Distinct correlates of hoarding and cleaning symptom dimensions in relation to onset of obsessive–compulsive disorder at menarche or the perinatal period

Ninety female outpatients with obsessive–compulsive disorder (OCD) completed a semistructured interview to assess the relationship between different OCD symptom dimensions and the onset of OCD at menarche or during the perinatal period. Patients with

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  ORIGINAL CONTRIBUTION Distinct correlates of hoarding and cleaning symptomdimensions in relation to onset of obsessive  –  compulsivedisorder at menarche or the perinatal period Javier Labad  &  Pino Alonso  &  Cinto Segalas  &  Eva Real  & Susana Jimenez  &  Blanca Bueno  &  Julio Vallejo  & Jose Manuel Menchon Received: 19 February 2009 /Accepted: 14 July 2009 /Published online: 6 August 2009 # Springer-Verlag 2009 Abstract  Ninety female outpatients with obsessive  –  compulsive disorder (OCD) completed a semistructuredinterview to assess the relationship between different OCDsymptom dimensions and the onset of OCD at menarche or during the perinatal period. Patientswithhoardingsymptomshad an earlier age at menarche than non-hoarders (12.1±1.3vs 13.0±1.5 years,  p =0.019) and were more likely to report OCD onset at menarche (OR=4.1,  p =0.034). Patients withsymptoms of the contamination/cleaning dimension weremore likely to report the onset of their disorder during pregnancy or postpartum (OR=9.3,  p =0.048). Keywords  Obsessive  –  compulsivedisorder .Symptomdimensions.Menarche.Pregnancy.Postpartum Abbreviations OCD Obsessive  –  compulsive disorder LogReg Logistic regressionSD Standard deviationOR Odds ratioYBOCS Yale  –  Brown Obsessive Compulsive Scale Introduction Some women with obsessive  –  compulsive disorder (OCD)report the onset of their disorder at menarche (Labad et al.2005), during pregnancy, or postpartum (Labad et al. 2005; Maina et al. 1999). A different pattern of symptomexpression has been described in patients with postpartumOCD, who show more aggressive obsessions (Maina et al.1999; Sichel et al. 1993; Uguz et al. 2007). Sex hormones may play a role in the relationship between OCD andfemale reproductive events, since estrogen interacts withthe serotonergic system (McEwen 2002), a key neurotrans-mitter system that is thought to be dysregulated in OCD(Zohar et al. 2004).OCD is a clinically heterogeneous condition, so different  patients may show completely distinct symptom patterns.Obsessions and compulsions are experienced within mul-tiple potentially overlapping symptom dimensions (Blochet al. 2008; Leckman et al. 2007). Factorial studies (Bloch et al. 2008) have yielded four (contamination/cleaning,aggressive/checking, symmetry/ordering, and hoarding) or five (some studies have considered sexual/religious obses-sions as a separate category from the aggressive/checkingdimension) symptom dimensions. In recent years, researchstudies have used a dimensional perspective to approachthe heterogeneous phenotype of OCD in the search of more robust endophenotypes (Leckman et al. 2007). Theseconsistent and temporally stable OCD symptom dimen-sions appear to be useful in studies of the natural history,genetics, neurobiology, and treatment outcome of OCD(Leckman et al. 2007).OCD symptom dimensions are also mediated bydifferent components of frontostriatal-thalamic circuitsinvolved in cognitive and emotion processing (Mataix-Colset al. 2004). Interestingly, of all the brain areas implicatedin the genesis of OCD symptoms, the areas related to thecontamination/washing dimensions [i.e., bilateral ventro-medial prefrontal regions and right caudate nucleus, as J. Labad ( * ) :  P. Alonso : C. Segalas :  E. Real :  S. Jimenez : B. Bueno :  J. Vallejo : J. M. MenchonObsessive-Compulsive Disorder Clinical and Research Unit,Department of Psychiatry, Bellvitge Hospital,c/Feixa Llarga s/n,08907 L ’ Hospitalet de Llobregat, Barcelona, Spaine-mail: j_labad@yahoo.esArch Womens Ment Health (2010) 13:75  –  81DOI 10.1007/s00737-009-0098-x  described in a functional MRI study (Mataix-Cols et al.2004)] have high levels of sex steroid hormone receptorsand show sexual dimorphism, with larger volumes inwomen than in men (Goldstein et al. 2001). Sexualdimorphism in relation to the contamination/cleaningdimension has been described in OCD patients (Labad et al. 2008), as patients with contamination/cleaning symp-toms are twice as likely to be female. As OCD dimensionsare mediated by different neural circuits, whose brain areasalso differ according to sex and levels of sex steroidhormone receptors, it is plausible that patients fromdifferent OCD dimensions may differ in