Impulsive disorders in Japanese adult patients with obsessive-compulsive disorder

Comprehensive Psychiatry 46 (2005) 43 – 49 www.elsevier.com/locate/comppsych

Impulsive disorders in Japanese adult patients with obsessive-compulsive disorder Hisato Matsunaga*, Nobuo Kiriike, Tokuzo Matsui, Kenzo Oya, Kenya Okino, Dan J. Stein Department of Neuropsychiatry, Osaka City University Medical School, Osaka, 545-8585, Japan

Abstract In this study, we sought to characterize obsessive-compulsive disorder (OCD) patients with impulsive features, and to determine whether they constitute a distinct subtype of OCD. Therefore we systematically assessed impulse control disorders and other impulsive conditions categorized as obsessive-compulsive spectrum disorders (OCSDs) in 153 Japanese adult patients with OCD. Forty-five subjects (29%) had concurrent impulsive disorders, and they were differentiated from other OCD patients on a range of demographic features (e.g., younger age at onset), and clinical features (e.g., pervasive and severe psychopathology, and poor treatment outcome). However, on logistic regression, none of these variables predicted comorbid impulsivity. The findings appear to support the argument that OCD patients with impulsive features constitute a subtype of OCD. However, further research is necessary to determine whether impulsivity should be conceptualized as lying on a spectrum with compulsivity or as a dimension that is orthogonal to compulsivity. D 2005 Elsevier Inc. All rights reserved.

1. Introduction In recent years, the term bobsessive-compulsive spectrum disordersQ (OCSDs) has been used to categorize a group of disorders that is characterized by intrusive obsessive thoughts or repetitive behaviors [1]. Putative OCSDs include a number of psychiatric diagnostic categories such as Tourette’s syndrome (TS), body dysmorphic disorder (BDD), hypochondriasis (HYP), trichotiliomania (TR), anorexia nervosa (AN), and bulimia nervosa (BN) [1]. obsessive-compulsive disorder (OCD) and OCSDs may not only have overlapping phenomenologic features, but may also share associated features (e.g., age of onset, clinical course, family history, or comorbidity), neurobiology, and response to selective pharmacologic or behavioral treatments [2-4]. Indeed, there are strong familial relationships between OCD and TS [5-7], and both OCD and BDD respond selectively to serotonin reuptake inhibitors (SRIs) [2]. Some classifications of the OCD spectrum also emphasize specific differences between conditions characterized by repetitive behaviors, arguing for example that certain

* Corresponding author. Department of Neuropsychiatry, Osaka City University Medical School, 1- 4-3 Asahi-machi, Abeno-Ku, Osaka, 5458585, Japan. E-mail address: [email protected] 0010-440X/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.comppsych.2004.07.001

disorders fall at opposite ends of such a spectrum [1,8]. In particular, it has been suggested that OCSDs fall on a spectrum between compulsivity and impulsivity [1,9]. For example, OCD, BDD, and HYP are characterized by increased harm avoidance and risk aversiveness, and may fall on the compulsive end of the spectrum. In contrast, disorders of impulse control, such as intermittent explosive disorder (IED), kleptomania (KLP), and pathological gambling (PG) are representative of impulsive disorders characterized by a defect in harm avoidance and increased risk seeking behavior. Impulsivity may also be an important construct in understanding certain repetitive self-destructive symptoms such as self-injurious behaviors (SIB), sexual compulsions [1,10], and personality traits in borderline personality disorder (BPD) and antisocial personality disorder (APD) [11]. Some classifications of the OCD spectrum include these disorders and conditions. The possibility that compulsive and impulsive conditions lie at opposite ends of a spectrum is arguably supported by a number of neurobiologic studies. Evidence from studies of cerebrospinal fluid 5-hydroxyindolacetic acid (5-HIAA), peripheral 5-hydroxy-tryptamine (5-HT) measures, and behavioral/neuroendocrine response to 5-HT agonists such as meta-chlorophenylpiperazine (m-CPP) has lent support to the idea that decreased serotonergic activity is associated with impulsive conditions such as SIBs,

