Obsessive-Compulsive Symptoms May Herald Mental Illness in Youth

Batya Swift Yasgur, MA, LSW

January 24, 2019

Obsessive-compulsive symptoms (OCS) in youth may be an early warning sign for subsequent mental illness, including psychosis, new research suggests.

Investigators analyzed data from the Philadelphia Neurodevelopmental Cohort (PNC), consisting of over 7000 youngsters ranging in age from 11 to 21 years. Participants, who were not seekers of mental health services, were screened for OCS as well as other psychiatric disorders.

The researchers found that OCS were common in these youth, affecting almost 40% of participants, although only 3% met criteria for full OCD.

Although all OCS were associated with higher rates of major psychiatric conditions (OCD, depressive episodes, psychosis, and suicidal ideation), "bad thoughts," which were reported by one fifth of the sample, showed the most "substantial" association.

"When we compared the kids with OCS to those without, we found odds ratios ranging from 3 to 5, in terms of association with lifetime psychiatric conditions, especially among those with bad, intrusive thoughts," lead author Ran Barzilay, MD, PhD, researcher at the Lifespan Brain Institute of Children's Hospital of Philadelphia and University of Pennsylvania, told Medscape Medical News.

"These findings have very critical clinical implications, namely that OCS are a red flag for the later development of psychiatric disorders and can therefore be used to stratify kids to higher or lower risk," he said.

The study was published online November 23 in the Journal of the American Academy of Child and Adolescent Psychiatry.

Sub-threshold OCS

"Engaging in repetitive and ritualistic behaviors is part of typical child behavior" but as children grow older, "these behaviors may no longer be necessary to help reach age-appropriate goals," the authors write.

Common comorbidities of OCD include depression, psychosis, and suicidal thoughts, both in children and in adults.

Previous studies have focused almost exclusively on identifying dimensions that emerge among children and adolescents meeting criteria for threshold OCD, but less research has focused on the potential association between OCS and other psychiatric conditions.

"In order to fulfill criteria for OCD, it's not enough to simply have some obsessions or compulsions," Barzilay said.

"OCS have to reach a very high threshold of clinical distress and impairment to meet diagnostic criteria for full-blown OCD, and we wanted to see if the presence of OCS without OCD could help flag out a serious, latent, undiagnosed psychiatric condition," he explained.

"We wanted to see whether having these symptoms could perhaps help stratify kids for higher or lower risk of other psychiatric conditions, and which types of OCS were most associated with these conditions."

"Amazing" Dataset

To address these questions, the researchers analyzed data from the PNC, a sample consisting of non–help-seeking children and adolescents (n = 7054) ages 11 to 21 years living in the greater Philadelphia region.

Participants were recruited from a larger pool of children previously genotyped as part of a genomic study at Children's Hospital of Philadelphia (n = 15,293).

Barzilay credited Raquel Gur, MD, PhD, senior author of the paper, for the "amazing dataset of the PNC that includes very comprehensive clinical, cognitive, imaging, and genetic evaluation of over 10,000 kids from the Philadelphia area."

Youngsters were psychiatrically assessed and reported on a lifetime occurrence of domains of psychopathology, including OCS and OCD, depression, psychosis, and suicidal ideation.

The researchers assessed psychopathology symptoms using a comprehensive computerized tool called GOASSESS to conduct structured evaluation of psychopathology domains.

The GOASSESS OCD screen assessed lifetime experiences of eight obsessions and nine compulsions. If at least one obsession/compulsion was endorsed, subsequent questions then assessed further lifetime criteria for OCD.

Barzilay noted that a "sophisticated" statistical technique called exploratory factor analysis was applied to the various OCS to see if associations could be found between specific symptoms and types of psychopathology.

OCs Common, OCD Uncommon

Of the sample, 209 participants (3%) met criteria for a lifetime OCD diagnosis and 2697 (38.2%) endorsed one or more obsessions or compulsions on the OCD screener (OCS participants).

OCS were more common in females (odds ratio [OR], 1.30, Wald = 25.97, df = 1, P < .001) and post-puberty (OR = 1.18, Wald = 9.95, df = 1, P = .002).

There was a sex-by-puberty interaction in association with OCS, manifested by higher OCS proportion in post-pubertal females (Wald = 4.30, df = 1, P = .038)

The OCS group was on average slightly older, had a higher proportion of females, and a lower proportion of white participants, compared to non-OCS participants.