terms of thesusceptibility to have the onset of OCD related to a femalereproductive event. To our knowledge, the question of whether patients from different symptom dimensions differ in their vulnerability to have the onset of OCD at menarcheor the perinatal period has not been studied to date.Thus, the main aim of our study was to explore therelationship between OCD symptom dimensions and theonset of OCD at menarche or during the perinatal period. Materials and method Patients and clinical assessment The study sample consisted of 94 consecutive female patients meeting Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for OCD who wereassessed at our OCD outpatient unit from January 2004 toJune 2008. Inclusion criteria were DSM-IV diagnosis of OCD, female gender, and lacking neither a comorbiddiagnosis of schizophrenia nor a history of psychoactivesubstance abuse. Four patients were excluded from thestudy for refusing to participate (  N  =2), comorbid diagnosisschizophrenia (  N  =1), and cognitive deficit that madecompletion of interviews difficult (  N  =1).After written-informed consent was obtained, all 90 patients were interviewed. OCD diagnosis was confirmed by two psychiatrists using the Structured Clinical Interviewfor DSM-IV (SCID-I/P) (First et al. 1997). Lifetime historyof tic disorder and other comorbid conditions were assessedretrospectively by direct interview. Symptom severity andlifetime presence of obsessive  –  compulsive symptoms wereassessed with the Yale  –  Brown Obsessive Compulsive Scale(YBOCS) (Goodman et al. 1989) and the YBOCSSymptom Checklist (Goodman et al. 1989). Due to thecross-sectional design of our study, changes in the type of OCD symptoms over time (between the onset of OCD andthe evaluation at our unit) were not assessed.A semistructured clinical interview was conducted toassess the relationship between reproductive cycle eventsand onset of OCD. This interview, which was previouslyused in another study (Labad et al. 2005), retrospectivelyassesses the onset of OCD related to reproductive events(including menarche, pregnancy, and postpartum) and alsoinquires about mood reproductive-related disorders. In brief, patients were asked about their current or previoushistory of premenstrual mood symptoms (we included thefour mood symptoms of the DSM-IV research criteria for  premenstrual dysphoric disorder: anxiety, irritability, moodlability, and depressed mood) or pregnancy and postpartum psychopathology. If a woman had more than one child,each pregnancy and postpartum period (defined as 6 monthsfollowing childbearing) was individually assessed, obtain-ing information about age at pregnancy, type of delivery, pregnancy or postpartum complications, OCD onset at pregnancy or postpartum, and depressive episodes during pregnancy or postpartum. Ages at onset of OCD andmenarche were obtained. Age at onset of OCD was definedas the age at which symptoms became a significant sourceof distress and interfered with the patient  ’ s social function-ing. The following events close to the onset of OCD werealso assessed: death or serious illness of a family member or a close friend, school or employment changes, geo-graphic changes in living, economic or legal problems, physical illness, and any other stressful event that wasconsidered important by the patient. In order not to induce patients to relate the onset of OCD to reproductive events,the age at onset of OCD and the role of major events wereassessed at the first part of the interview, before the specificquestions about reproductive cycle events were made.Patients were asked about major events (but not reproduc-tive cycle events) related to the onset. OCD onset wasconsidered to be related to the perinatal period if the patient reported spontaneously that her OCD was related to pregnancy or postpartum. To determine the onset of OCDat menarche, we calculated the difference in years betweenage at onset of OCD and age at menarche. When thisdifference was 0 or 1 (which means that a patient reportedthe onset of OCD within 1 year after menarche), a patient was considered to have the onset of OCD at menarche.As our unit is a referral center for OCD, most patientswere taking psychopharmacological treatment (mainlyserotonin selective reuptake inhibitors or clomipramine) at admission to our unit. There were no significant differencesin the treatment between patients with symptoms fromdifferent OCD dimensions.Statistical analysisData were analyzed with SPSS v.15.0 (SPSS Inc.,Chicago, Ill.).OCD symptoms were recoded in dichotomousvariables representing five OCD symptom dimensions: (1)symmetry/ordering (including symmetry obsessions and 76 J. Labad et