44

H. Matsunaga et al. / Comprehensive Psychiatry 46 (2005) 43–49

suicidality, and outward-directed aggression [2,12,13]. In contrast, it is possible that compulsivity is characterized by increased 5-HT sensitivity. In addition, the findings reported in the neurosurgical, neuropsychologic, and functional imaging literatures support the idea that compulsivity may be associated with hyperfrontality (especially) increased activation of the orbitofrontal lobes), whereas impulsive/disinhibited activity may be associated with hypofrontality [2,8]. Nevertheless, it can also be argued that compulsivity and impulsivity are orthogonal dimensions. Compulsive and impulsive disorders, may share clinical features, such as the inability to inhibit or delay repetitive behaviors [1,9], and certain conditions, such as SIB, may have both compulsive and impulsive features [9,10]. Indeed both compulsive and impulsive symptoms may be observed simultaneously, or at different times in the course of the same illness; individuals with OCSDs may have one set of behaviors driven by the need to reduce anxiety, and another set of behaviors driven to obtain pleasure [1]. For example, the symptoms of eating disorders (EDs), especially bulimia, can be conceptualized in these terms [14,15]. It has also been suggested that there may be a group of OCD patients characterized by coexistence of disorders of impulse control, or other impulsive disorders or symptoms [8,16]. However, clinical characteristics of OCD patients with impulsive features have not fully been described. Thus it remains unclear as to whether the notion of an impulsive subtype of OCD is valid or not. In this study, therefore, we sought to systematically assess impulse-control disorders (ICDs) and other impulsive conditions in OCD to characterize those patients with impulsive features, and to determine whether they constitute a distinct subtype of OCD.

2. Method Subjects were 153 outpatients (65 men and 88 women) who met both the DSM-III-R [17] and the DSM-IV [11] criteria for OCD. Each subject was diagnosed according to both the Structured Clinical Interview for DSM-III-R and DSM-IV Patient versions [18,19]. A relatively high interrater reliability for a diagnosis of OCD using the interview methods has already been reported in our previous studies [15,20,21]. All patients had contacted our clinic for the evaluation or treatment of OCD, and had given us informed consent to participate in the study. Subjects were excluded if they were under the age of 18 years, had any psychotic symptoms, or had any other axis I disorder that had developed prior to the onset of current OCD. Most subjects (83%) were currently in their first episode of OCD. 2.1. Assessment procedures All subjects were interviewed within 2 weeks after their initial visit to our hospital by a clinician well experienced with OCD. They provided information regarding the

demographic profile, family and medical history, and the clinical course and features related to OCD. Each subject was consecutively evaluated regarding social, occupational, and interpersonal areas of functioning in a face-to-face interview. Global functioning was assessed using the DSMIV Axis V Global Assessment of Functioning Scale (GAFS) [11] by one of the authors who had been extensively trained to yield a reliable GAFS score (H.M.). OCD symptoms in each subject were evaluated using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) [22,23] in a Japanese version [24]. This assessment was performed in a semi-structured interview by one of the authors who had been trained under the supervision of senior psychiatrists according to the instructions of the scale developers. For the identification of current OCD symptoms in each patient, up to three primary obsessions and compulsions were listed using the Y-BOCS symptom checklist. The severity of OCD symptoms was assessed using the Japanese version of the Y-BOCS severity rating scale, which has already been validated as a reliable instrument for assessing OCD symptom severity [24]. Comorbid personality disorders were concurrently assessed using the Japanese version of the SCID personality disorders (SCID-II) [25] in a face-to-face style by one or two of the authors who were blind to the clinical features of each subject. The acceptable reliabilities for each personality disorder diagnosis in OCD subjects obtained by the SCID-II Japanese version were previously reported [20]. The State-Trait Anxiety Inventory (STAI) [26], the Zung’s Self-Rating Depression Scale (SDS) [27], and the Frost Multi-dimensional Perfectionism Scale (FMPS) [28] were administered concurrently on each subject to assess anxiety, depressive symptoms, and perfectionism respectively. Subjects were subsequently distinguished by presence or absence of any lifetime history of impulsive control disorders (ICDs) and other impulsive conditions categorized as OCSDs by Hollander and Wong [1]. Diagnoses of ICDs were made using a semistructured interview for DSM-IV ICD sin a face-to-face style, by one or two of the authors who was blind to the clinical features of each patient. To standardize the diagnostic process, each interviewer was trained for at least 3 months through conducting a minimum of 10 interviews under the supervision of a senior interviewer. In our preliminary study of the reliability of the diagnostic interview, we chose 24 patients randomly from among the subjects. The assessment of the inter-rater reliability based on a joint interview design revealed that the kappa coefficients derived for each ICD except for pyromania ranged from 0.63 to 1.0. In addition, lifetime history of a number of impulsive conditions (SIB, compulsive buying, and sexual compulsions) was concurrently assessed using a self-report questionnaire method [15,29], because Japanese subjects often do not respond directly about sensitive issues in interviews [30]. The questionnaire is composed of individual items pertaining to impulsive conditions thought to be part of the OCSD. After the

