Obsessive-Compulsive Spectrum Symptoms Are Associated With Functional Impairment in Children and Adolescents With Psychosis Risk Syndrome: The CAPRIS Study

In recent decades, research concerning clinical high risk for psychosis (CHR-P) patients has focused on detection, prognosis, and intervention. Efforts to better understand the neurodevelopment of schizophrenia^1,2 have included attempts to detect individuals with CHR-P to facilitate early intervention³ during the prepsychotic period, or “prodromal” stage.^4,5 From a prospective point of view, the course of CHR-P shows considerable heterogeneity, with positive symptoms, functioning, cognition, and negative and affective symptoms all following partly independent trajectories.⁶ A meta-analysis⁷ found that 25% of individuals at CHR-P developed psychosis within 3 years, and a systematic review focusing on children and adolescents⁸ reported a 17%–20% rate of transition to psychosis during the first year, which is similar to what has been found in adults. The aforementioned meta-analysis⁷ recorded that transition rates were associated with brief limited intermittent psychotic symptoms (BLIPS) and being male and found that the majority of CHR-P individuals who did not develop psychosis also did not recover. Another meta-analysis⁹ showed that obsessive-compulsive disorder (OCD) is fairly common in schizophrenia, with an estimated prevalence of 13.6% after meta-regression and a higher prevalence in chronic populations. The estimated prevalence of obsessive-compulsive symptoms (OCS) is 30.3% after meta-regression,⁹ in comparison with 1.1%–1.8% among the general population.¹⁰ The rate of OCD in adolescents with schizophrenia is 26%,¹¹ although many cases do not meet clinical criteria for OCD and are considered subclinical. The psychotic disorders that have been most commonly associated with OCD are schizophrenia followed by schizoaffective disorder and delusional disorder.¹² OCD and schizophrenia share the same etiologic risk factors: older age of the father, obstetric complications, and infections.^13–16

Although few studies have focused on CHR-P and OCS, findings in adult patients have indicated that subjects with both of these factors have more positive and negative prodromal symptoms.^17,18 Some studies have also found more depressive symptoms,^17,19 while others have not.¹⁸ None of the studies have found an association between OCS and patients’ level of global functioning.^17,19 The prevalence of OCD in patients with CHR-P is between 5% and 8.1%, and between 11% and 35% if subclinical symptoms are included.^12,18,19 The prevalence of OCS among patients with CHR-P and a first episode of psychosis seems to be quite similar.²⁰ Up to now, no studies have focused exclusively on the child and adolescent population. The DSM-5¹⁰ created a new chapter entitled “Obsessive-Compulsive Disorder and Related Disorders,” which includes OCD and body dysmorphic disorder (BDD). This suggests a relationship between these disorders, although the association between BDD and CHR-P has not yet been determined.

The main objective of our study was to explore the clinical and functional differences between 3 groups of subjects: patients with CHR-P and OCS (OCS+), patients with CHR-P who do not have OCS (OCS–), and a group of healthy controls (HC). Our main hypothesis was that OCS+ subjects would show more clinical and functional impairment than OCS– subjects, who, in turn, would show more impairment than HC. Our second hypothesis was that the OCS+ group would present symptomatology that is more similar to BDD compared to the other groups.

METHODS

Subjects

This was a cross-sectional study undertaken as part of the Child and Adolescent Psychosis Risk Syndrome (CAPRIS) project, a longitudinal study that began in 2011 (study dates: January 1, 2011, through December 31, 2018). General baseline data for these patients have been published elsewhere.²¹ CHR-P subjects were recruited through the inpatient and outpatient setting of the Child and Adolescent Psychiatry and Psychology Department of Hospital Clinic of Barcelona and Hospital Sant Joan de Déu (HSJD) (Barcelona, Spain). The HC were matched for age and gender. All children and adolescents were between 10 and 17 years old.