Participants with OCS were found to have a higher prevalence of major psychopathology phenotypes — including lifetime depression, psychosis, and suicidal ideation — compared to controls (26.4% vs 7.8%, 9.6% vs 2.1%, and 16.5% vs 4.6%, respectively, all Ps <.001).

Participants with OCS were also rated (based on the Children's Global Assessment Scale [C-GAS]) as having a lower level of global function, vs those without OCS (75.4 vs 81.2 respectively, P <.001).

"Notably, of 2697 OCS participants, the vast majority did not fulfill criteria for a lifetime OCD diagnosis (n = 2488; 92.3%)," the authors emphasize.

"Compelling" Finding

Factor analysis yielded four factor domains: (F1) bad thoughts; F2 (repeating/checking); F3 (symmetry); and F4 (cleaning/contamination). Hoarding was listed as a separate factor.

"Endorsement of symptoms across factors showed substantial overlap," the authors report.

Self-reported OCS were more prevalent in females, with main effect for puberty in F1 and F2, but not in other OCS factors.

The researchers then investigated the association of each factor with lifetime report of major comorbid psychopathology, controlling for pubertal status, age, sex, and socioeconomic status.

They found that endorsement of one or more OCS was significantly associated with a higher rate of lifetime history of depression, psychosis, and suicidal ideation (all ORs >4.0, all Ps <.001).

Moreover, F1 had "the most robust associations" with comorbid psychopathology phenotypes: OCD (OR = 11.7; P < .001), depression (OR = 4.3; P < .001), psychosis (OR = 3.3; P < .001), and suicide ideation (OR = 4.4; P < .001).

F2 was found to be significantly associated with depression, F3 with psychosis, and hoarding with depression. F4 was not associated with any major psychiatric conditions that were evaluated except for OCD itself.

A regression model, including all F1 symptoms and controlling for pubertal status, age, sex, and socioeconomic status, revealed that thoughts concerning self-harm or harming others were significantly associated with OCD, depression, psychosis, and suicidal ideation.

"The biggest and most compelling finding of this study is that, using factor analysis, we found that of the five OC symptoms clusters we analyzed, having bad, intrusive thoughts was most strongly associated with serious psychiatric conditions," Barzilay said.

"That is why this study is so clinically relevant — because it can guide clinicians, when dealing with kids who are not seeking help, to probe for a few symptoms which are golden in their capacity to stratify risk for serious psychiatric conditions," he added.

Screening, Monitoring Warranted

Commenting on the study for Medscape Medical News, Michael H. Bloch, MD, associate professor at the Yale School of Medicine Child Study Center in New Haven, Connecticut, who was not involved with the study, noted that although "many kids have OCS, few have OCD — meaning that usually these symptoms do not cause significant impairment or distress."

Nevertheless, clinicians should "assess for OCS in children in psychiatric distress," he advised, noting that these symptoms are common and "can be a sign not just of OCD but also of other psychiatric illnesses."

Also commenting on the study for Medscape Medical News, Marc-André Roy, MD, FRCP, research and clinical psychiatrist at the CERVO Brain Research Centre in Quebec, Canada, said it "adds to available evidence that the boundaries between disorders are porous and that OCS may be a harbinger for other disorders."

Roy, who was not involved with the study, noted that "we tend to underestimate the importance of nonspecific symptoms, as symptoms that are seen as developmentally normal may not always be so." These symptoms, he said, "may warrant implementing some longitudinal monitoring."

Barzilay, the study's lead author, added that the relevance of these findings "go beyond child psychiatric clinicians and apply also to pediatricians, who should be aware that some of these symptoms can be a clinical window through which they can learn that these kids need further probing, and have a higher level of clinical index of suspicion."

This work was supported by the National Institutes of Health, the Dowshen Neuroscience fund, and the Lifespan Brain Institute of Children's Hospital of Philadelphia and Penn Medicine, University of Pennsylvania.  Barzilay has served on the scientific board and has reported stock ownership in Taliaz Health, with no relevant financial relationships tied to this work. The other authors' disclosures are listed on the original paper. Bloch and Roy have disclosed no relevant financial relationships.

J Am Acad Child Adolesc Psychiatry. Published online November 23, 2018. Full text

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