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Obsessive–compulsive symptoms in Egyptian schizophrenic patients

El Dawla, Aeida S.; Assad, Tarek; El Habiby, Mahmoud M.; Shorub, Eman M.; Kasem, Rania

Middle East Current Psychiatry: January 2015 - Volume 22 - Issue 1 - p 21–26
doi: 10.1097/01.XME.0000457268.13354.e8
Original articles
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Background Despite the growing body of evidence supporting the existence of an epidemiologic and biologic relation between obsessive–compulsive disorder and schizophrenia, the association remains poorly understood.

Patients and methods The sample consisted of 60 individuals, 30 healthy controls and 30 patients, of both sexes, recruited from the outpatient clinics and inpatient wards of the Institute of Psychiatry, Ain Shams University. The included patients had to fulfill the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., criteria for schizophrenia and had to be aged between 18 and 60 years. All participants were subjected to psychiatric assessment for obsessive–compulsive symptoms on the basis of the Yale–Brown Obsessive–Compulsive Scale and to functional assessment on the basis of the Global Assessment of Function scale.

Results The frequency of obsessive–compulsive symptoms and obsessive–compulsive disorder in the sample was estimated to be 23.3 and 13.3%, respectively. The most frequent obsessions were contamination (30%), religious obsession (26.7%), and sexual ideas (16.7%). The most common compulsions were cleaning (33%), checking (23.3%), and hoarding (16.7%). There was no significant correlation between Axis IV, admission times, and Yale–Brown Obsessive–Compulsive Scale scores.

Conclusion This study concluded that obsessive–compulsive symptoms are prevalent among schizophrenic patients, especially among those with paranoia, and strongly affect the global functions of those patients.

Neuropsychiatry Department, Institute of Psychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Correspondence to Eman M. Shorub, MD, PhD, Neuropsychiatry Department, Institute of Psychiatry, Faculty of Medicine, Ain Shams University, Postal Code 22, Cairo 11657, Egypt Tel/fax: +01003080305; e-mail: emanshorab@yahoo.com

Received May 3, 2014

Accepted October 27, 2014

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Introduction

The connection between obsessive–compulsive symptoms (OCS)/obsessive–compulsive disorder (OCD) and schizophrenia has been of interest to clinicians and researchers since the beginning of this century 1,2. OCS have been frequently studied in patients with schizophrenia, with the majority showing an increased rate of both OCS and OCD 3–7. Recent studies have reported prevalence rates for OCD in schizophrenia ranging from 7.8 to 25%. OCS have been found in up to 60% of schizophrenic patients 8,9.

The term ‘schizo-obsessiveness’ was coined by Hwang and Opler in 1994 and refers to a dual diagnosis of schizophrenia and OCD or OCS. Although large variance exists in the documented prevalence rates of schizo-obsessive disorder, higher than expected comorbidity rates for OCD and schizophrenia have ignited a controversy. It remains unclear whether this reflects a true comorbidity, more severe illness, or perhaps a unique diagnostic subcategory of schizophrenia 10.

Emerging neurobiological and genetic evidence suggests that persons with comorbid OCD and schizophrenia may represent a special category of the schizophrenic population. A different neuroanatomical profile has also been associated with schizophrenia and comorbid OCD. MRI studies have identified significantly reduced volumes in the left hippocampus, frontal lobes, and anterior horn of the lateral and third ventricle in schizophrenic patients with OCS when compared with their schizophrenic counterparts without OCS 11.

In addition, schizo-obsessive patients show more neurological signs, motor symptoms including catatonia, loss of motor ability or hyperactive motor activity, and extrapyramidal symptoms compared with schizophrenic patients, and more tics when compared with patients with OCD 12,13.

The presence of OCD in schizophrenic patients is reported to predict cognitive impairment, a severe course, greater social isolation, poor outcome, and greater resistance to treatment, compared with patients without OCS 9. The aim of this work was to investigate the frequency of OCS in an Egyptian sample of schizophrenic patients and evaluate the association between OCS and schizophrenia.

