JOURNAL READING

OBSESSIVE COMPULSIVE SYMPTOMS IN FIRST EPISODE

PSYCHOSIS AND IN SUBJECTS AT ULTRA HIGH RISK FOR
DEVELOPING PSYCHOSIS; ONSET AND RELATIONSHIP TO
PSYCHOTIC SYMPTOMS

Pembimbing : dr. Elly Noerhidajati, SpKJ

Presented by : Afifatul Hakimah (01.209.5822)

Introduction

it has been noted that co-occurrence of

obsessive compulsive symptoms (OCS)
and obsessive compulsive disorder
(OCD) is frequently seen in patients with
schizophrenia and related disorders

Introduction

Recent studies reveal high co-morbidity

rates for OCS in schizophrenia patients
varying from 7.8% to 46.6%
Prevalence rates for OCD reported in
schizophrenia populations vary from
7.8% to 26%
Estimated prevalence figures for OCS in
the general population are similar (21
24%), but clearly lower for OCD (2 3%)

Introduction

The wide range of reported cooccurrence rates of OCS in schizophrenia

patients is probably due to differences in
definitions of obsessive compulsive
features and sample characteristics (i.e.
Age of subjects, inpatient-outpatient,
stage of illness)

Earlier studies concluded that patients

with schizophrenia can develop OCS as a
sign of emerging reality testing of
psychotic symptoms and stated that the
presence of OCS could be an indicator of
good prognosis
However, subsequent studies reported
poorer outcome and higher levels of
positive and negative symptoms in
schizophrenia patients with OCS

Hypotheses concerning the association of OCS in schizophrenia :

OCS in schizophrenia might be

considered as a subtype of schizophrenia
Second, the occurrence of OCS in
schizophrenia patients may be
associated with the treatment with
second generation antipsychotic
medications

OCS in schizophrenia might be

considered as a subtype of
schizophrenia

OCS can either begin prior, during or after the first

episode of psychosis (FEP). If OCS typically occurs prior
to FEP, it would be likely that OCS together with
schizophrenia can be seen as above
mean age at onset of OCS in patients with first episode
schizophrenia reported by Poyurovsky et al is 16.6
years (SD 8.7) and the mean age at onset of psychosis
is 23.4 (SD 5.9) years, this would also support the
hypothesis
high incidence of OCS in patients at ultra high risk
(UHR) of developing psychosis [18], suggesting that
OCS could be a part of the prodromal phase of
schizophrenia.

The occurrence of OCS in schizophrenia

patients may be associated with the
treatment with second generation
antipsychotic medications

Byerly et al . [19] report in their study

that OCS predominantly concurs with, or
develops after the onset of the psychotic
disorder in patients with schizophrenia or
a schizoaffective disorder

Purpose

to assess the prevalence of OCS and OCD

among all referrals with a FEP or with a
potential UHR
determined the time of onset of OCS
related to the time of onset of FEP: prior,
during or after first episode psychosis

Materials and methods

Participants

Subjects with FEP and subjects who are at

ultra high risk of developing psychosis,
located in the Academic Medical Centre
from 1 July 2006 until 1 July 2008.
Sampling technique : consecutive

Instruments and
procedure

patients
were
interviewed
by
psychiatrist
or a
psychologist
with
extensive
In this
clinical 2-h
approximately
experience
face-to-face

interview, subjects
were asked about
their premorbid
history of
complaints,
psychotic
symptoms, OCS
and general
Diagnosis
of
characteristics.
psychotic
disorders was
established using
the
Comprehensive
Assessment of
Symptoms and
History (CASH)
schedule

In referrals to the
diagnostic facility
of our clinic with
no evident
psychosis, the
Structured
Interview for
Prodromal
Syndromes (SIPS)
was
Diffi administered
culties in
assessing
symptom status or
diagnostic criteria
were discussed
and resolved by
reaching
agreement
between all
professionals
involved

All cases were

discussed in a
weekly meeting
with three senior
psychiatrists
and all residents
and researchers
involved

Patients were also

classified as being
UHR when they
had a genetic risk
and reduced
functioning or brief
limited
intermittent
psychotic
symptoms
in a separate
interview the
parents or
guardians were
asked about the
premorbid
emergence and
presence of
symptoms and
signs of the
patient
patients whose
obsessional
thoughts or
compulsions are
elated exclusively
to psychotic
content of
thoughts are not
included in the
OCS or OCD group

After the diagnostic

procedure the
presence of OCS was
assessed
independently by two
of the authors (B.S.,
K.L.), taking
longitudinal, clinical,
and heteroanamnestic
information into
account

all patients were

screened for
the presence of
OCS and if
present, we
determined the
time of onset of
OCS
To determine
ethnicity we
used the
classification
used by the
Dutch Central
Bureau of
Statistics

Statistical analyses

All statistical analyses were performed

using SPSS 16.02 software.
By using chi-square tests and logistic
regression we compared different
variables (gender, ethnicity, living in
Amsterdam or not) in patients with OCS
to patients without OCS.

Results

Results

Results

Discussion

In this study 9.3% of the patients with recent

onset schizophrenia, schizophreniform or
schizoaffective disorder had OCS, when a
strict definition of OCS used. 1.5% also met
the criteria for OCD
These prevalence figures for OCS and OCD
are not as high as reported prevalence rates
in other recent studies that examined OCS
and OCD in schizophrenia and related
disorders

In contrast with the relatively low

prevalence rates for OCS and OCD in
schizophrenia and related disorders in
our sample, we did find relatively high
rates of OCS (20.7%) and OCD (3.4%) in
UHR patients, although this finding
should be interpreted with caution, since
the sample size of this UHR group was
reasonably small (N 29) and
predominantly male.

