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Symptom Dimensions in Obsessive-Compulsive Disorder: Implications for the DSM-V

Published online by Cambridge University Press:  07 November 2014

James F. Leckman ,
Scott L. Rauch  and
David Mataix-Cols
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Abstract

In the absence of definitive etiological markers of vulnerability or a unitary profile of pathophysiology for obsessive-compulsive disorder (OCD), obsessive-compulsive (OC) symptom dimensions seem to offer a fruitful point of orientation.The complex clinical presentation of OCD can be summarized using a few consistent and temporally stable symptom dimensions. These can be understood as a spectrum of potentially overlapping features that are likely to be continuous with “normal” worries and extend beyond the traditional nosological boundaries of OCD. Although the understanding of the dimensional structure of obsessive-compulsive symptoms (OCS) is still imperfect, this quantitative approach to phenotypic traits has the potential to advance our understanding of OCD and may aid in the identification of more robust endophenotypes. Preliminary data suggest that these dimensional phenotypes may be useful in studies of the natural history, genetics, neurobiology, and treatment outcome of OCD. A dimensional approach is not mutually exclusive of other methods to parse the larger spectrum of disorders related to OCD. Thus far, age-of-onset of OCS and the individual's “tic-related” status seem to be particularly useful categorical distinctions. Finally, existing assessment methods are inadequate and new dimensional scales are needed to take full advantage of a dimensional approach in clinical and population-based studies.

Type
Review Articles
Information
CNS Spectrums , Volume 12 , Issue 5 , May 2007 , pp. 376 - 387
Copyright
Copyright © Cambridge University Press 2007

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References

REFERENCES

1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. text rev. Washington, DC: American Psychiatric Association; 2000.Google Scholar
2.International Classification of Diseases. Geneva, Switzerland: World Health Organization; 1992.Google Scholar
3.Hantouche, EG, Lancrenon, S. Modern typology of symptoms and obsessive-compulsive syndromes: results of a large French study of 615 patients [French]. Encephale. 1996;22:9–21.Google ScholarPubMed
4.Rachman, SJ, Hodgson, RJ. Obsessions and Compulsions. Englewood Cliffs, NJ: Prentice-Hall; 1980.Google Scholar
5.Khanna, S, Mukherjee, D. Checkers and washers: valid subtypes of obsessive compulsive disorder. Psychopathology. 1992;25:283–288.CrossRefGoogle ScholarPubMed
6.Horesh, N, Dolberg, OT, Kirschenbaum-Aviner, N, Kotler, M. Personality differences between obsessive-compulsive disorder subtypes: washers versus checkers. Psychiatry Res. 1997;71:197–200.CrossRefGoogle ScholarPubMed
7.Matsunaga, H, Kiriike, N, Matsui, T, et al.A comparative study of clinical features between pure checkers and pure washers categorized using a lifetime symptom rating method. Psychiatry Res. 2001;105:221–229.CrossRefGoogle ScholarPubMed
8.Goodman, WK, Price, LH, Rasmussen, SA, et al.The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989;46:1006–1011.CrossRefGoogle ScholarPubMed
9.Baer, L. Factor analysis of symptom subtypes of obsessive-compulsive disorder and their relation to personality and tic disorders. J Clin Psychiatry. 1994;55(suppl):18–23.Google ScholarPubMed
10.Leckman, JF, Grice, DE, Boardman, J, et al.Symptoms of obsessive-compulsive disorder. Am J Psychiatry. 1997;154:911–917.Google ScholarPubMed
