Int J Psychiatry Clin Pract 2014; 18: 156–160. © 2014 Informa Healthcare ISSN 1365-1501 print/ISSN 1471-1788 online. DOI: 10.3109/13651501.2013.855792

ORIGINAL ARTICLE

Characterizing impulsivity profile in patients with obsessive–compulsive disorder

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Beatrice Benatti1, Bernardo Dell’Osso1, Chiara Arici1, Eric Hollander2 & A. Carlo Altamura1 1

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Dipartimento di fisiopatologia medico-chirurgica e dei trapianti, Università degli Studi di Milano, Dipartimento di Salute Mentale, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milano, Italy and 2Department of Psychiatry, Montefiore Medical Center University Hospital for Albert Einstein College of Medicine, Child Psychiatry Annex, Bronx, NY, USA Abstract Objective. Impulsivity represents a key dimension in obsessive–compulsive disorder (OCD), in relation to outcome and course. It can be assessed through the Barratt Impulsiveness Scale (BIS), which explores three main areas: attentional, motor, and nonplanning. Present study was aimed to assess level of impulsivity in a sample of OCD patients, in comparison with healthy controls, using the BIS. Methods. Seventy-five OCD outpatients, 48 of them having psychiatric comorbidities and 70 healthy controls, were assessed through the BIS, and their scores were analyzed using Student’s t-test for independent samples, on the basis of demographic and clinical characteristics. Results. BIS total scores were significantly higher (P: 0.01) in patients compared to controls, with no difference between pure and comorbid patients. Attentional impulsivity scores were significantly higher than controls in patients with pure (P ⬍ 0.001) and comorbid OCD (P ⬍ 0.001), without differences among them. Patients with multiple OC phenotypes showed higher, though statistically non significant, total and attentional scores, compared to single phenotype patients. In addition, patients with comorbid major depressive disorder had higher, though statistically non significant, total and attentional scores, compared to patients with comorbid bipolar disorder, generalized anxiety disorder, and other disorders. Conclusions. Present findings showed higher impulsivity levels in OCD patients versus controls, particularly in the attentional area, and ultimately suggest a potential cognitive implication. Key words: Barratt impulsiveness scale, comorbidity, impulsivity, obsessive–compulsive disorder (Received 10 May 2013; accepted 7 October 2013)

Introduction Obsessive–compulsive disorder (OCD) is a prevalent, disabling, and comorbid condition, responsible for a substantial reduction of quality of life and significant functional impairment of patients and caregivers (Grabe et al. 2006; Dell’Osso et al. 2007; Andrews et al. 2002; Norberg et al. 2008). Traditionally included among anxiety disorders, OCD has been recently classified, in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, within a new chapter of obsessive–compulsive and related disorders, including, among other conditions, some disorders characterized by impulsive features, such as excoriation (skin-picking) disorder and trichotillomania (APA 2013). Impulsivity, in fact, represents a core dimension of many OC-related disorders and has been defined as ‘a predisposition toward rapid, unplanned reactions to internal or external stimuli, with diminished regard to the negative consequences of such reactions to the individual or to others’ (Moeller et al. 2001). Indeed, it is worth noting that obsessions are defined, by the diagnostic and statistical

Correspondence: Bernardo Dell’Osso, MD, Ass. Prof. of Psychiatry, Department of Psychiatry, University of Milan, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milano, Italy. Tel: ⫹ 02-55035206. Fax: ⫹ 02-55033140. E-mail: [email protected]

manual of mental disorders (DSM), as recurring, persistent impulses (APA 2000). Given that impulsivity represents a nuclear dimension of OC-related disorders, it is of clinical interest – in relation to management, treatment selection, and long-term outcome – to assess and quantify its presence in OCD patients. Recently, in fact, a large Australian study reported that OCD patients with impulsive features showed poor clinical outcome, in terms of scarce insight, low resistance, and reduced control toward compulsions (Kashyap et al. 2012). OCD presentation can significantly vary, on the basis of comorbidity patterns, symptom severity (Narayanaswamy et al. 2012), as well as predominant clinical phenotype (single vs. multiple phenotype) (Rosario-Campos et al. 2006). Comorbidity, in particular, can influence presentation, long-term outcome, and treatment response of OCD patients, with negative impact on health and psychosocial function (De Mathis et al. 2013; Fineberg et al. 2013; Jakubovski et al. 2013). In such perspective, impulsivity levels may, in turn, show different variations on the basis of the aforementioned variables, which may be of clinical interest in terms of treatment selection and long-term outcome. In order to quantify and disentangle the impulsivity dimension in OCD, exploring potential differences across patients versus healthy controls, in terms of specific