Inclusion criteria were derived from the ultra-high risk criteria set by Miller et al²² along with the attenuated negative symptoms from the clinical high risk criteria established by Lencz et al²³ and the second-degree relative genetic risk criteria by Klosterkötter et al.²⁴ Inclusion criteria for the CHR-P group consisted of having one or more of the following included in the Scale of Prodromal Symptoms (SOPS):

1. Attenuated positive symptoms (APS), scored as 3 to 5 in the SOPS interview, starting in the previous 12 months or presenting current worsening of clinical symptoms.
2. Attenuated negative symptoms (ANS), identified as a score of 3 to 5 on the negative subscale of the SOPS, appearing in the previous 12 months or presenting current worsening of the clinical symptoms.
3. BLIPS, scored as 6 on the SOPS positive subscale, with a duration no longer than 1 week, and appearing in the previous 3 months.
4. Genetic risk (GR) criteria consisting of having a first- or second-degree relative with schizophrenia or having a diagnosis of schizotypal disorder plus functional decline (30% decrease in Global Assessment of Functioning [GAF] score in the previous year).

Exclusion criteria for all groups were (a) IQ below 70 with impaired functioning; (b) autism spectrum disorders; (c) neurologic disorders, including history of head trauma with loss of consciousness; (d) problems with language comprehension; and (e) any history of psychotic symptoms. Exclusion criteria for HC were having a psychiatric diagnosis according to DSM-IV-TR criteria and/or having a first- or second-degree relative with psychotic illness.

The study was approved by the Ethics Committee of each institution. All parents or legal guardians and all participants older than 12 years provided written informed consent.

Clinical Assessment

Prodromal symptoms were evaluated with the Semistructured Interview for Prodromal Syndromes (SIPS) and scored on the SOPS. The SOPS is a 19-item scale designed to assess the severity of prodromal symptoms via 4 subscales: positive, negative, disorganize, and general symptoms.²⁵ Each item is rated on a scale of 0 (not present) to 6 (extreme or psychotic intensity). Items scored from 3 to 5 are considered prodromal.

Psychiatric diagnoses were obtained from the structured interview Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version (K-SADS-PL). This interview is considered a reliable and valid instrument to assess present and lifetime diagnosis²⁶ and has been validated in Spanish.^27,28

All subjects were evaluated, with examination of their psychiatric history, prior and current treatments, the reason for their medical visit, their socioeconomic status, and relevant aspects of their personal and family background by means of an interview with the participants’ parents or legal guardians. Socioeconomic status (SES) of the sample was estimated with the Hollingshead and Redlich scale.²⁹ Obstetric complications were registered using the Lewis-Murray scale.³⁰

Functioning, both current and over the previous year, was evaluated with the GAF, which is scored from 1 to 100, indicating the general level of functioning and clinical symptomatology.³¹ Higher scores indicate better functioning.

Affective symptomatology was evaluated using the Young Mania Rating Scale (YMRS) to assess manic symptoms³² and the Hamilton Depression Rating Scale (HDRS) for depressive symptoms.³³

The Leyton Obsessional Inventory–Child Version (LOI-CV)^34,35 questionnaire was used to evaluate OCS. This instrument includes 20 items that are used to determine two separate scores: one shows the presence/absence of symptoms, while the other relates to the degree of interference that these symptoms cause. The total score is obtained by adding these two scores together. This total score is generally considered to provide better predictability than either of the separate scores alone. A total score of 21 points or above is considered to show the presence of significant OCS. In our study, the LOI-CV was used to divide patients into two groups: OCS+ (total score of 21 or above) and OCS– (total score of 20 or below).

The Body Dysmorphic Disorder Questionnaire (BDDQ) is a 7-item self-report instrument that is used to screen for BDD. The items are all yes/no questions, and at-risk cases are considered to be those with a score of 4 or higher along with affirmative answers both for items 1 and 2 as well as for either item 3 or item 6, in addition to option 2 or 3 in item 7.^36,37

Intelligence quotient (IQ) was assessed using the Spanish version of the Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV),³⁸ which evaluates IQ in children aged between 6 and 16 years, and with the Wechsler Intelligence Scale for Adults, Third Edition (WAIS-III),³⁹ when subjects were over the age of 16 years. The Wechsler scales provide a verbal comprehension index (VCI), a perceptual reasoning index (PRI), a working memory index (WMI), and a processing speed index (PSI). A measure of general intelligence (GI) was derived from the VCI and the PRI and has been used as a more valid measure of fluid intelligence than IQ.⁴⁰ The mean of each index is 100, with a standard deviation of 15.