11.Leckman, JF, Walker, WK, Goodman, WK, Pauls, DL, Cohen, DJ. “Just right” perceptions associated with compulsive behaviors in Tourette's syndrome. Am J Psychiatry. 1994;151:675–680.Google ScholarPubMed
12.Pauls, DL, Alsobrook, J, Goodman, W, Rasmussen, S, Leckman, JF. A family study of obsessive compulsive disorder. Am J Psychiatry. 1995;152:76–84.Google ScholarPubMed
13.Summerfeldt, LJ, Richter, MA, Antony, MM, Swinson, RP. Symptom structure in obsessive-compulsive disorder: a confirmatory factor-analytic study. Behav Res Ther. 1999;37:297–311.CrossRefGoogle ScholarPubMed
14.Mataix-Cols, D, Rosario-Campos, MC, Leckman, JF. A multidimensional model of obsessive-compulsive disorder. Am J Psychiatry. 2005;162:228–238.CrossRefGoogle ScholarPubMed
15.Hasler, G, LaSalle-Ricci, VH, Ronquillo, JG, et al.Obsessive-compulsive disorder symptom dimensions show specific relationships to psychiatric comorbidity. Psychiatry Res. 2005;135:121–13.CrossRefGoogle ScholarPubMed
16.Hasler, G, Kazuba, D, Murphy, DL. Factor analysis of obsessive-compulsive disorder YBOCS-SC symptoms and association with 5-HTTLPR SERT polymorphism. Am J Med Genet B Neuropsychiatr Genet. 2006;141:403–408.CrossRefGoogle Scholar
17.Denys, D, de Geus, F, van Megen, HJ, Westenberg, HG. Symptom dimensions in obsessive-compulsive disorder: factor analysis on a clinician-rated scale and a self-report measure. Psychopathology. 2004;37:181–189.CrossRefGoogle ScholarPubMed
18.Denys, D, de Geus, F, van Megen, HJ, Westenberg, HG. Use of factor analysis to detect potential phenotypes in obsessive-compulsive disorder. Psychiatry Res. 2004;128:273–280.CrossRefGoogle ScholarPubMed
19.Summerfeldt, LJ, Kloosterman, PH, Antony, MM, Richter, MA, Swinson, RP. The relationship between miscellaneous symptoms and major symptom factors in obsessive-compulsive disorder. Behav Res Ther. 2004;42:1453–1467.CrossRefGoogle ScholarPubMed
20.Kim, BN, Lee, CB, Hwang, JW, Shin, MS, Cho, SC. Effectiveness and safety of risperidone for children and adolescents with chronic tic or tourette disorders in Korea. J Child Adolesc Psychopharmacol. 2005;15:318–324.CrossRefGoogle ScholarPubMed
21.Delorme, R, Bille, A, Betancur, C, et al.Exploratory analysis of obsessive compulsive symptom dimensions in children and adolescents: a prospective follow-up study. BMC Psychiatry. 2006;6:1.CrossRefGoogle ScholarPubMed
22.McKay, D, Piacentini, J, Greisberg, S, Graae, F, Jaffer, M, Miller, J. The structure of childhood obsessions and compulsions: dimensions in an outpatient sample. Behav Res Ther. 2006;44:137–146.CrossRefGoogle Scholar
23.Cavallini, MC, Di Bella, D, Siliprandi, F, Malchiodi, F, Bellodi, L. Exploratory factor analysis of obsessive-compulsive patients and association with 5-HTTLPR polymorphism. Am J Med Genet. 2002;114:347–353.CrossRefGoogle ScholarPubMed
24.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;116:60–68.CrossRefGoogle Scholar
25.McKay, D, Abramowitz, JS, Calamari, JE, et al.A critical evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms. Clin Psychol Rev. 2004;24:283–313.CrossRefGoogle ScholarPubMed
26. Mataix-Cols, D, Rauch, SL, Manzo, PA, Jenike, MA, Baer, L. Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder. Am J Psychiatry. 1999;156:1409–1416.CrossRefGoogle Scholar
27.Tek, C, Ulug, B. Religiosity and religious obsessions in obsessive-compulsive disorder. Psychiatry Res. 2001;104:99–108.CrossRefGoogle ScholarPubMed
28.Mataix-Cols, D, Marks, IM, Greist, JH, Kobak, KA, Baer, L. Obsessive-compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychother Psychosom. 2002;71:255–262.CrossRefGoogle ScholarPubMed