al.  repeating, counting, and ordering compulsions), (2) con-tamination/cleaning (including contamination obsessionsand cleaning compulsions), (3) aggressive/checking(including aggressive obsessions and checking compul-sions), (4) sexual/religious obsessions, and (5) hoarding(including hoarding obsessions and compulsions). Wedecided to use five instead of four dimensions because previous studies suggest that patients with sexual/religious OCD and reproductive cycle variablesAge at assessment (years), mean ± SD 36.0±12.5Age at onset of OCD (years), mean ± SD 20.0±8.7Major events (not reproductive) at onset of OCD,  N   (%) 25 (27.8)Age at menarche (years), mean ± SD 12.7±1.5History of tic disorder,  N   (%) 8 (8.9)YBOCS at assessment, mean ± SD 25.9±6.9Patients with at least one live-born child,  N   (%) 35 (38.9)Reproductive-related anxiety/mood disorders,  N   (%)Premenstrual anxiety 26 (28.9)Premenstrual mood symptoms (irritability, emotional lability or depressive mood) 55 (61.1)Postpartum depression 10 (28.6)OCD symptom dimensionsLifetime presence of symptoms (not exclusive categories),  N   (%)Contamination/cleaning 51 (56.6)Symmetry/ordering 49 (54.4)Aggressive/checking 73 (81.1)Sexual/religious 17 (18.8)Hoarding 24 (26.6)Prominent symptoms (exclusive categories),  N   (%)Contamination/cleaning 29 (32.2)Symmetry/ordering 11 (12.2)Aggressive/checking 34 (37.8)Sexual/religious 9 (10)Hoarding 7 (7.7) Number of OCD symptom dimensions a  ,  N   (%)1 19 (21.1)2 31 (34.4)3 26 (28.9)4 14 (15.6)Onset of OCD related to menarche,  N   (%)Before menarche 12 (13.3)At menarche (within the 12 following months) 19 (21.1)2  –  5 years after menarche 12 (13.3)6  –  10 years after menarche 18 (20)>10 years after menarche 29 (32.2)Perinatal onset of OCD(at pregnancy or postpartum),  n /   N   b (%)All patients 9/90 (10)Patients with children 9/35 (25.7)Onset at pregnancyAll patients 2/90 (2.2)Patients with children 2/35 (5.7)Onset at postpartumAll patients 7/90 (7.8)Patients with children 7/35 (20) Table 1  Clinical characteristicsof the sample (  N  =90) OCD  obsessive  –  compulsivedisorder  a  Coexistence of different typesof lifetime OCD symptoms(defined as present) fromfive dimensions: contamination/ cleaning, symmetry/ordering,aggressive/checking,sexual/religious, and hoarding.  b n /   N  :  n  = number of patientswith onset of OCD at areproductive event;  N   = number of total patients from the wholesample (for all patients) or subsample (patients who had been pregnant).OCD symptom dimensions and onset of OCD at menarche or the perinatal period 77  obsessions may differ from the aggressive/checking dimen-sion inclinicalcharacteristics suchasanearlier age atonsetof OCD (Labad et al. 2008) and a poorer treatment response(Alonso et al. 2001), as well as gender differences in theexpression of symptoms, being sexual/religious obsessionsmore prevalent in male patients (Labad et al. 2008).In the univariate analyses, two approaches were used tocategorize the lifetime history of symptoms from different OCD dimensions. In the first analysis, each OCD symptomdimension was considered to be present if at least onesymptom category related to that dimension scored 1.Patients could score on one or more symptom dimensions, sooverlapping categories could coexist in a same patient. Thestudy of the relationship between OCD dimensions and onset of OCD at reproductive events with this approach may belimited by the issue of not controlling interdependencies between different categories. To solve this limitation, we also performed a multivariate analysis to control for all these fiveOCD dimensions (defined as present symptoms).In another univariate analysis, we used the main or most  prominent OCD symptoms (instead of present symptoms) todefine five exclusive categories. Each patient was included in Table 2  Relationship between OCD symptom dimensions and onset of OCD related to reproductive and non-reproductive life events in 90female patients with OCDOnset of OCD related to life events  p  value  N   No event At menarche At perinatal period Other event (not reproductive)Present symptoms a  Contamination/cleaning 0.112 No 39 19 (48.7) 10 (25.6) 1 (2.6) 9 (23.1)Yes 51 18 (35.3) 9 (17.6) 8 (15.7) 16 (31.4)Symmetry/ordering 0.028 No 41 21 (51.2) 3 (7.3) 4 (9.8) 13 (31.7)Yes 49 16 (32.7) 16 (32.7) 5 (10.2) 12 (24.5)Aggressive/checking 0.957 No 17 6 (35.3) 4 (23.5) 2 (11.8) 5 (29.4)Yes 73 31 (42.5) 15 (20.5) 7 (9.6) 20 (27.4)Sexual/religious 0.241 No 73 31 (42.5) 17 (23.3) 8 (11.0) 17 (23.3)Yes 17 6 (35.3) 2 (11.8) 1 (5.9) 8 (47.1)Hoarding 0.035 No 66 29 (43.9) 9 (13.6) 7 (10.6) 21 (31.8)Yes 24 8 (33.3) 10 (41.7) 2 (8.3) 4 (16.7)Prominent symptoms  