Statistical Analysis

Descriptive statistics were used (means and standard deviations) to summarize the quantitative results, and these were compared using analysis of variance (ANOVA). Categorical variables were reported with percentages and compared using the χ² test. To compare continuous variables between two groups, t tests were performed. To ensure normal sample distributions, clinical variables were examined using the Kolmogorov-Smirnov test. The Levene test was also used with the same variables to assess the equality of variances. The different clinical variables were analyzed with a generalized linear model using age, sex, and socioeconomic status as covariables. Post hoc analysis was performed with the Bonferroni correction for multiple comparisons to avoid the presence of false positives. A P value less than or equal to .05 was the confidence interval used for all of the analyses, and all analyses were performed using the statistical package SPSS 18.0.

RESULTS

Sociodemographic and Clinical Variables and Family History

A total of 128 patients, 64 OCS+ and 64 OCS–, were included along with 98 HC. Figure 1 shows how the sample was distributed. Among the CHR-P OCS+ subjects, a total of 3 patients were diagnosed with OCD. No significant differences were found in terms of age or sex between the 3 groups. Differences in SES were observed between patients (both OCS+ and OCS–) compared to HC (P < .001). Because of this, SES was included only as a covariable in the generalized linear models (Table 1).

No differences were found between OCS+ and OCS– patients in terms of personal psychiatric background or family history. Patients had both a more extensive family background in general (OCS+ = 78.1% and OCS– = 84.4%) and relatives with a greater number of comorbid disorders (OCS+ mean ± SD = 0.9 ± 0.1 and OCS– mean ± SD = 1.0 ± 0.9) compared to HC. Regarding medication, OCS+ subjects were prescribed antidepressants significantly more often than the OCS– group (56.3% vs 29.7%, respectively; P = .004), but there was no difference between groups in the frequency of antipsychotic prescription (OCS+ = 45.3% and OCS– = 46.9%). Also, psychological treatment alone was received by both groups of patients at exactly the same rate (29.7%). No significant differences were found in hospitalization rates or cannabis use between OCS+ and OCS– patients.

Differences Between OCS+ Patients, OCS– Patients, and HC in Clinical and Functioning Scales

Significant differences were found in SOPS scale scores between the 3 groups (Table 2). The OCS+ group had the highest scores, followed by the OCS– group, which obtained significantly lower scores on the positive (P = .004) and negative (P = .047) subscales as well as higher general subscale (P = .039) and total (P = .007) scores (Figure 2). Results from the BDDQ also showed certain differences between the 3 groups. The OCS+ group had higher scores (P < .001) than did OCS– subjects and HC. Significant differences were found in functioning, both current (P = .044) and over the previous year (P = .004), with the OCS+ group showing the worst functioning, followed by the OCS– group and, lastly, HC.

Clinical and functional variables were examined to compare OCS+ patients with dysmorphophobia (OCS+BDDQ+) versus those without dysmorphophobia (OCS+BDDQ–), and we found that OCS+BDDQ+ patients had higher rates of depression and worse functionality (Supplementary Table 1). In our sample, the positive Pearson correlation was significant between BDDQ total scores and LOI-CV scores (R = 0.428, P < .001).

There were no significant differences when the 3 patients diagnosed with OCD were excluded from the analysis (Supplementary Table 2). As outlined in Supplementary Tables 3 and 4, we compared OCS+, OCS–, and HC without OCS and found no results different from those already presented in this study.

DISCUSSION

The current study explored differences in terms of clinical presentation, cognition, and functioning in patients with CHR-P plus OCS versus those with no OCS. To our knowledge, this study is the first to have focused on this issue with a sample composed entirely of children and adolescents. Our study found that 50% of the CHR-P subjects had OCS, and this group showed more prodromal and dysmorphophobic symptoms and worse functioning than the OCS– group.

This high percentage of OCS in subjects with CHR-P compared to HC is one of our main findings. Our sample included 128 CHR-P patients, and exactly half of them had OCS, which is considerably higher than what other studies have found in older subjects. Those studies have reported rates of OCS of 11%–35%.^18,19

Regarding clinical symptomatology, all of the studies conducted with adult samples have reported similar findings to what we have found: more OCS is associated with higher levels of prodromal symptomatology.^17,18 Soyata et al,¹⁹ looking at an adult sample, suggested that these symptoms are of longer duration.