29.Foa, EB, Huppert, JD, Leiberg, S, et al.The Obsessive-Compulsive Inventory: development and validation of a short version. Psychol Assess. 2002;14:485–496.CrossRefGoogle ScholarPubMed
30.Feinstein, SB, Fallon, BA, Petkova, E, Liebowitz, MR. Item-by-item factor analysis of the Yale-Brown Obsessive Compulsive Scale Symptom Checklist. J Neuropsychiatry Clin Neurosci. 2003;15:187–193.CrossRefGoogle ScholarPubMed
31. Rosario-Campos, MC, Miguel, EC, Quatrano, S, et al.The Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS): an instrument for assessing obsessive-compulsive symptom dimensions. Mol Psychiatry. 2006;11:495–504.CrossRefGoogle Scholar
32.Rettew, DC, Swedo, SE, Leonard, HL, Lenane, MC, Rapoport, JL. Obsessions and compulsions across time in 79 children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry. 1992;31:1050–1056.CrossRefGoogle ScholarPubMed
33.Mataix-Cols, D, Rauch, SL, Baer, L, et al.Symptom stability in adult obsessive compulsive disorder: data from a naturalistic two-year follow-up study. Am J Psychiatry. 2002;159:263–268.CrossRefGoogle ScholarPubMed
34.Rufer, M, Grothusen, A, Mass, R, Peter, H, Hand, I. Temporal stability of symptom dimensions in adult patients with obsessive-compulsive disorder. J Affect Disord. 2005;88:99–102.CrossRefGoogle ScholarPubMed
35.Halmi, KA, Sunday, SR, Klump, K, et al.Obsessions and compulsions in anorexia nervosa subtypes. Int J Eat Disord. 2003;33:308–319.CrossRefGoogle ScholarPubMed
36.Halmi, KA, Tozzi, F, Thornton, LM, et al.The relation among perfectionism, obsessive-compulsive personality disorder and obsessive-compulsive disorder in individuals with eating disorders. Int J Eat Disord. 2005;38:371–374.CrossRefGoogle ScholarPubMed
37. Mataix-Cols, D, Baer, L, Rauch, SL, Jenike, MA. Relation of factor-analyzed symptom dimensions of obsessive-compulsive disorder to personality disorders. Acta Psychiatr Scand. 2000;102:199–202.CrossRefGoogle Scholar
38.Frost, RO, Steketee, G, Williams, LF, Warren, R. Mood, personality disorder symptoms and disability in obsessive-compulsive hoarders: a comparison with clinical and nonclinical controls. Behav Res Ther. 2000;38:1071–1081.CrossRefGoogle ScholarPubMed
39.Samuels, J, Bienvenu, OJ 3rd, Riddle, MA, et al.Hoarding in obsessive compulsive disorder: results from a case-control study. Behav Res Ther. 2002;40:517–528.CrossRefGoogle ScholarPubMed
40.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.CrossRefGoogle ScholarPubMed
41.Hasler, G, Pinto, A, Greenberg, BD, et al.Familiality of factor analysis-derived YBOCS dimensions in OCD-affected sibling pairs from the OCD Collaborative Genetics Study. Biol Psychiatry. 2007;61:617–625.CrossRefGoogle ScholarPubMed
42.Alsobrook, JP II, Pauls, DL. Molecular approaches to child psychopathology. Hum Biology. 1998;70:413–432.Google ScholarPubMed
43.Nicolini, H, Kuthy, I, Hernandez, E, Velazquez, F. A family study of obsessive-compulsive disorder in Mexican population. Am J Hum Genet Suppl. 1991;49:477–447.Google Scholar
44.Cavallini, MC, Pasquale, L, Bellodi, L, Smeraldi, E. Complex segregation analysis for obsessive-compulsive disorder and related disorders. Am J Med Genet. 1999;88:38–43.3.0.CO;2-#>CrossRefGoogle ScholarPubMed
45.Alcais, A, Abel, L. Maximum-Likelihood-Binomial method for genetic model-free linkage analysis of quantitative traits in sibships. Genet Epidemiol. 1999;17:102–117.3.0.CO;2-6>CrossRefGoogle ScholarPubMed