H. Matsunaga et al. / Comprehensive Psychiatry 46 (2005) 43–49 Table 1 List of impulsive disorders in 153 patients with OCD Impulsive disorder Impulsive-control disorders not elsewhere classified Intermittent explosive disorder (IED) Kleptomania (KLP) Pathological gambling (PG) Trichotillomania (TR) Impulsive personality disorders Borderline personality disorder (BPD) Antisocial personality disorder (APD) Behavioral problems of impulsive control Sexual compulsion Compulsive buying Self-injurious behavior (SIB) (including compulsive skin picking)

No. (%)

45

treatment for at least 1 year, and also agreed to participate in the follow-up assessments, treatment responses were evaluated using the Y-BOCS. 2.2. Data analysis

11 (7) 9 (6) 4 (3) 7 (5) 14 (9) 5 (3) 3 (2) 10 (7) 18 (12)

Significant group differences for parametric variales were evaluated using two-tailed group t tests. For categorical data, chi-square tests with Yate’s correction for discontinuity or Fisher’s exact test (if the minimum expected cell size was b5) were used. In addition, stepwise logistic regression analyses were performed to investigate the extent to which different demographic and clinical variables predicted comorbid impulsive featues. The significant level was set at P b .05.

Values are expressed as number (%).

3. Results screening test, each subject with any history of impulsive conditions was interviewed face to face to clarify whether his or her behaviors were repetitive (not episodic), potentially harmful, and consistent with the criteria for impulse control disorders as defined in the DSM-IV1 [11]: (1) the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others; (2) an increasing sense of tension or arousal before committing the act; and (3) an experience of either pleasure, gratification, or relief at the time of committing the act. For example, the presence of SIB was determined after confirming the following features: (1) preoccupation with harming oneself physically; (2) recurrent failure to resist impulse to harm oneself physically, resulting in the destruction or alteration of body tissue; (3) an increased sense of tension immediately before the act of self-harm; and (4) gratification of a sense of relief when committing the act of self-harm [10]. After the pretreatment assessments, each subject was treated by a standardized combination of cognitivebehavioral treatment (CBT) and medication, such as clomipramine (CMI) or selective SRIs (SSRIs) including fluvoxamine or paroxetine. The treatment was usually started with daily dosages of 50 mg of CMI or fluvoxamine, or 10 mg of paroxetine. If disturbing side effects did not occur, the dosage was gradually increased over 4 weeks to a maximum of 250 mg/d of CMI or fluvoxamine or 50 mg/d of paroxetine. Augmentation with anticonvulsants such as carbamazepine (CBZ) was also considered for patients with serious impulsive problems [31]. CBT was subsequently initiated with informational interventions designed to orient patients to a basic cognitive-behavioral model of OCD. Exposure was conducted in a stepwise fashion according to a constructed hierarchy of feared situations. Exposure was consistently initiated with low-level fear situations, and as patients become more comfortable in these situations, they were asked to progress to exposure situations with greater difficulty. In each subject who consecutively received the

Of the 153 subjects, 45 (29%) were assessed to have any ICD or other impulsive condition (Table 1). Among the ICDs, IED was most frequently found (7%), followed by KLP (6%), and TR (5%). No subjects were diagnosed as having pyromania. Fourteen of the subjects (9%) met the DSM-IV criteria for BPD, and five subjects (3%) met the criteria for APD. Of the 19 subjects with either comorbid BPD or APD, 15 (79%) subjects also met the criteria for one of the disorders categorized as an ICD. SIB was the most prevalent of the other impulsive conditions. Table 2 shows the comparison of demographic profiles and clinical features between patients with and without any impulsive disorder. Compared to the 108 subjects without any history of impulsive disorder [Impulsivity( ) group], 45 subjects with these disorders [Impulsivity(+) group] were demographically characterized by younger age (t = 4.98, df = 151, P b .01), younger age at onset (t = 5.23, df = 151, P b .01), lower rate of being married (m2 = 9.36, df = 1, P b .01) Table 2 Comparison of demographic profiles and clinical features between patients with and without any impulsive disorder

Male:female Age (yr) Age at onset (yr) Duration of illness (yr) Education (yr) Married subjects GAFS (score) Presence of any precipitating event Poor insight Lifetime prevalence of major depression (MD) Involvement of others

Impulsivity(+) (n = 45)

Impulsivity( ) (n = 108)

16/29 25.9 F 5.2* 19.3 F 4.8* 6.4 F 4.0 12.6 F 2.1 7 (16)* 44.7 F 8.1* 22 (49) 27 (60)* 29 (64)*

49/59 30.8 F 9.9 24.4 F 7.0 6.0 F 4.8 13.1 F 2.0 48 (44) 51.0 F 7.6 47 (44) 36 (33) 39 (36)

18 (40)*

14 (13)

Values are expressed as mean F SD or no. (%). Group means of parametric variables were compared using 2-tailed t test. Comparisons of nonparametric variables were made by chi-square test with Yate’s correction for discontinuity. * P b .01.