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Patients and methods

This was designed as a cross-sectional case–control study. It was conducted in the outpatient clinics and the inpatient ward of the Institute of Psychiatry, Ain Shams University Hospitals, located in Eastern Cairo, which serves a catchment area of about a third of greater Cairo. It serves both urban and rural areas, including areas around greater Cairo as well.

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Patients

Thirty patients fulfilling the diagnosis of schizophrenia using the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria were chosen in a convenient manner from among the outpatients and inpatients of the Institute of Psychiatry, Ain Shams University Hospitals. Thirty healthy volunteers were included as a control group. Both cases and controls were matched for sex and age to avoid selection bias. The study was performed from November 2012 until July 2013.

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Inclusion criteria

  • Patients aged 18–60 years.
  • Patients of either sex.
  • Patients on medication or not.
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Exclusion criteria

  • Having major physical illness (major cardiac, hepatic, or renal problems).
  • Agitated patients.
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Procedures

The study was conducted in the outpatient clinics and inpatient department of the Institute of Psychiatry, Ain Shams University Hospitals. All individuals who signed a written informed consent form according to the rules of the ethical committee involved in the study were assessed using the following tools:

  • A detailed psychiatric sheet stressing on the following: demographic information, medication history, physical history, and physical examination.
  • Structured clinical interview for DSM-IV Axis I Disorders (SCID-I): It is a clinician-administered semistructured interview for use in psychiatric patients. It is used for the diagnosis of both schizophrenia and OCD. It provides a broad coverage of psychiatric diagnosis according to DSM-IV and consists of nine diagnostic modules (mood episode, psychotic symptom, psychotic disorder differential, mood disorder differential, substance use, anxiety, somatoform disorder, eating disorder, and adjustment disorder). It was designed to be more efficient and simpler to use than other existing instruments and, consequently, to require less time for training and administration 14.
  • The Yale–Brown Obsessive–Compulsive Scale (YBOCS): The Arabic version was used to specifically measure the types and severity of symptoms of OCD. OCD patients seeking treatment usually obtain scores of 17 or higher. It has five items on obsessions and five items on compulsions, each with a score ranging from 0 to 4, where 0=no symptom, 1=mild symptoms, 2=moderate symptoms, 3=severe symptoms, and 4=extreme symptoms; the maximum total score is 40. The total score ranges of severity for patients who have both obsessions and compulsions are as follows: 0–7=subclinical, 8–15=mild, 16–23=moderate, 24–31=severe, and 32–40=extreme. The cutoff score for clinically significant symptoms is greater than 16 15,16.
  • DSM-IV Axis IV: Global Assessment of Function Scale (GAF): This is a numeric scale used by psychiatrists to subjectively rate the social, occupational, and psychological functioning of adults on a hypothetical continuum of mental health illness and do not include impairment in functioning due to physical (or environmental) limitations 17.
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Statistical analyses

The computer software package SPSS (version 19; SPSS Inc., Chicago, Illinois, USA) for Windows was used for the data analysis. Continuous variables such as age were expressed as mean±SD, whereas categorical variables such as sex were presented as frequencies (%). The independent-samples T-test was used to assess the statistical significance of the difference between the mean values of two study groups and the χ2-test was used to examine the relationship between two qualitative variables. One-way ANOVA was used to assess the statistical significance of the difference between the mean values of more than two study groups. Pearson’s correlation test (r) was used whenever a linear relationship between two quantitative data was to be tested. An r of 1.0 indicates that all the plotted points lie on a straight line and that the dependent variable can be predicted from the independent variable with 100% accuracy. Significance level was set at P values less than 0.05.