DOI: 10.3109/13651501.2013.855792

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socio-demographic and clinical features, such as gender, comorbidity, single versus multiple phenotype, illness severity, and current treatment, we conducted the present naturalistic study. Methods Seventy-five consecutive outpatients with a diagnosis of OCD, according to DSM-IV-TR criteria, and 70 healthy controls, without any psychiatric diagnosis, as determined by the Structured Clinical interview for DSM-IV (SCID-I and II), nonpatient edition (First et al. 2002a), matched for age and gender, were recruited. The sample could include subjects with other DSM-Axis I comorbidities, besides OCD. However, in case of psychiatric comorbidity, OCD had to be the primary disorder, i.e., causing the most significant distress and dysfunction and providing the primary motivation to seek treatment. Diagnoses were obtained by means of the structured clinical interview based on DSM-IV Axis I (SCID I) and II criteria (SCID II) (First et al. 2002b), during which patients’ main demographic and clinical characteristics were collected. These included: age of onset, illness duration, phenotype (single vs. multiple), psychiatric comorbidity, and current treatment (mono- vs. polytherapy), including psychotherapy. Moreover, OCD severity was assessed using the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) and the main OCD phenotypes were identified through the Y–BOCS-Symptom Checklist, a list of common obsessions and compulsions that patients might have experienced during their life (Goodman et al. 1989a, 1989b). All patients were on stable pharmacological treatment when clinically interviewed. The Barratt Impulsiveness Scale (BIS) was used for the assessment of impulsivity. The scale was proposed for the first time, in 1959, by Barratt and Stanford, as a self-report measure of impulsiveness that was not part of a personality inventory (Barratt 1959). Since then, the BIS has been revised several times, the latest version being BIS-11, a 30-item self-report questionnaire investigating three main areas of impulsivity: attentional, motor, and nonplanning (Patton et al. 1995; Fossati et al. 2001). The BIS-11 was administered to the whole study sample, after collecting patients’ written informed consent to participate in the study and have their records used for clinical research purposes. Student’s t test was used to compare total and subtotal scores of the three main areas of the BIS-11, attentional, motor, and non-planning, in patients versus controls. Furthermore, in the patients sample, the BIS-11 total and subtotal scores, using Student’s t test and ANOVA, were compared between groups divided on the basis of: gender, comorbidity, single versus multiple phenotype, monoversus polytherapy, and absence/presence of antidepressant treatment. Finally, a simple linear regression analysis was performed, considering patients’ BIS-11 total score as dependent variable and the Y-BOCS score as independent variable, in order to assess the relationship between impulsivity and OCD severity. The level of significance was set at 0.05. All the statistical analyses were performed using the Statistical Package for

Impulsivity profile in obsessive–compulsive disorder 157 the Social Sciences for Windows software (version 17.0; SPSS Inc., Chicago, Illinois, USA). Results The main demographic and clinical variables of the whole sample are summarized in Tables I and II. Within the sample of 75 outpatients, 48 subjects (64%) had comorbidities, of which major depressive disorder (MDD, 30%), generalized anxiety disorder (GAD, 14%), and bipolar disorder (BD, 9%) were the main ones. Comorbidities like impulse control disorders and cluster B personality disorders were not found. Patients sample consisted of 34 females and 41 males, with a mean age of 41.62 ⫾ 10.78 years. Among patients with comorbidities, there was a prevalence of females (33 subjects, 69% of patients with comorbidities), with 19 subjects (40%) on monotherapy and 29 (60%) on polytherapy. Antidepressants were the most frequently prescribed compounds in the patients sample and, among them, the most common were selective serotonin reuptake inhibitors (SSRIs; 76%), followed by tricyclic antidepressants (TCAs; 14%), and serotonin noradrenaline reuptake inhibitors (SNRIs; 12%). Statistically significant differences in terms of antidepressant intake between comorbid versus noncomorbid patients were not found (96% vs. 89%, respectively). BIS-11 total score of OCD patients was significantly higher compared to controls (t: 2.79; P: 0.01) (Figure 1). In particular, with respect to the main areas of BIS-11, attentional impulsiveness score was significantly higher in patients with OCD (t: 4.93; P ⬍ 0.001), compared to controls (Figure 2). Motor and nonplanning impulsiveness sub-scale scores showed no significant difference between patients and controls. The comparison of BIS-11 total and attentional impulsiveness scores between patients with single versus multiple OCD phenotype showed borderline, statistically non significant results (BIS-11 total scores: t ⫽ 2.63, P ⫽ 0.07, BIS-11 attentional impulsiveness scores: t ⫽ 4.52, P ⫽ 0.065), indicating higher scores in patients with multiple phenotypes. The multiple OCD phenotypes did not show patterns of aggregation with specific comorbidities. In patients’ sample, BIS-11 total and subtotal scores did not show any difference on the basis of gender, monoversus polytherapy, and absence/presence of antidepressant medication. The comparison of BIS-11 total and attentional impulsiveness scores among patients with comorbidities showed that subjects with comorbid MDD had higher Table I. Demographic variables of the sample. Total sample Controls Total cases Cases with comorbidities Cases without comorbidities