46

H. Matsunaga et al. / Comprehensive Psychiatry 46 (2005) 43–49

Table 3 Comparison of psychometric test results between patients with and without any impulsive disorder

Y-BOCS Total Obsession score Compulsion score STAI Trait score State score SDS FMPS total Doubts about actions

Impulsivity(+) (n = 45)

Impulsivity( ) (n = 108)

28.9 F 5.6* 14.9 F 2.6** 14.1 F 2.9

27.1 F 3.9 13.7 F 2.0 13.4 F 2.1

71.8 66.4 60.1 87.8 16.5

64.2 60.3 54.3 78.3 14.5

F F F F F

6.1** 7.8* 4.9** 17.6 3.3*

F F F F F

7.0 7.9 6.0 19.5 2.9

Table 5 Comparison of compulsions between patients with and without any impulsive disorder Compulsion

Total (n = 153)

Impulsivity(+) (n = 45)

Impulsivity( ) (n = 108)

Cleaning/washing Checking Repeating rituals Counting Ordering/arranging Hoarding/collecting Miscelleneous

79 76 57 28 26 12 44

26 23 20 5 5 3 14

53 53 37 23 21 9 30

(52) (50) (37) (18) (17) (8) (29)

(58) (51) (44) (11) (11) (7) (31)

(49) (49) (34) (21) (19) (8) (28)

Values are no. (%). Comparisons of nonparametric variables were made by chi-square test with Yate’s correction for discontinuity, or by Fisher’s exact test if the minimum cell size was b 5.

Values are expressed as mean F SD. * P b .05. ** P b .01 (2-tailed t test).

and lower level of GAFS (t = 6.12, df = 151, P b .01). Moreover, subjects in the Impulsivity(+) group were significantly more likely than subjects in the Impulsivity( ) group to exhibit poor level of insight (m2 = 8.12, df = 1, P b .01), and involvement of others (m2 = 9.85, df = 1, P b .01), and also to have lifetime comorbidity of major depression (MD) (m2 = 7.16, df = 1, P b .01). However, logistic regression analysis revealed that there were no variables that made significant unique contributions to the prediction of impulsive disorders. Table 3 shows the psychometric test results of the subjects. Subjects in the Impulsivity(+) group showed significantly more severe psychopathologic features than subjects in the Impulsivity( ) group, including higher OCD symptom severity such as total (t = 2.00, df = 151, P b .05) and obsession subtotal scores (t = 2.74, df = 151, P b .01) on the Y-BOCS, more elevated level of trait (t = 4.02, df = 151, P b .01) and state (t = 2.63, df = 151, P b .05) anxiety, greater depression (t = 4.58, df = 151, P b .01), and a higher level of doubt about their own actions assessed by the FMPS (t = 2.43, df = 151, P b .05). However, no significant

Table 4 Comparison of obsessions between patients with and without any impulsive disorder Obsession

Total (n = 153)

Impulsivity(+) (n = 45)

Impulsivity( ) (n = 108)

Aggressive Contamination Sexual Hoarding Religious Symmetry/exactness Somatic Miscelleneous

52 78 15 12 7 65 13 42

26 26 7 4 3 14 2 14

26 (24) 52 (48) 8 (7) 8 (7) 4 (4) 51 (47) 11 (10) 28 (26)

(34) (51) (10) (8) (5) (42) (8) (27)

(58)* (58) (16) (9) (7) (31) (4) (31)

Values are no. (%). Comparisons of nonparametric variables were made by chi-square test with Yate’s correction for discontinuity, or by Fisher’s exact test if the minimum cell size was b 5. * P b .01.