Unike Byerly et al . [19], we found no

significant difference between the time
of onset of OCS prior to or after the time
of onset of first-episode psychosis
Also we did not confirm the finding that
OCD precedes the onset of schizophrenia
in co-morbid patients as found at a trend
level in the meta-analysis by Devulapalli
and colleagues

An explanation of these differences

might be the heterogeneity and possible
selection bias (i.e. Chronically ill and
older age at assessment) in the study
samples included in this meta-analysis.
We specifically studied a young, recentonset population

The equal distribution of the time of onset of OCS

related to the time of onset of first-episode psychosis
suggests that OCS and schizophrenia are two separate
disorders which have their onset in adolescence
However, it could still be that both hypotheses, OCS as
a schizophrenia-subtype and OCS induced by
antipsychotic medication, are true. It is not ruled out
that maybe a small number of the patients with OCS
occurrence prior to FEP suffer from a schizo-obsessive
disorder, and possibly another subgroup of patients
with OCS occurrence after FEP, developed OCS
associated with the effects of antipsychotic
medication.

We found prevalence rates of OCS and

OCD in patients with schizophrenia that
are almost the same, or even lower, as
the rates of OCS and OCD found in the
general population.
More importantly, these findings show
lower prevalence rates of OCS and OCD
in schizophrenia than many other
studies.

This difference might be caused by several

reasons:

Our criteria for defining OCS were strict: obsessive

compulsive symptoms needed to be unrelated to the
psychotic content.
The symptoms of schizophrenia or related disorders in
our patients were probably not as severe as chronic
schizophrenia patients as described in other studies.
Most patients were not using antipsychotic medication
yet or had only recently started antipsychotic
medication.
It has been suggested by other authors that the use of
low dose of antipsychotic medication may reduce OCS in
schizophrenia and schizophrenia related disorders

Limitations

The sample size might be still insufficient to

comprehensively evaluate the prevalence of OCS
and OCD and the association of occurring OCS
with the onset of first-episode psychosis.
There might be a reporting bias
On the other hand, OCS might have been over
reported due to the possible presence of referral
bias
Although we suppose that we were able to
include almost all FEP in contact with mental
health care in Amsterdam, we probably have
missed several cases.
The relatively small sample of UHR subjects

Conclusion

we found a relatively low prevalence of OCS and OCD in a

large consecutively diagnosed cohort of patients with a
first episode of schizophrenia or related disorder.
OCS either developed prior, during, or after the onset of
FEP, which may have implications for understanding the
relationship of the two conditions and their association
with each other.
We found a relatively high incidence of OCS in subjects
who met UHR criteria, possibly prodromal for FEP,
suggesting that OCS might be a part of the prodromal
phase of first-episode psychosis.
The predictive validity of OCS for transition to psychosis in
UHR subjects warrants further investigation.

CRITICAL APPRAISAL

Identitas Jurnal

Title : Obsessive compulsive symptoms

in first episode psychosis and in subjects at
ultra high risk for developing psychosis;
onset and relationship to psychotic
symptoms
Author : Bouke Sterk , Kay Lankreijer ,
Don H Linszen , Lieuwe de Haan
Pubisher : Australian and New Zealand
Journal of Psychiatry
Tahun terbit : 2011

PICO

Patients : first episode psychosis patients

and ultra high risk subjects
Intervention : Obsessions and compulsions
were defined in accordance with DSM-III-R
criteria and assessed by clinicians
Comparison : previous studies
Outcome : prevalence of OCS and OCD
among all referrals with a FEP or with a
potential UHR

Critical Appraisal

Title :
consists more than 12 words
content :
describe enough the content of the
study, interesting enough, without
abbreviation

Author :
Bouke Sterk , Kay Lankreijer , Don H
Linszen , Lieuwe de Haan

The authors are psychiatrists from

Department of Psychiatry, Academic
Medical Centre, University of
Amsterdam and their journal was
published at Australian and New
Zealand Journal of Psychiatry

Publisher :
Australian and New Zealand Journal
of Psychiatry
the publisher is one of well-known
publisher among Netherlands and
Europe.

Abstract :
(+):
Di dalamnya terdapat Tujuan, Bahan dan

Metode, Hasil Diskusi, kesimpulan

Kata kunci dicantumkan dan tepat

(-):

jumlah kata>321

Result :
dijelaskan dengan lengkap
methods:
Metode tidak dijelaskan secara ekplisit tetapi dapat
diketahui bahwa study ini merupakan observational study.
Sampling:
subjects that qualified with Comprehensive Assessment
of Symptoms and History (CASH) schedule, Structured
Interview for Prodromal Syndromes (SIPS), The Scale of
Prodromal Symptoms (SOPS), and Structured Clinical
Interview for DSM-III-R
Sampling technique : consecutive sampling

Conclusion :
Kesimpulan menjawab tujuan dari
penelitian

Reference :
Referensi yang digunakan sesuai tetapi
beberapa diantaranya diterbitkan tahun
1990an.

ValidITY
Question
Were subjects chosen
randomly?

No

Were the observation long

enough and detailed?

No

Were randomized subjects

analyzed?

No

Were subjects and clinician

No
blinded in medication, besides
medication that examined?
Were the therapeutic group
and controlled group
homogen?

Unknown

Application
Question
are there any differences in
our patients compared with
this study so that the findings
cannot be applied to our
patients?

Unknown

Was the therapy applicable to

our patients?

No

Were the patients have

Unknown
beneficial or harmful
potention whether the therapy
being applied?

Conclusion
Clinical evidence :
not valid
cannot be applied