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symptom subtypes of obsessive compulsive disorder

Given the wide variety of symptom patterns that may be present in obsessive compulsive disorder, a number of attempts have been made to subclassify the disorder to enhance understanding of its pathophysiology and treatment. Most often, attempts to identify subtypes have been based on the predominant type of rituals reported by the patient. In these schemes, subgroups of patients always include (but are not limited to) those with predominant washing and checking rituals. As noted earlier, these types of rituals are the most commonly reported by clinic patients.
As such, it is not surprising that much of the evidence that supports the utility of behavioral treatment for obsessive compulsive disorder has been obtained largely with patients who can be classified as ‘‘washers’’ or ‘‘checkers’’. Studies of the potential utility of subclassifying obsessive compulsive disorder in this manner have indicated a variety of differences in demographic and clinical variables for patients classified as ‘‘washers’’ and ‘‘checkers.’’ For example, patients in these two subgroups differ in age of onset and gender distribution, frequency of personality disorders, triggers for obsessional fears, and retrospective reports of parental style. These data suggest the potential utility of a symptom classification scheme to enhance understanding and treatment of obsessive compulsive disorder. Recent factor analyses of obsessive compulsive disorder symptoms in larger groups of patients suggested three or four major subgroups of symptoms. Baer reported an analysis of symptoms in 107 patients that yielded three factors characterized by symmetry/ hoarding (symmetry and saving obsessions, and ordering, hoarding, repeating, and counting rituals), contamination/cleaning, and pure obsessions (aggressive, sexual, and religious obsessions). Leckman and colleagues reported four factors in two independent samples of more than 300 patients with obsessive compulsive disorder. These factors included obsessions/checking (aggressive, sexual, religious, and somatic obsessions and checking rituals), symmetry/ordering (including also repeating and counting compulsions), cleanliness/washing, and hoarding.
Overlap in the factor structures of these two reports is evident, although no data yet have addressed the utility of subclassifying patients according to these broader subgroups of symptoms. In fact, despite evidence of meaningful differences between washers and checkers, the general utility of classifying patients according to symptom subtypes has been questioned, given that symptom clusters generally are not mutually exclusive and constellations of symptoms may change over time. Other subclassification schemes have also been suggested, the most viable of them probably is based on coexistent diagnoses. In particular, coexistent Tourette’s syndrome or chronic tic disorder in obsessive compulsive disorder has been associated with differential obsessive-compulsive symptom profiles, gender distribution, age of onset for obsessive compulsive disorder and neurochemical findings, and treatment response. This literature taken together supports the potential utility of subclassifying patients with obsessive compulsive disorder who also have a chronic tic disorder to enhance clinical understanding and treatment of patients. Similarly, patients with some coexistent personality disorders or features have unique patterns of obsessive compulsive disorder symptoms and differential treatment response. This literature is less well developed, however, and requires further study. Possibly of even more heuristic value are subclassification schemes based on function rather than content of symptoms. Such systems allow subclassification of patients regardless of specific symptom constellations that may vary over time.
Mavissakalian proposed such a system that included four forms of obsessive-compulsive symptoms: (1) obsessions only, (2) obsessions plus anxiety-reducing compulsions, (3) obsessions plus anxiety-increasing compulsions, and (4) compulsions independent of anxiety and/or obsessions. Although this type of system holds some promise for treatment refinement, very little relevant empirical work has addressed the utility of functional classification schemes. In the context of a DSM-IV field trial, Foa and Kozak examined the usefulness of subcategories of obsessive compulsive disorder including predominantly obsessions, predominantly compulsions, and mixed obsessions and compulsions. Results revealed that more than 90% of patients reported both obsessive and compulsive symptoms, although based on interview data, clinicians categorized 30% of patients with predominantly obsessions, 21% with predominantly compulsions, and 49% with mixed obsessions and compulsions. Significant differences in the frequency of various specific symptoms occurred across these subgroups, although data overall were equivocal with regard to the utility of this type of classification. In summary, numerous models have been proposed for subclassifying obsessive compulsive disorder. To date, the most promising of these involve subgroups based on the presence or absence of co-occurring chronic tic disorders and the predominant type of symptom reported; the majority of data here address differences between patients with primary washing or checking compulsions.

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