association between psychometric variables and impulsive disorders was detected on the logistic regression analysis. As for the contents of obsessions, aggressive obsessions were more frequently prevalent in the Impusivity(+) group than in the Impulsivity( ) group (m2 = 14.10, df = 1, P b .01) (Table 4). However, there were no other significant differences in the prevalence of each obsession between the groups. Table 5 demonstrates the contents of compulsions in the subjects. No significant differences were found between the groups. While 21 (14%) of 153 patients dropped out during the 1year treatment period, there were no significant differences in dropout rates between the Impulsivity( ) group (12%) and the Impulsivity(+) group (18%) (Table 6). As for medication used in the standardized combination treatment, there were no significant differences in the mean maximum daily dosage of CMI or each SSRI between the two groups. In 95 subjects in the Impusivity( ) group, the mean maximum dosages of CMI (27 patients), fluvoxamine (41 patients), or paroxetine (27 patients) were 165 mg/d (SD = 62), 185 mg/d (SD = 68), and 34 mg/d (SD = 12), respectively. The mean maximum daily dosages of CMI (11 patients), fluvoxamine (18 patients), or paroxetine (8 patients) in the Impulsivity(+) group were 195 mg (SD = 75), 223 mg (SD = 85), and 43 mg (SD = 14), respectively. Of the 37 impulsive patients, six

Table 6 Comparison of 1-year treatment outcome between patients with and without any impulsive disorder

Drop-out (%) Y-BOCS total score Pretreatment After 1-year treatment Improvement rate (%)

Impulsivity(+) (n = 37)

Impulsivity( ) (n = 95)

8 (18)

13 (12)

28.9 F 5.8* 21.0 F 7.4** 30.1 F 2.1**

26.7 F 4.2 14.8 F 7.2 45.8 F 23.1

Values are expressed as mean F SD. * P b .05. ** P b .01 (2-tailed t test).

H. Matsunaga et al. / Comprehensive Psychiatry 46 (2005) 43–49

(16%) received augmentation with CBZ at a mean dosage of 583 mg/day, ranging from 800 mg/d to 300 mg/d, in contrast to the Impulsivity( ) group in which none of the subjects received CBZ. In addition to the medication, each participant received 10 to 20 sessions of CBT. Subjects in the Impulsivity(+) group were significantly more likely than those in the Impulsivity( ) group to show a poor level of treatment response after receiving the 1-year treatment, as assessed with total scores on the Y-BOCS (t = 3.00, df = 130, P b .01) (Table 6). 4. Discussion The results of the current study suggest that there are a considerable number of OCD subjects (29%) who can specifically be characterized as concurrently having impulsive OCSDs. These subjects were differentiated from other OCD patients on a range of demographic and clinical features, including more pervasive and severe psychopathology, and poorer treatment outcome. These findings are rather consistent with those of a number of previous studies that have emphasized that some patients with OCD have significant impulsivity [4,8]. It has been suggested that OCD subjects with elevated impulsivity are more likely than nonimpulsive OCD controls to have more behavioral dysregulation, conduct disturbance in childhood, and a greater range of psychopathology in adulthood [32]. In particular increased impulsive- aggressive features have been found in OCD patients with neurologically based disorders including tic, TS, or pervasive developmental disorders, and early-onset OCD patients [16,31,33-35]. Swedo et al [34] found that 33% of their pediatric OCD sample had either a disruptive disorder or abused a substance, and that 24% of them had a specific developmental disability. Even though both pharmacotherapies such as the SSRIs and CBT have proven efficacy in the treatment of early-onset OCD, some types of comorbid disorders such as oppositional disorder may predict treatment resistance to both therapies [36]. Consistently, adults with early-onset OCD (onset before age of 10) showed poorer responses to treatment with CMI or SSRIs compared to those with late-onset OCD (onset after age 17) [37]. Earlyonset OCD is generally considered likely to continue into adulthood [35], and disruptive disorders in this group often predate the development of OCD [34]. Thus impulsive behaviors and problems observed in some adult OCD patients may endure from early on. Indeed, our OCD subjects with impulsive features were significantly more likely than nonimpulsive subjects to have early age at onset. However, age at onset was not itself a significant predictor of impulsive disorders on logistic regression, suggesting that the differences between impulsive and nonimpulsive patients were not simply due to this variable. To further clarify this issue, information regarding childhood conduct disturbance, or developmental, learning, or neurologic disorders such as tic disorders, should be obtained from subjects.