46.Gu, C, Province, M, Todorov, A, Rao, DC. Meta-analysis methodology for combining non-parametric sibpair linkage results: genetic homogeneity and identical markers. Genet Epidemiol. 1998;15:609–626.3.0.CO;2-N>CrossRefGoogle ScholarPubMed
47.Zhang, H, Risch, N. Mapping quantitative-trait loci in humans by use of extreme concordant sib pairs: selected sampling by parental phenotypes. Am J Hum Genet. 1996;59:951–957.Google ScholarPubMed
48.Alsobrook, JP II, Leckman, JF, Goodman, WK, Rasmussen, SA, Pauls, DL. Segregation analysis of obsessive-compulsive disorder using symptom-based factor scores. Am J Med Genet. 1999;88:669–675.3.0.CO;2-N>CrossRefGoogle Scholar
49.Hanna, GL, Fischer, DJ, Chadha, KR, Himle, JA, Van Etten, M. Familial and sporadic subtypes of early-onset obsessive-compulsive disorder. Biol Psychiatry. 2005;57:895–900.CrossRefGoogle ScholarPubMed
50.Zhang, H, Leckman, JF, Tsai, CP, Kidd, KK, Rosario-Campos, MC. Genomewide scan of hoarding in sib pairs in which both sibs have Gilles de la Tourette syndrome. Am J Hum Genet. 2002;70:896–904.CrossRefGoogle ScholarPubMed
51.Hu, XZ, Lipsky, RH, Zhu, G, et al.Serotonin transporter promoter gain-of-function genotypes are linked to obsessive-compulsive disorder. Am J Hum Genet. 2006;78:815–826.CrossRefGoogle ScholarPubMed
52.Sutcliffe, JS, Delahanty, RJ, Prasad, HC, et al.Allelic heterogeneity at the serotonin transporter locus (SLC6A4) confers susceptibility to autism and rigid-compulsive behaviors. Am J Hum Genet. 2005;77:265–279.CrossRefGoogle ScholarPubMed
53.Lawrence, NS, Wooderson, S, Mataix-Cols, D, David, R, Speckens, A, Phillips, ML. Decision making and set shifting impairments are associated with distinct symptom dimensions in obsessive-compulsive disorder. Neuropsychology. 2006;20:409–419.CrossRefGoogle ScholarPubMed
54.Saxena, S, Rauch, SL. Functional neuroimaging and the neuroanatomy of obsessive-compulsive disorder. Psychiatr Clin North Am. 2000;23:563–586.CrossRefGoogle ScholarPubMed
55.Rauch, SL, Dougherty, DD, Shin, LM, et al.Neural correlates of factor-analyzed OCD symptom dimension: a PET study. CNS Spectr. 1998;3:37–43.CrossRefGoogle Scholar
56.Phillips, ML, Marks, IM, Senior, C, et al.A differential neural response in obsessive-compulsive patients with washing compared with checking symptoms to disgust. Psych Med. 2000;30:1037–1050.CrossRefGoogle ScholarPubMed
57.Shapira, NA, Liu, Y, He, AG, et al.Brain activation by disgust-inducing pictures in obsessive-compulsive disorder. Biol Psychiatry. 2003;54:751–756.CrossRefGoogle ScholarPubMed
58.Van den Heuvel, OA, Veltman, DJ, Groenewegen, HJ, et al.Amygdala activity in obsessive-compulsive disorder with contamination fear: a study with oxygen-15 water positron emission tomography. Psychiatry Res. 2004;132:225–237.CrossRefGoogle Scholar
59.Saxena, S, Brody, AL, Maidment, KM, et al.Cerebral glucose metabolism in obsessive-compulsive hoarding. Am J Psychiatry. 2004;161:1038–1048.CrossRefGoogle ScholarPubMed
60.Mataix-Cols, D, Wooderson, S, Lawrence, N, Brammer, MJ, Speckens, A, Phillips, ML. Distinct neural correlates of washing, checking, and hoarding symptom dimensions in obsessive-compulsive disorder. Arch Gen Psychiatry. 2004;61:564–576.CrossRefGoogle ScholarPubMed
61.Lawrence, NS, An, SK, Mataix-Cols, D, Ruths, F, Speckens, A, Phillips, ML. Neural responses to facial expressions of disgust but not fear are modulated by washing symptoms in OCD. Biol Psychiatry. In press.Google Scholar
62.Rauch, SL, Wedig, MM, Wright, CI, et al.Functional magnetic resonance imaging study of regional brain activation during implicit sequence learning in obsessive-compulsive disorder. Biol Psychiatry. 2007;61:330–336.CrossRefGoogle ScholarPubMed