Males

Females

Age (years)

70 75 48 (64%)

25 45 41 34 15 (31%) 33 (69%)

40,65 ⫾ 15,19 41,62 ⫾ 10,78 40,70 ⫾ 13,27

27 (36%)

16 (59%) 11 (41%)

39,00 ⫾ 12,48

Mean values for continuous variables and number of patients for dichotomic ones are provided. Standard deviations for continuous variables and percentages for dichotomic ones are shown in brackets.

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Table II. Main clinical variables of the sample. Cases with comorbidities N ⫽ 48

Cases without comorbidities N ⫽ 27

Age of Onset (years) Duration of Illness (months) Single OCD Phenotype/ Multiple OCD Phenotype

25,04 ⫾ 12,87 169,85 ⫾ 117,20 17 patients (35%) ⬎ 1 phenotype Most frequent phenotype: hygiene/contamination

23,26 ⫾ 10,34 186,35 ⫾ 114,26 9 patients (33%) ⬎ 1 phenotype. Most frequent phenotype: hygiene/contamination

Most Frequent Comorbidities

• • • •

Monotherapy/Polytherapy

Comorbidity patterns and antidepressant intake

Major Depressive Disorder (30%) Generalized Anxiety Disorder (14%) Bipolar Disorder (9%) Panic disorder, Substance abuse, Anorexia nervosa, Bulimia nervosa, Non otherwise specified Psychosis, Somatization Disorder, Post traumatic stress disorder, Schizophrenia, Social Phobia (4%) • Paranoid Personality Disorder, Hypochondria, Schizoid Personality Disorder, Avoidant Personality Disorder, Schizotypal personality disorder (2%) • 19 patients (40%) on monotherapy • 29 patients (60%) on polytherapy

• 8 patients (30%) on monotherapy • 19 patients (70%) on polytherapy

• Major Depressive Disorder: 100% on antidepressant treatment (SSRIs: 65%; SNRIs 23%; TCAs 12%) • Generalized Anxiety Disorder: 100% on antidepressant treatment (SSRIs: 87%; SNRIs 13%) • Bipolar Disorder: 86% on atypical antipsychotic treatment (alone: 71%; in association with lithium/valproate: 15%); 14% on antidepressant treatment in association with lithium or valproate.

scores, compared to patients with comorbid bipolar disorder, generalized anxiety disorder and other disorders (F ⫽ 6,51; P ⫽ 0,081). Specific rates of antidepressants intake and type, according to comorbidity pattern, are provided in Table II. No significant association was found between presence of antidepressant medications and higher BIS-11 total and subtotal scores. Finally, simple linear regression test, assessing the relationship between BIS-11 and YBOCS total scores, did not show any significant result. Discussion The results of the present study pointed out the presence of high impulsivity levels – as assessed through the BIS-11 – in OCD patients versus healthy controls. Such result suggests that, on one hand, impulsivity may be a core feature of OCD per se, without excluding, however, a potential influence of clinical phenotypes and comorbidity patterns.

This finding has clinical relevance, supporting the need to explore impulsivity in OCD patients, in relation to treatment selection and long-term outcome. In fact, OCD patients with impulsive features may present poor clinical outcome (Eisen et al. 2013). In the study sample, high impulsivity scores, at the BIS-11, were due, in particular, to an increased attentional impulsivity, which is related to the ability to keep concentration in different situations and to focus carefully, before acting or speaking (Potenza et al. 2009). Such result may be of relevance in the understanding of neuropsychological alterations, as well as for the investigation of cognitive endophenotypes in OCD (Fineberg et al. 2010; Stein and Hollander 1995). In fact, neuropsychological alterations, including deficits in certain executive functions, decision making and nonverbal memory – arguably related to an orbitofrontal loop dysfunction (Chamberlain et al. 2006) – have been indicated as candidate endophenotype markers for OCD (Rao et al. 2008; Viswanath et al. 2009). In such perspective,

Figure 1. Barratt total scores (Student’s t test; t: 2.79; P: 0.01).

Figure 2. Barratt attentional area scores (Student’s t test; t: 4.93, P ⬍ 0.001).