47

In OCD patients, prevalence of comorbid BPD assessed using the structured interview method is reported to range from 5% to 31% [20,38], and a significant positive relationship between BPD and the probability of OCD symptoms was pointed out in a community sample [39]. Thus there is substantial comorbidity between OCD and BPD, and this subgroup of OCD patients has increased impulsive-aggressive behaviors [31,40]. It has also been suggested that the manifestation of BPD psychopathology in OCD patients can be found as a sequel of their OCD.41 For example, their OCD symptoms are characterized by (1) being pervasive and affecting extensive areas of the patients’ lives, (2) poor insight and resistance, and (3) involvement of others with symptoms such as persistent reassurance seeking [41-43]. Indeed, OCD patients who involve others in their compulsive acts and rituals may be manipulative, and may even involve violence [21,43]. Regardless of possible comorbidity of OCD with ICDs [4,44], personality disorders with impulsive features such as BPD or APD may well be primary disorders of impulse control. In fact, many of the specific behaviors of ICDs substantially overlap with those listed as diagnostic criteria for the personality disorders such as self-damaging (e.g., SIB, sex, or spending), and the current study revealed that of the 19 subjects with either comorbid BPD or APD, 15 (79%) subjects also met the criteria for one of the disorders categorized as an ICD. However, the nature of the relationship between ICDs and impulsive personality disorders remains unclear; they may represent separate but related conditions that are highly comorbid, identical entities, or independent entities that may co-occur by chance. For example, both ICDs and impulsive personality disorders have commonly been suggested to have significant association with MD [4,45,46]. Taking into account that in the current study, OCD patients with impulsive features were significantly more likely than nonimpulsive OCD patients to have lifetime MD, it can be speculated that comorbid MD may play some role in mediating the relation between OCD, BPD, or ICDs. Taken together the data here suggest that there may be a specific subtype of OCD patients characterized as having elevated impulsivity. Even though this impulsive type of OCD may be heterogeneous rather than homogeneous, it is more likely than nonimpulsive OCD to exhibit pervasive and severe psychopathology and poor treatment outcome. The findings of the current study also support the possibility that compulsivity and impulsivity can be seen as lying on orthogonal dimensions rather than on a linear spectrum. Indeed, both compulsive and impulsive features are often observed simultaneously or at different times in the course of the same illness [1,9]. It is often seen in comorbidity of OCD or BPD [4,9,44,47] and conditions such as SIB may also be characterized by a mixture of both compulsive and impulsive symptoms [10]. Indeed, SIB has been subdivided into compulsive SIB (such as hair pulling, skin picking, and severe nail biting, which are habitual and repetitive with

48

H. Matsunaga et al. / Comprehensive Psychiatry 46 (2005) 43–49

greater resistance to an ego-dystonic urge) and impulsive SIB (such as skin-cutting and burning, which are episodic and gratifying and seem to be an ego-syntonic impulse often triggered by events and involving little resistance). To further examine the relationship between compulsive and impulsive symptoms, neurobiologic approaches such as neuroimaging methods may be useful. For example, the possibility exists that impulsivity and compulsivity may be more clearly defined using a biologic framework of hyperfrontality and increased serotonergic sensitivity in compulsive disorders, versus hypofrontality and low presynaptic serotonergic sensitivity in impulsive disorders [2,8]. In conclusion, OCD patients who concurrently exhibit increased impulsive features such as impulsive OCSDs may constitute a distinct subtype of OCD. This impulsive OCD may be characterized by more pervasive and severe psychopathology and poorer treatment outcome compared to nonimpulsive OCD. However, on logistic regression, no clinical variables, such as age at onset, predicted comorbid impulsivity in OCD patients. Although some authors have argued for a dichotomy between compulsive and impulsive disorders, there may be an overlap in the phenomenology of these conditions; both impulsive and compulsive characteristics may be found in disorders that are generally considered to be manifestations of elevated compulsivity, as well as in disorders with poor impulsive control. Further studies from phenomenologic, psychopathologic, and biologic perspectives are required to clarify the relationship between impulsivity, compulsivity, and OCD.

References [1] Hollander E, Wong CM. Introduction: obsessive-compulsive spectrum disorders. J Clin Psychiatry 1995;56:3 - 6. [2] Hollander E. Treatment of obsessive-compulsive spectrum disorders with SSRIs. Br J Psychiatry 1998;173(Suppl 35):7 - 12. [3] Lopez-Ibor JJ. Impulse control in obsessive-compulsive disorder; a biopsychopathological approach. Progn Neuropsychopharmacol Biol Psychiatry 1990;14:709 - 14. [4] McElroy SL, Pope HG, Keck PE, Hudson JI. Disorders of impulse control. In: Hollander E, Stein DJ, editors. Impulsivity and aggression. Sussex (England)7 Wiley; 1995. p. 109 - 36. [5] Pauls DL, Alsobrook JP, Goodman W, Rasmussen S, Leckman JF. A family study of obsessive-compulsive disorder. Am J Psychiatry 1995;152:76 - 84. [6] Sheppard DM, Bradshaw JL. Tourette’s and comorbid syndromes; obsessive-compulsive and attention deficit hyperactivity disorder. A common etiology? Clin Psychol Rev 1999;19:531 - 52. [7] O’Conner KP. Clinical and psychological features distinguishing obsessive-compulsive and chronic tic disorder. Clin Psychol Rev 2001;21:631 - 60. [8] Hollander E, Wong CM. Spectrum, boundary, and subtyping issues; implications for treatment refractory obsessive-compulsive disorder. In: Goodman WK, Rudorfer MV, Maser JD, editors. Obsessivecompulsive disorder; contemporary issues in treatment. Mahwah (NJ)7 Erlbaum; 2000. p. 3 - 22. [9] Skodol AE, Oldham JM. Phenomenology, differential diagnosis and comorbidity of the impulsive-compulsive spectrum disorders. In: Hollander E, Stein DJ, editors. Impulsivity and aggression. Sussex (England)7 Wiley; 1995. p. 1 - 36.