63.Pujol, J, Soriano-Mas, C, Alonso, P, et al.Mapping structural brain alterations in obsessive-compulsive disorder. Arch Gen Psychiatry. 2004;61:720–730.CrossRefGoogle ScholarPubMed
64.Mataix-Cols, D, Fullana, MA, Alonso, P, Menchon, JM, Vallejo, J. Convergent and discriminant validity of the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist. Psychother Psychosom. 2004;73:190–196.CrossRefGoogle ScholarPubMed
65.Hollander, E, Bienstock, CA, Koran, LM, et al.Refractory obsessive-compulsive disorder: state-of-the-art treatment. J Clin Psychiatry. 2002;63:20–29.Google ScholarPubMed
66.Black, DW, Monahan, P, Gable, J, Blum, N, Clancy, G, Baker, P. Hoarding and treatment response in 38 nondepressed subjects with obsessive-compulsive disorder. J Clin Psychiatry. 1998;59:420–425.CrossRefGoogle ScholarPubMed
67.Winsberg, ME, Cassic, KS, Koran, LM. Hoarding in obsessive-compulsive disorder: a report of 20 cases. J Clin Psychiatry. 1999;60:591–597.CrossRefGoogle ScholarPubMed
68.Erzegovesi, S, Cavallini, MC, Cavedini, P, Diaferia, G, Locatelli, M, Bellodi, L. Clinical predictors of drug response in obsessive-compulsive disorder. J Clin Psychopharmacol. 2001;21:488–492.CrossRefGoogle ScholarPubMed
69.Saxena, S, Brody, AL, Maidment, KM, Baxter, LR Jr.Paroxetine treatment of compulsive hoarding. J Psychiatr Res. 2007;41:481–487.CrossRefGoogle ScholarPubMed
70.Alonso, MP, Menchón, JM, Pifarré, J, et al.Long-term follow-up and predictors of clinical outcome in obsessive-compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy. J Clin Psychiatry. 2001;62:535–540.CrossRefGoogle ScholarPubMed
71.Ferrão, YA, Shavitt, RG, Bedin, NR, et al.Clinical features associated to treatment response in obsessive–compulsive disorder. J Affect Disord. 2006;94:199–209.CrossRefGoogle ScholarPubMed
72.Shetti, CN, Reddy, YC, Kandavel, T, et al.Clinical predictors of drug nonresponse in obsessive-compulsive disorder. J Clin Psychiatry. 2005;66:1517–1523.CrossRefGoogle ScholarPubMed
73.Jenike, MA, Baer, L, Minichiello, WE, Rauch, SL, Buttolph, ML. Placebo-controlled trial of fluoxetine and phenelzine for obsessive-compulsive disorder. Am J Psychiatry. 1997;154:1261–1264.Google ScholarPubMed
74.Baer, L, Rauch, SL, Ballantine, HT, et al.Cingulotomy for intractable obsessive compulsive disorder: prospective long-term follow-up of 18 patients. Arch Gen Psychiatry. 1995;52:384–392.CrossRefGoogle ScholarPubMed
75.Basoglu, M, Lax, T, Kasvikis, Y, Marks, IM. Predictors of improvement in obsessive-compulsive disorder. J Anxiety Disord. 1988;2:299–317.CrossRefGoogle Scholar
76.Foa, EB, Goldstein, A. continuous exposure and complete response prevention in the treatment of obsessive-compulsive neurosis. Behav Ther. 1978;9:821–829.CrossRefGoogle Scholar
77.Christensen, H, Hadzai-Pavlovic, D, Andrews, G, Mattick, R. Behavior therapy and tricyclic medication in the treatment of obsessive-compulsive disorder: a quantitative review. J Consult Clin Psychol. 1987;55:701–711.CrossRefGoogle ScholarPubMed
78.Abramowitz, JS, Franklin, ME, Schwartz, SA, Furr, JM. Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. J Consult Clin Psychol. 2003;71:1049–1057.CrossRefGoogle ScholarPubMed
79.Ball, SG, Baer, L, Otto, MW. Symptom subtypes of obsessive-compulsive disorder in behavioral treatment studies: a quantitative review. Behav Res Ther. 1996;34:47–51.CrossRefGoogle ScholarPubMed
80.Rufer, M, Fricke, S, Moritz, S, Kloss, M, Hand, I. Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behavior therapy outcome. Acta Psychiatr Scand. 2006;113:440–446.CrossRefGoogle ScholarPubMed