Our study found no significant differences between OCS+ and OCS– groups regarding family background of psychotic illness. This result supports the findings of Soyata et al.¹⁹ Some studies have proposed a common neurobiological mechanism that includes a dysregulation of serotonin and an alteration of the corticostriatal circuit and of the anterior cingulate cortex in psychotic disorders and OCD.^41–43

Our study, looking at GAF results, found that the OCS+ group had worse functioning at baseline compared to the OCS– group, who, in turn, showed worse functioning than HC. This same pattern was observed regarding subjects’ functioning over the previous year. Nevertheless, some studies with adults maintain that there are no differences between OCS+ subjects, OCS– subjects, and HC in terms of functioning.^17,18

Regarding medication, more than 70% of our patients were taking psychopharmaceuticals at the time of their baseline visit. Among CHR-P patients, the most frequently prescribed medications were antipsychotics (17%–63%) and antidepressants (15%–50%).²¹ This finding is significant since antipsychotics can cause secondary symptoms that are similar to OCD, which could blur findings.¹⁸ However, it is worth noting that ongoing antipsychotic treatment in CHR-P could possibly mitigate the initial clinical presentation and modulate the later outcome trajectory.⁴⁴

Regarding BDD, this study is the first to evaluate BDD symptoms in child and adolescent CHR-P patients with and without OCS. The main finding was that OCS+ patients had an increased number of dysmorphophobic symptoms, and these patients have higher rates of depression and poorer functioning. This finding supports the idea that, within the obsessive-compulsive spectrum, OCD and BDD may share common underlying mechanisms.⁴⁵ In our sample, we found a positive correlation between OCS and dysmorphophobia symptomatology. Some experts suggest that there is combined involvement of the serotonergic, dopaminergic, and glutamatergic systems in OCD and BDD.⁴⁶ A systematic review⁴⁷ shows the similarities between BDD and OCD: age at onset, illness course, symptom severity, and level of functional impairment, along with high degree of perfectionism and fear of negative evaluation. Some differences were also found: BDD insight was clearly worse, and patients with BDD showed impaired facial affect recognition, increased social anxiety severity, and overall greater social-affective dysregulation.

Strengths and Limitations

The main strengths of this study include the fact that it includes a large and homogeneous sample of children and adolescents along with a control group matched for age and sex, thus making the results more generalizable. Additionally, the instruments used have all been validated in Spanish.

The study’s limitations include the following: (1) Overall, 19.4% of HC had LOI-CV scores that showed OCS (19 of 98 subjects), which made the control group somewhat heterogeneous. That said, some studies have found OCS rates of up to 21%–25% in the general population,⁴⁸ which would put our findings well within the normal range. We compare the differences found between OCS+ patients and HC with OCS in Supplementary Tables 5 and 6. (2) The LOI-CV has been validated in the general population only with a sample of 8- to 12-year-old subjects and not in a clinical population. Our sample included subjects between the ages of 11 and 17 years, with the mean age being about 15 years. Nevertheless, this instrument has high reliability, with an intraclass correlation of 0.79–0.90,³⁵ and it is considered to be an effective tool for detecting OCS. For greater validity and reliability, a structured interview specific to OCD could be administered. (3) Our CHR-P criteria included attenuated negative symptoms. This approach follows that of Cornblatt et al,⁴ although not all studies of high risk for psychosis have included these symptoms. (4) Lastly, the patients and HC were not matched for SES, although this was corrected for by using this factor only as a covariable in the statistical analysis.

In conclusion, patients with CHR-P who are OCS+ are a population that needs to be closely monitored, considering that they present high-level prodromal symptoms and worse functioning compared to OCS– subjects. Greater awareness of the risks these subjects face, along with more intensive and specific treatments, can help improve these subjects’ functioning and quality of life. Systematic evaluation of OCS in subjects with CHR-P could help clinicians optimize pharmacologic and psychological interventions to improve these individuals’ functioning and prognosis.