[10] Favazza A, Simeon D. Self-mutilation. In: Hollander E, Stein J, editors. Impulsivity and aggression. Sussex (England)7 Wiley; 1995. p. 185 - 200. [11] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC)7 American Psychiatric Association; 1994. [12] Walsh MT, Dinan TG. Selective serotonin reuptake inhibitors and violence; a review of the available evidence. Acta Psychiatr Scand 2001;104:84 - 91. [13] Winchel RM, Stanley M. Self-injurious behavior; a review of the behavior and biology of self-mutilation. Am J Psychiatry 1991; 148:306 - 17. [14] Claes L, Vandereycken W, Vertommen H. Impulsive and compulsive traits in eating disordered patients compared with controls. Pers Individ Differ 2002;32:707 - 14. [15] Matsunaga H, Kiriike N, Iwasaki Y, Miyata A, Matsui T, Yamagami S. A comparison of clinical features among Japanese eating disordered women with obsessive compulsive disorder. Compr Psychiatry 1999;40:337 - 42. [16] Cath DC, Spinhoven P, Hoogduin CAL, Landman AD, van Woerkom TCAM, van de Wetering BJM, et al. Repetitive behaviors in Tourette’s syndrome and OCD with and without tics: what are the differences? Psychiatr Res 2001;25:171 - 85. [17] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Rev. Washington (DC)7 American Psychiatric Association; 1987. [18] Spitzer RL. SCID-P for DSM-III-R. In: Williams JB, Gibbon M, editors. The structured clinical interview for DSM-III-R Patient Edition. New York (NY)7 Biometrics Research, New York State Psychiatric Institute; 1987 [Japanese version: translated by K. Takahashi, et al, Tokyo, Japan: Igaku-shoin, 1992]. [19] First MB, Spitzer RL, Gibbon M, Williams JBW. Structured clinical interview for DSM-IV Axis I disorders. New York (NY)7 Biometrics Research Department, New York State Psychiatric Institute; 1997. [20] Matsunaga H, Kiriike H, Miyata A, Iwasaki Y, Matsui T, Nagata T, et al. Personality disorders in patients with obsessive-compulsive disorder in Japan. Acta Psychiatr Scand 1998;98:128 - 34. [21] Matsunaga H, Kiriike N, Matsui T, Iwasaki Y, Miyata A, Fujimoto K. Gender differences of social and interpersonal features and personality disorders among Japanese patients with obsessive-compulsive disorder. Compr Psychiatry 2000;41:266 - 72. [22] Goodman WK, Price L, Rasmussen SA, Mazure C, Fleishmann RL, Hill C, et al. The Yale-Brown Obsessive-Compulsive Scale, I: development, use, and reliability. Arch Gen Psychiatry 1989;46: 1006 - 11. [23] Goodman WK, Price L, Rasmussen SA, Mazure C, Delgado P, Heninger GR, et al. The Yale-Brown Obsessive-Compulsive Scale II: validity. Arch Gen Psychiatry 1989;46:1012 - 6. [24] Nakajima T, Nakamura M, Taga C, Yamagami S, Kiriike N, Nagata T, et al. Reliability and validity of the Japanese version of the YaleBrown Obsessive-Compulsive Scale. Psychiatry Clin Neurosci 1995; 49:121 - 6. [25] Spitzer RL, Williams JB, Gibbon M. The structured clinical interview for DSM-III-R personality disorders. New York (NY)7 Biometrics Research, New York State Psychiatric Institute; 1987 [Japanese version: translated by K. Takahashi, et al, Tokyo, Japan: Igaku-shoin, 1992]. [26] Spielberger CD, Gorsuch R, Lushene RE. Manual for the state-trait anxiety inventory (Self-Evaluation Questionnaire). Palo Alto (Ca)7 Consultants Psychologists Press; 1970. [27] Zung WWK. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63 - 70. [28] Frost RO, Marten P, Lahart C, Rosenblate R. The dimensions of perfectionism. Cogn Ther Res 1990;14:449 - 68. [29] Matsunaga H, Kiriike N, Iwasaki Y, Miyata A, Matsui T, Nagata T, et al. Multi-impulsivity among bulimic patients in Japan. Int J Eat Disord 2000;27:348 - 52.

