OCD Subtypes & Treatment Resistance
What is OCD?
Obsessive-compulsive disorder (OCD) has a variety of phenotypic expressions and commonly is comorbid with a number of other psychiatric conditions, specifically schizophrenia. A neurodevelopmental disorder designated by recurrent/persistent thoughts, images, or impulses (obsessions), and rituals or mental acts (compulsions), OCD causes severe impairment.1 It affects approximately two to three percent of the population and is known as the fourth most common psychiatric disorder.1 OCD is frequently comorbid with the following psychiatric disorders: schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorders. However, it is also genetically related to Tourette syndrome. Director of Research at Tirat Carmel Mental Health Center in Israel, Michael Poyurovsky, M.D. discusses the common phenotypes of OCD in his article “Exploring OCD Subtypes and Treatment Resistance.”1
According to Poyurovsky, about 30 percent of patients with OCD also have Tourette syndrome or chronic tics. Features of the tic-related OCD phenotype include the presence of sensory phenomena, violent and sexual images or thoughts, hoarding or counting rituals, tic-like compulsions, trichotillomania, body dysmorphic disorder, bipolar disorder, and substance abuse. McDougle and colleagues found that patients with both OCD and tics benefited greatly from a combination of fluvoxamine and haloperidol, while patients without tics did not benefit from the combination. The most common adverse effects are sedation, increased appetite, and weight gain.1
Four OCD Principal Symptom Dimensions
Four OCD principal symptom dimensions that are accounted for in 70 percent of the variance have been revealed by eleven different studies that have assessed over 2,000 patients: factor one—aggressive and sexual obsessions and related compulsions; factor two—symmetry, ordering and counting obsessions and compulsions; factor three—contamination obsessions and cleaning compulsions; and factor four—hoarding obsessions and compulsions. These dimensions represent different phenotypes, which come with different ages of onset, comorbidity, and treatment avenues.5 Specifically, compulsive hoarders have an earlier age of onset, ordering and counting compulsions, lower insight, and older age when entering into treatment. However, hoarding symptoms are associated with poor response to SRI medicines and cognitive-behavioral therapy (CBT).8 Therefore, most clinicians recommend a combination of pharmacotherapy, intensive daily CBT, and psychosocial rehabilitation in order for the patient to achieve positive results.
Schizoid personality disorder shares some characteristics with schizophrenia and oftentimes appears in persons who have OCD. In fact, according to Poyurovsky, persons with schizotypal-related OCD have a more deteriorative course and poorer prognosis than those who have OCD alone.1 Features often include early age of onset, counting compulsions, and a history of a specific phobia.1 Regarding treatment, adding a low-dose of an antipsychotic agent to an SSRI has been found to be effective.
According to Poyurovsky, persons with a diagnosis of schizophrenia oftentimes have a higher rate of OCD as well.1 OCD symptoms in persons with schizophrenia are similar to those of OCD alone, and it often precedes the onset of schizophrenia.1 The OCD symptoms with comorbid schizophrenia worsens with progression and often affects the prognosis of schizophrenia.1 This comorbidity is difficult to treat; however, research has stated that clozapine and olanzapine in combination with SSRIs, may help alleviate both symptoms of OCD and schizophrenia successfully.1
Subtypes of OCD
The subtypes of OCD, such as OCD-schizotypal, hoarding OCD, and schizo-obsessive, may all be placed along the schizophrenia-OCD axis, while tic-related OCD is a distinct subgroup.1 These subtypes share a diminished response to treatment, as well; therefore, patients who fit into these subgroups should receive treatment from specialized centers that include intensive combination therapy.1
 Poyurovsky, M. (2007, Sept. 1). Exploring OCD Subtypes and Treatment Resistance. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/ocd/content/article/10168/54171
 Fineberg NA, Saxena S, Zohar J, Craig KJ. Obsessive-compulsive disorder: boundary issues. CNS Spectr. 2007;12:359-364.
 Leckman JF, Pauls DL, Zhang H, et al. Obsessive-compulsive symptom dimensions in affected sibling pairs diagnosed with Gilles de la Tourette syndrome. Am J Med Genet B Neuropsychiatr Genet. 2003;1:60-68.
 Pauls DL, Raymond CL, Stevenson JM, Leckman JF. A family study of Gilles de la Tourette syndrome. Am J Hum Genet. 1991;48:154-163.
 Miguel EC, Leckman JF, Rauch S, et al. Obsessive-compulsive disorder phenotypes: implications for genetic studies. Mol Psychiatry. 2004;10:258-275.
 McDougle CJ, Goodman WK, Leckman JF, et al. Haloperidol addition in fluvoxamine-refractory obsessive-compulsive disorder: a double-blind, placebo-controlled study in patients with and without tics. Arch Gen Psychiatry. 1994;51:302-308.
 Mataix-Cols D, Rosario-Campos MC, Leckman JF. A multidimensional model of obsessive-compulsive disorder. Am J Psychiatry. 2005;162:228-38.
 Saxena S. Is compulsive hoarding a genetically and neurobiologically discrete syndrome? Implications for diagnostic classification. Am J Psychiatry. 2007;164:380.
 Saxena S, Maidment KM, Vapnik T, et al. Obsessive-compulsive hoarding: symptom severity and response to multimodal treatment. J Clin Psychiatry. 2002;63:21-27.
 Poyurovsky M, Koran LM. Obsessive-compulsive disorder (OCD) with schizotypy vs schizophrenia with OCD: diagnostic dilemmas and therapeutic implications. J Psychiatr Res. 2005;39:399-408.
 Bogetto F, Bellini S, Vaschetto P, Ziero S. Olanzapine augmentation of fluvoxamine-refractory obsessive-compulsive disorder (OCD): a 12-week open trial. Psychiatry Res. 2000;96:91-98. OCD.