b 0.032Contamination/cleaning 29 13 (44.8) 2 (6.9) 4 (13.8) 10 (34.5)Symmetry/ordering 11 1 (9.1) 6 (54.5) 2 (18.2) 2 (18.2)Aggressive/checking 34 17 (50.0) 6 (17.6) 3 (8.8) 8 (23.5)Sexual/religious 9 4 (44.4) 1 (11.1) 0 (0) 4 (44.4)Hoarding 7 2 (28.6) 4 (57.1) 0 (0) 1 (14.3) Number of OCD dimensions c 0.6251 19 10 (52.6) 1 (5.3) 2 (10.5) 6 (31.6)2 31 15 (48.4) 7 (22.6) 2 (6.5) 7 (22.6)3 26 9 (34.6) 7 (26.9) 3 (11.5) 7 (26.9)4 14 3 (21.4) 4 (28.6) 2 (14.3) 5 (35.7)Data are  N   (%) OCD  obsessive  –  compulsive disorder  a  Each patient could score in different OCD dimensions. Each dimension is defined by presenting one symptom of five different categories(not exclusive)  b Patients are divided in five exclusive categories. Each OCD dimension is defined by the most prominent type of OCD symptom. c Coexistence of different types of lifetime OCD symptoms (defined as present) from five dimensions: contamination/cleaning, symmetry/ ordering, aggressive/checking, sexual/religious, and hoarding.78 J. Labad et al.  one type ofOCD symptom dimension ifat least one symptomcategory related to that dimension scored 2 and reflected themost prominent type of symptom reported by the patient.The  t   test was used to compare continuous variables for each OCD dimension and chi-square for categorical compar-isons (e.g., hoarding vs non-hoarding). A  p <0.05 (two-tailed)was considered significant. The initial univariate analyseswere not corrected for multiple comparisons, as we used amultivariate analysis to test our hypothesis. Moreover, the risk of missing actual differences could be more problematic thanthe risk of finding false differences concerning the selectionof variables for inclusion in the multivariate analyses.Logistic regression (LogReg) was used to test theassociation between OCD dimensions and onset of OCD at different reproductive events. Onset of OCD at menarche(LogReg model 1) or during the perinatal period (LogRegmodel 2) was set as the dependent variable. OCD dimensionsand other covariates (age, age at onset of OCD, history of ticdisorder, and YBOCS) were included in each model asindependent variables. Significant variables were selectedthrough a backward stepwise procedure. For LogReg model 2two other covariates were also added (premenstrual moodsymptoms and postpartum depression), as previous studieshad reported a relationship between these variables and postpartum OCD (Labad et al. 2005; Sichel et al. 1993). Results The mean age of the sample at assessment was 36 years(range, 18  –  74 years). The mean age at onset of OCD was20 years (range, 6  –  50 years), and the mean age at menarchewas 12.7 years (range, 9  –  17 years). Patients with symptomsfrom the symmetry/ordering dimension had, when com- pared to those patients without symmetry/ordering symp-toms, an earlier age at onset of OCD (17.9±8.1 vs 22.4±8.8 years,  p =0.013). Hoarders reported an earlier age at menarche than non-hoarders (12.1±1.3 vs 13.0±1.5 years,  p =0.019). There were no significant differences in relationto age, age at onset of OCD or age at menarche between patients with symptoms from other OCD symptom dimen-sions. The mean ± SD YBOCS score of the sample was25.9±6.9. There were no significant differences in YBOCSscores between patients with symptoms from different OCDsymptom dimensions. The clinical characteristics of thesample are described in Table 1. As can be seen, most  patients with OCD reported symptoms from different dimensions (78.9% of all patients reported symptoms fromtwo or more dimensions).A substantial proportion of patients reported the onset of OCD related to menarche (21.1%), the perinatal period(10%), or other non-reproductive major events (27.8%).The different proportion of onset of OCD at life events(reproductive and non-reproductive) for each OCD symp-tom dimension is described in Table 2.In the univariate analysis, patients reporting symmetry/ ordering symptoms as well as hoarding symptoms weremore likely to relate the onset of OCD at menarche. As both OCD symptoms may coexist in a same patient, wefurther assessed all OCD symptom dimensions with amultivariate analysis. In the LogReg, only the hoardingdimension entered the final equation (OR=4.1,  p =0.03), 024681012141618-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 >25 Time (in years) from age at menarche to age at onset of OCD    P  a   t   i  e  n   t  s ,   N HoardingNot hoarding Fig. 1  Distribution of ages at onset of OCD in relation to menarche in patients with (  N  =24) or without (  N  =66) hoarding symptomsOCD symptom dimensions and onset of OCD at menarche or the perinatal period 79
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