Article Information

Published Online: October 16, 2023. https://doi.org/10.4088/JCP.22m14698
© 2023 The Authors. Published by Physicians Postgraduate Press, Inc. This is an open access article under the CC BY-NC-ND license.
Submitted: October 23, 2022; accepted June 21, 2023.
To Cite: Vergara L, de la Serna E, Sugranyes G, et al. Obsessive-compulsive spectrum symptoms are associated with functional impairment in children and adolescents with psychosis risk syndrome: the CAPRIS study. J Clin Psychiatry. 2023;84(6):22m14698.
Author Affiliations: Hospital Universitari Mútua de Terrassa, Barcelona, Spain (Vergara); Centro de Investigación biomédica en Red de Salud Mental (CIBERSAM), ISCIII, Barcelona, Spain (de la Serna, Sugranyes, Puig, Ilzarbe, Fortea, Dolz, Baeza); Child and Adolescent Psychiatry and Psychology Department, SGR-881, Hospital Clínic de Barcelona, Barcelona, Spain (Sugranyes, Puig, Ilzarbe, Fortea, Baeza); Child and Adolescent Mental Health Research Group, Insitut de Recerca Sant Joan de Déu, Barcelona, Spain (Tor, Muñoz-Samons, Rodriguez-Pascual, Alvarez-Subiela, Dolz); Child and Adolescent Psychiatry and Psychology Department, Hospital Sant Joan de Déu of Barcelona, Barcelona, Spain (de la Serna, Muñoz-Samons, Rodriguez-Pascual, Alvarez-Subiela, Dolz); IDIBAPS (Institut d’Investigacions Biomèdiques August Pi Sunyer), Barcelona, Spain (Sugranyes, Baeza); University of Barcelona, CIBERSAM (Centro de Investigación Biomédica en Red de Salud Mental), Madrid, Spain (Baeza).
Corresponding Author: Laura Vergara, BSc, Psychiatry Department, Hospital Universitari Mútua de Terrassa. Doctor Robert, 5. Terrassa 08221. Barcelona, Spain (lvergara@mutuaterrassa.cat).
Relevant Financial Relationships: Dr Sugranyes has received speaker fees for Angelinia Pharma. She has received research funding from the Instituto de Salud Carlos III (PI1800976, PI2100330), the Fundació Clinic Recerca Biomèdica (Ajut a la Recerca Pons Bartran), and the Alicia Koplowitz Foundation. Dr Ilzarbe has received continuing medical education support from Rubió and Angelini. Dr Fortea has received travel and educational support from Otsuka-Lundbeck. Dr Rodriguez-Pascual has received support to attend conferences for lectures from Angelini. Dr Dolz has received grants from Instituto de Salud Carlos III and Fundación Alicia Koplowitz and has received support to attend conferences or honoraria for lectures from Otsuka-Lundbeck, Angelini, and Janssen. Dr Baeza has received honoraria or travel support from Otsuka-Lundbeck, Angelini, and Janssen and grants from the Spanish Ministry of Health, Instituto de Salud Carlos III. Ms Vergara and Drs de la Serna, Puig, Tor, Muñoz-Samons, and Alvarez-Subiela have no conflicts of interest.
Funding/Support: The study was funded by a grant from Instituto de Salud Carlos III (Fondo de investigación Sanitaria PI18/00242), supported by grants from the same institution (Fondo de investigación Sanitaria PI11/1349, PI11/02684, PI15/0444, PI15/00509, PI18/00976, PI21/00330, PI21/0391, and PI21/00090) and co-funded by the European Union.
Role of the Funders/Sponsors: The study sponsors did not contribute to authorship, including design, acquisition of data, analysis, and interpretation of data, or writing of the article.
Acknowledgments: The CAPRIS Study is a coordinated-multicenter Project funded in part by Instituto de Salud Carlos III (ISCIII), the Alicia Koplowitz Foundation and Ajut a la Recerca Pons Bartran (Fundació Clínic Recerca Biomèdica). This study has been funded by ISCIII through the project PI18/00242 and co-funded by the European Union. The authors would also like to thank the patients and families who collaborated in the study; Mr R. Borras, BSc, for his statistical advice; and Mr. A. D. Pierce, for his English editorial assistance. Mr Borras is affiliated in IDIBAPS (Institut d’Investigacions Biomèdiques August Pi Sunyer), Barcelona, Spain. Mr Pierce has no affiliation. Neither Mr Borras nor Mr Pierce has any potential conflict of interest relevant to the subject of this study. The authors would also like to thank the patients and families who collaborated in the study.
Previous Presentation: Poster presented at the Congress of the Schizophrenia International Research Society (SIRS); April 6–10, 2022; Florence, Italy.
Supplementary Material: Available at Psychiatrist.com.

Clinical points

• Most research regarding clinical high risk for psychosis (CHR-P) and comorbid obsessive-compulsive symptoms (OCS) has focused on adults. This study is the first conducted with a child and adolescent sample.
• Subjects with CHR-P plus OCS are considered an especially susceptible group clinically in terms of functioning. Systematic evaluation of OCS symptoms would allow for effective treatments that can improve these patients’ functioning and prognosis.