsessive–compulsive symptoms in schizophrenic illness. In addition, type and dosage of antipsychotics were not evenly distributed among groups according to the presence of obsessive–compulsive symptoms in many previous studies (Rajkumar et al., 2008, Lee et al., 2009, Tumkaya et al., 2009, Owashi et al., 2010, Schirmbeck et al., 2013a). Particularly, previous findings that populations with obsessive–compulsive symptoms are more likely to have longer duration of illness or take clozapine, which is mainly used in treatment refractory patients, may confound study results with poorer outcome (Patel et al., 2010, Schirmbeck et al., 2013a). Therefore, it is necessary to control for type of antipsychotics and duration of illness in investigating the effect of obsessive–compulsive symptoms on clinical course of schizophrenia.

The present study aimed to investigate the association of comorbid obsessive–compulsive symptoms with neurocognitive functioning, severity of psychopathology, and quality of life in patients with schizophrenia. To control for potentially serious confounding effects of antipsychotic medications, we only included schizophrenia patients using risperidone monotherapy. In addition, the associations were analyzed separately in different clinical stages, a variable that may be related to the inconsistent results of previous studies.

Section snippets

Subjects

This study was based mainly on a dataset obtained from four clinical trials conducted by the authors from December 2004 to February 2011 (Kim et al., 2007a, Kim et al., 2009b, Kim et al., 2009c, Kim et al., 2012). All subjects met the 4th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for schizophrenia (American Psychiatric Association, 1994) and were required to be symptomatically stable, as judged by the treating psychiatrists, and to have had no changes in

Subjects

The neurocognitive functioning, quality of life, and psychopathology, including obsessive–compulsive symptoms of 163 subjects were analyzed. The sample was about half females (49.1%); their mean age was 33.5 years (standard deviation 8.8, range 16–59 years), and their median education was 14 years (interquartile range [IQR] 12–16). The median age at onset of schizophrenia was 24.5 years (IQR 19.9–30.0), and the median duration of illness was 6.8 years (IQR 2.9–11.3). The median daily dose of

Discussion

The fifth edition of the DSM introduced a dimensional diagnosis system for the research criteria; it includes cognition as one of key domains of psychopathology that require dimensional assessment (Barch et al., 2013). In this study, schizophrenia patients with obsessive–compulsive symptoms had more severe psychotic and depressive symptoms and poorer quality of life. However, results of the present study indicate that comorbid obsessive–compulsive symptoms in patients with schizophrenia may be

Financial support

This work was supported by the Chonnam National University Hospital Research Institute of Clinical Medicine (S.W.K., Grant number CRI12006-1); Data collection was supported in part by investigator-initiated grants from Korea Otsuka Pharmaceutical, Sanofi-Aventis Korea, and Janssen Korea (J.S.Y.). M.B. is supported by a NHMRC Senior Principal Research Fellowship. The funding sources had no further role in study design; in the analysis and interpretation of data; in the writing of the manuscript,

Conflicts of interests

S.W.K. has served as a consultant for Janssen, Otsuka, AstraZeneca, Sanofi-Aventis, Pfizer, MSD, and GlaxoSmithKline. J.S.Y. has received unrestricted research funds from Sanofi-Aventis, Janssen, Roche, Otsuka, and Lundbeck. Other authors have declared that there are no conflicts of interest in relation to the subject of this study.

Acknowledgments

The authors would like to thank Anna Jo for her assistance with data collection and entry.

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