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DOI: 10.3109/13651501.2013.855792

the result of a high attentional impulsivity in OCD patients might be interpreted as an aspect contributing to the neurocognitive impairment, in particular in relation to executive function and decision making. BIS-11 total and subtotal scores comparison among patients with single versus multiple OCD phenotype showed borderline statistically non significant higher scores in latter patients. Such result may suggest that major complexity in obsessions and compulsions may increase the overall impulsivity load and, in particular, the attentional deficit, leading to more severe cognitive dysfunctions, which may, in turn, predict a worse outcome (Chamberlain et al. 2005). In our sample, however, the multiple OCD phenotype subgroup did not show any pattern of aggregation with specific comorbidities, as previously shown by Perugi and colleagues (Perugi et al. 1998). Indeed, such difference might be related to the small sample size of multiple phenotype subgroup in the present study. With respect to comorbidity, it is of clinical interest to highlight that two-thirds of patients presented comorbidities, the most common being MDD, GAD, and BD, stressing how comorbidity in OCD tends to be the rule rather than the exception (Fineberg et al. 2013). A further analysis on the sample of comorbid OCD patients showed higher – even though with borderline statistical significance – BIS-11 total and attentional scores in patients with MDD, compared to GAD and BD patients. Such findings might support the presence of a worse clinical outcome in these kind of affected patients, as reported in a previous study, showing a higher number of suicide attempts and hospitalizations in OCD patients with MDD, compared to OCD patients with BD and OCD patients without MDD (Perugi et al. 1997). In order to exclude that higher BIS-11 scores in OCD patients with comorbid MDD might be related to the antidepressant treatment (Ramasubbu 2004), a comparison between presence versus absence of antidepressant treatment in the group of OCD patients with comorbidities was performed. However, no significant association was found, suggesting that higher impulsivity – as assessed through the BIS-11 – was not related to the antidepressant treatment. Nevertheless, it needs to be taken into account that only a minority of OCD patients with comorbidities (4%) were not taking antidepressants. Furthermore, the possible presence of subthreshold cyclothymic mood dysregulation might have influenced BIS-11 scores in OCD patients with comorbid MDD. The possible presence of gender differences within the whole sample of OCD patients was specifically analyzed, in relation to the impulsivity scores, without showing any significant difference. Such finding may be consistent with available literature, showing that OCD global severity, disability (Torresan et al. 2009) and, arguably impulsiveness severity, are similar in either gender. Study findings did not show any other significant difference in BIS-11 total and subtotal scores on the basis of monotherapy versus polytherapy nor in terms of Y-BOCS severity. We might have expected that patients on polytherapy could show higher impulsivity scores. In such perspective,

however, a negative finding might depend on the efficacy of current therapies. On the other hand, the lack of a specific correlation between impulsivity and Y-BOCS severity suggests that the two dimensions may be independent and not necessarily correlated. The presence of high impulsivity – as assessed through the BIS-11 – in our study sample of OCD patients, seems to be a trait feature, not determined – but possibly influenced – by comorbidity patterns, clinical phenotypes, and standard pharmacological treatments. Even though a higher BIS-11 score does not seem to specifically affect OC severity (quantified through the Y-BOCS), it could be responsible for patients’ global, functional, and cognitive impairment, which may be of clinical interest for future investigation to assess. In terms of methodological limitations, the following aspects need to be taken into account. First, reported findings may refer to patients seeking treatment and such population might not adequately represent the entire population of OCD patients. Second, the limited sample size, in particular across subgroups divided on the basis of comorbidity patterns, clinical phenotype, and pharmacological therapy may somehow limit the confidence in the results. Finally, the assessment of impulsivity on the exclusive basis of BIS-11 may have provided a limited analysis perspective of such dimension. Further studies with larger samples of patients are, therefore, necessary to clarify the real presence and impact of impulsivity in OCD and investigate the possible relation between attentional impulsivity and cognitive dysfunction. Key points • • •

Impulsivity represents a key dimension in OCD, in relation to outcome and course (Kashyap et al. 2012). We assessed the level of impulsivity in a sample of OCD patients and healthy controls, using the BIS-11. A higher impulsivity was found in OCD patients versus controls, particularly in the attentional area, suggesting a potential cognitive implication.

Ethical Standards This study has been approved by the local ethics committee and has, therefore, been performed in accordance with the ethical standards laid down in the 1964 declaration of Helsinki. Acknowledgments None. Statement of interest None of the authors reports conflicts of interest. References American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders. 4th edition, text revision. Washington, DC: American Psychiatric Association. American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders. 5th edition. Washington, DC: American Psychiatric Association.

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Characterizing impulsivity profile in patients with obsessive-compulsive disorder.

Impulsivity represents a key dimension in obsessive-compulsive disorder (OCD), in relation to outcome and course. It can be assessed through the Barra...
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