81.Gesell, A, IIg, F. Infant and Child in the Culture of Today. The Guidance of Development in Home and Nursery School. New York, NY: Harper & Brothers Publishers; 1943.Google Scholar
82.Evans, DW, Leckman, JF, Carter, A, Reznick, JS, Henshaw, D, Pauls, DL. Ritual, habit, and perfectionism: the prevalence and development of compulsive like behavior in normal young children. Child Dev. 1997;68:58–68.CrossRefGoogle ScholarPubMed
83.Zohar, AH, Felz, L. Ritualistic behavior in young children. J Abnorm Child Psychol. 2001;29:121–128.CrossRefGoogle ScholarPubMed
84.Evans, DW, Gray, FL, Leckman, JF. The rituals, fears and phobias of young children: insights from development, psychopathology and neurobiology. Child Psychiatry Hum Dev. 1999;29:261–276.CrossRefGoogle ScholarPubMed
85.Leckman, JF, Mayes LC. Understanding developmental psychopathology: how useful are evolutionary perspectives? J Am Acad Child Adolesc Psychiatry. 1998;37:1011–1021.CrossRefGoogle Scholar
86.Feygin, DL, Swain, JE, Leckman, JF. The normalcy of neurosis: evolutionary origins of obsessive-compulsive disorder and related behaviors. Prog Neuropsychopharmacol Biol Psychiatry. 2006;30:854–864.CrossRefGoogle ScholarPubMed
87.Bracha, HS. Human brain evolution and the “Neuroevolutionary Time-depth Principle”: implications for the reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic stress disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2006;30:827–853.CrossRefGoogle ScholarPubMed
88.Leckman, JF, Mayes, LC, Feldman, R, Evans, D, King, RA, Cohen, DJ. Early parental preoccupations and behaviors and their possible relationship to the symptoms of obsessive-compulsive disorder. Acta Psychiatr Scand Suppl. 1999;396:1–26.CrossRefGoogle Scholar
89.Maser, JD, Patterson, T. Spectrum and nosology: implications for DSM-V. Psychiatr Clin North Am. 2002;25:855–885.CrossRefGoogle ScholarPubMed
90.Darwin, CR. On the Origin of the Species By Means of Natural Selection, or the Preservation of Favored Races in the Struggle for Life. London, UK: John Murray; 1859.Google Scholar
91.McDougle, CJ, Goodman, WK, Leckman, JF, Barr, LC, Heninger, GR, Price, LH. The efficacy of fluvoxamine in obsessive-compulsive disorder: effects of comorbid chronic tic disorder. J Clin Psychopharmacol 1993;13:354–358.CrossRefGoogle ScholarPubMed
92.McDougle, CJ, Goodman, WK, Leckman, JF, Lee, NC, Heninger, GR, Price, LH. 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.CrossRefGoogle ScholarPubMed
93.Leckman, JF, Grice, DE, Barr, LC, et al.Tic-related vs. non-tic-related obsessive compulsive disorder. Anxiety. 1994–1995;1:208–215.CrossRefGoogle ScholarPubMed
94.Grados, MA, Riddle, MA, Samuels, JF, et al.The familial phenotype of obsessive-compulsive disorder in relation to tic disorders: the Hopkins OCD family study. Biol Psychiatry. 2001;50:559–565.CrossRefGoogle ScholarPubMed
95.Rosario-Campos, MC, Leckman, JF, Mercadante, MT, et al.Adults with early-onset obsessive-compulsive disorder. Am J Psychiatry. 2001;158:1899–1903.CrossRefGoogle ScholarPubMed
96.Wewetzer, C, Jans, T, Muller, B, et al.Long-term outcome and prognosis of obsessive-compulsive disorder with onset in childhood or adolescence. Eur Child Adolesc Psychiatry. 2001;10:37–46.CrossRefGoogle ScholarPubMed
97.de Mathis, MA, Diniz, JB, do Rosario, MC, et al.What is the optimal way to subdivide obsessive-compulsive disorder? CNS Spectr. 2006;11:762–779.CrossRefGoogle ScholarPubMed
98.Coles, ME, Pinto, A, Mancebo, MC, Rasmussen, SA, Eisen, JL. OCD with comorbid OCPD: a subtype of OCD?J Psychiatr Res. 2007 Mar 22: [Epub ahead of print].Google Scholar