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Results

Demographic and clinical characteristics across groups

The two study groups were matched for age, sex, and education, with no significant differences. The mean age of the patient group was 32.83±7.7 years and that of the control group was 34.47±11.4 years. The majority of respondents were male (76.7%), single (63.3%) and working (20 patients, 66.7%). Meanwhile, there was significant difference between patients and controls regarding marital status and working status because of the burden of the disease on patients.

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Obsessive–compulsive disorder prevalence and Yale–Brown Obsessive–Compulsive Scale scores

Table 1 shows that the majority of patients had paranoid schizophrenia (56.7%), followed by undifferentiated schizophrenia (26.7%). The prevalence of OCD in the sample on the basis of SCID-I was 13.3% (N=4). Among the schizophrenic patients, 23.3% (N=7) had clinically obsessive symptoms; their mean scores on the GAF was 55±15.9.

Table 1

Table 1

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Comparison between patients and controls as regards Yale–Brown Obsessive–Compulsive Scale items

Total YBOCS scores ranged from 17 to 36. Among the patients, as shown in Tables 2 and 3, the most frequent obsessions were for contamination (30%), religious ideas (26.7%), and sexual obsessions (16.7%) and the most common compulsions were cleaning/washing (33.3%), checking (23.3%), repeating (16.7%), and hoarding (16.7%).

Table 2

Table 2

Table 3

Table 3

As can be seen in Table 4, on the YBOCS Egyptian schizophrenic patients scored higher on degree of indecisiveness, pervasive slowness, pathological doubting, global severity, reliability, obsession subscore, and total YBOCS score, whereas there was a highly statistical significance between cases and controls regarding avoidance score (P=0.008) and insight (P=0.006).

Table 4

Table 4

With regard to the diagnosis of patients using one-way ANOVA, cases of paranoid schizophrenia had significantly higher prevalence of obsessions and compulsions with higher global severity score compared with other types of schizophrenia. Meanwhile, the disorganized schizophrenic patients had less reliability score compared with both paranoid and undifferentiated schizophrenic patients.

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Correlations

On using Pearson’s correlation, no significant correlation was found between Axis IV, admission times, and the YBOCS items, as seen in Tables 5 and 6.

Table 5

Table 5

Table 6

Table 6

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Discussion

Co-occurrence of OCS and psychotic illness was recently revived because of increased recognition of higher than expected comorbidity rates and observations of the emergence or exacerbation of OCS during treatment of psychosis with atypical antipsychotics 18–20. Despite growing knowledge about OCD and schizophrenia, little is known about the links between them, and, to our knowledge, only a few studies have investigated the relationship between OCS and OCD in Egyptian schizophrenic patients. Therefore, the aim of the study was to ascertain the frequency of OCS among patients with schizophrenia in an Egyptian patient sample and assess the relation between the two disorders.

In this study, the frequency of OCS and OCD among Egyptian schizophrenic patients was estimated to be 23.3 and 13.3%, respectively. This is consistent with the results of other studies, which have revealed comorbidity rates for OCS in the schizophrenia population of 10–52% 7,21,22 and for OCD of 7.8–26% 23–27. In addition, In Malaysia, Abdul Hamid and Abdul Razak 28 reported that 15% of their schizophrenic sample met the criteria for OCD. In another study conducted in Iran on 100 schizophrenic patients (in whom antipsychotics were stopped for at least 1 week and who were studied during the first 10 days of hospitalization), 10% had OCD, of whom 6% had OCD before the onset of schizophrenia 29. These results indicate that schizophrenic patients have a higher possibility of developing OCD when compared with the normal population. However, the observations of the emergence of new OCS with atypical antipsychotic treatment for schizophrenia 18–20,30 raise the possibility that some of these comorbid OCD cases are medication induced. Guillem et al. 31 also reveal a strong positive relationship between psychosis and OCS, which suggests that they share common mechanisms.