H. Matsunaga et al. / Comprehensive Psychiatry 46 (2005) 43–49 [30] Berger D, Saito S, Ono Y, Tezuka I, Shirahase J, Kuboki T, et al. Dissociation and child abuse histories in an eating disorder cohort in Japan. Acta Psychiatr Scand 1994;90:274 - 80. [31] Hollandar E. Managing aggressive-behavior in patients with obsessive-compulsive disorder and borderline personality disorder. J Clin Psychiatry 1999;60:38 - 44. [32] Hoehn-Saric R, Barksdale VC. Impulsiveness in obsessive-compulsive patients. Br J Psychiatry 1983;143:177 - 82. [33] Geller DA, Biederman J, Griffin S, Jones J, Lefkowitz TR. Comorbidity of juvenile obsessive-compulsive disorder with disruptive behaviour disorders. J Am Acad Child Adolesc Psychiatry 1996;35:1637 - 46. [34] Swedo SE, Rapoport JL, Leonard H, Lenane M, Cheslow D. Obsessivecompulsive disorder in children and adolescents; clinical phenomenology of 70 consecutive cases. Arch Gen Psychiatry 1989;46:335 - 41. [35] Geller DA, Biederman J, Jones J, Park K, Schwartz S, Shapiro S, et al. Is juvenile obsessive-compulsive disorder a developmental subtype of the disorder? A review of the pediatric literature. J Am Acad Child Adolesc Psychiatry 1998;37:420 - 7. [36] March JS, Leonard HL. Obsessive-compulsive disorder in children. In: Swinson RP, Antony MM, Rachman S, Richter MA, editors. Obsessive-compulsive disorder; theory, research and treatment. New York (NY)7 Guilford Press; 1998. p. 367 - 96. [37] Rosario-Campos MC, Leckman JF, Mercadante MT, Shavitt RG, Silva Prado H, Sada P, et al. Adults with early-onset obsessivecompulsive disorder. Am J Psychiatry 2001;158:1899 - 903. [38] Pigott TA, L’Heureux F, Dubbert B, Bernstein S, Murphy DL. Obsessive-compulsive disorder: comorbid conditions. J Clin Psychiatry 1994;55(Suppl 10):15 - 27.

49

[39] Nastadt G, Samuels JF, Romanoski AJ, Folstein MF, McHugh PR. Obsessive- compulsive disorder in the community. Acta Psychiatr Scand 1994;89:219 - 24. [40] Stein DJ, Hollandar E, DeCaria CM, Simeon D, Cohen L, Aronowitz B. m-clorophenylpiperazine challenge in borderline personality disorder; relationship of neuroendocrine response, behavioral response and clinical measures. Biol Psychiatry 1996; 40:508 - 13. [41] Hayashi N. Obsessive-compulsive disorder comorbid with borderline personality disorder; a long-term case study. Psychiatr Clin Neurosci 1996;50:51 - 4. ¨ zdemir O ¨ , Karali A. Comparison of clinical [42] Tqrksoy N, Tqkel R, O characteristics in good and poor insight obsessive-compulsive disorder. J Anxiety Disord 2002;16:413 - 23. [43] Narita Y, Nakamura Y, Mizuno N, Ishikawa A, Kawata A, Kawata M. A consideration on obsessional neurosis. Seishin Igaku (Clinical Psychiatry) 1974;16:957 - 64. [44] McElroy SL, Hudson JI, Pope HG, Keck PE, Aizley HG. The DSMIII-R impulse control disorders not elsewhere classified; clinical characteristics and relationship to other psychiatric disorders. Am J Psychiatry 1992;149:318 - 27. [45] Coid JW. An affective syndrome in psychoraths with borderline personality disorder ? Br J Psychiatry 1993;162:641 - 50. [46] Michel L, Marie A, Mary M, Jean A. Impulsive control disorders and depression. J Nerv Ment Dis 2002;190:310 - 4. [47] Zanarini MC, Weinberg E. Borderline personality disorder; impulsive and compulsive features. In: Hollander E, Stein DJ, editors. Impulsivity and aggression. Sussex (England)7 Wiley; 1995. p. 37 - 58.