The most frequent obsessions were contamination (30%), religious obsession (26.7%), and sexual ideas (16.7%). The most common compulsions were cleaning (33%), checking (23.3%), and hoarding (16.7%). Patients with schizophrenia had higher degree of indecisiveness, pervasive slowness, pathological doubting, global severity, and reliability scores. In previous studies also the types of obsessions and compulsions experienced by patients with schizophrenia were similar to those found in our results 26,29. Türkcan et al. 32 have reported contamination and sexual obsessions, cleaning compulsions, and repetitive rituals in schizophrenic patients. In addition, in the study by De Haan et al. 33 the obsessions found were similar to ours but checking, arranging, repetition, and washing compulsions had higher prevalence. The differences in types of symptoms in different studies can be due to the characteristics of the disorder, personality background, psychopathology, and chronicity of schizophrenia, course of the disorder, and culture impact.

With regard to the diagnosis of the patients, paranoid schizophrenia had significantly higher prevalence of obsessions and compulsions with higher global severity score compared with other types of schizophrenia, which may be due to the participation of more paranoid schizophrenic patients (n=17) in the study. Meanwhile, disorganized schizophrenic patients had a lower reliability score compared with both paranoid and undifferentiated schizophrenic patients, which may be related to the presence of formal thought disorder and the fact that they are more disturbed. Similar to our results, in India, Jaydeokar et al. 34 found that OCS were more prevalent among paranoid schizophrenic patients, with the frequent obsessions being those for contamination and sexual and aggressive thoughts, and frequent compulsions being the need to ask or confuse. Rajkumar et al. 35 studied the clinical profile of schizophrenic patients with and without comorbid OCD. They found that schizo-obsessive patients were more likely to have paranoid symptoms and first-rank symptoms of schizophrenia 35.

There was no significant correlation between admission times (as a reflection of the duration of illness) and YBOCS score. These results are in accordance with those of Hosseini et al. 29, who reported no significant relationship between demographic factors, rank of hospitalization, duration of symptoms, age, and severity of schizophrenia in the group with OCS, but are in contrast to the results of Hemrom et al. 36 and Jaydeokar et al. 34, who suggested that schizophrenic patients with OCS had significantly longer duration of illness. These symptoms were more prominent in patients with more than 5 years of total duration of illness.

With regard to DSM-IV Axis IV (GAF), in our study the Axis IV score was higher among those diagnosed clinically with OCS compared with those who were not (60±16.3 vs. 54.48±15.8); yet, no statistical significance was found between the two groups (P=0.17). In contrast, Nolfe et al. 37 found that the average GAF scores were higher in patients without OCS compared with patients with OCS. This discrepancy may be attributed either to the small number of our sample or to the fact that OCS in schizophrenia has a protective effect on functioning. Therefore, the GAF should be applied on a larger sample of patients for further validation.

The present study has several limitations. The small sample size might have affected the accuracy of the prevalence rate and factors associated with OCS in schizophrenic patients and prevented us from conducting further analyses comparing subgroups based on diagnosis. Moreover, the cross-sectional nature of the study limited our ability to draw causal inferences on OCS or OCD and schizophrenia. Further, we did not investigate the drug history of the patients in a way that could be included in a research to reveal the effects of antipsychotic medications on OCS. Despite these limitations, the current findings are important in clarifying the relation between OCS and schizophrenia, and provide guidance for future research.

In conclusion, OCS are prevalent among schizophrenic patients, especially among those with paranoia, and strongly affect the global functions of those patients.

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Recommendation

Detailed assessment of schizophrenic patients is required to evaluate probable comorbid OCS as subsyndromal symptoms as it may require treatment for a longer duration and possibly require additional interventions.

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Acknowledgements

The authors thank patients and controls for their participation and cooperation.

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Conflicts of interest

There are no conflicts of interest.

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Keywords:

Egyptian sample; obsessive–compulsive disorder; obsessive–compulsive symptoms; schizophrenia; Yale–Brown Obsessive–Compulsive Scale

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