INVESTIGATION ON SYMPTOM SUBTYPES AND OTHER

Ph.D. Thesis INVESTIGATION ON SYMPTOM SUBTYPES AND OTHER CLINICAL FEATURES OF OBSESSIVE- COMPULSIVE SPECTRUM DISORDERS Tamás Treuer, M.D. National Institute of Psychiatry and Neurology Program leader: Prof. Zoltán Nagy, M.D., Ph.D., DSc. Subprogram leader: Prof. János Füredi, M.D., Ph.D. Tutor: Erika Szádóczky, M.D., Ph.D. 2001. Budapest Semmelweis University Ph.D. School

1. Introduction This paper summerises my research efforts in the last five years identifying symptom subtypes of obsessive-compulsive spectrum disorders such as obsessive-compulsive disorder and eating disorders and to differentiate clinical features with different methodologies. There are several psychiatric disorders related to this spectrum beside the classical obsessivecompulsive disorder which share common features on biological background and symptom fenomenology. One of the most interesting products of this spectrical way of classification the concept of obsessive-compulsive spectrum from a clinical point of view. This spectrum summerises those syndromes which are very similar to each other in special clinical aspects: compulsions related to body image distorsion in eating disorders, compulsive-ritualistic behaviours such as hair pulling in trichotillomania, or such compulsive behaviours like pathological gambling. My questions arised from my clinical practice were tested in the following studies. In spite of the leading clinical standard that obsessive-compulsive spectrum disorders are unitary nosological entities there are research efforts to identify symptom subtypes of the disorder. The importance of these disorders highlighted by recent epidemiological data which reflects that eg. obsessive-compulsive disorder is the fourth ranked among psychiatric disorders followinng phobias, alcoholism and depression more common than schizophrenia or panic disorder. According to epidemiological data the lifetime prevalence of obsessive-compulsive disorder is 2-3 % in the normal population, which means that it affects at least 200-300 thousand people in Hungary during their life period. 2. Goal of the study The identification and treatment of obsessive-compulsive spectrum disorders emerged in clinical psychiatry and research in the last decades. In this study I summarise my research efforts to identify symptom subtypes of obsessive- compulsive spectrum disorders such as obsessive-compulsive disorder and eating disorders and to differentiate clinical features with different methodologies. Four research studies were presented detaily in this paper: The main questions were the followings: 2.1 Differentiation on symptom subtypes of obsessive- compulsive disorder: a factor analytic study Is obsessive- compulsive disorder a homogenous or heterogenous condition regarding its clinical features? Are there symptom subtypes which can be differentiated by factoranalytic statistical procedures? Can the statistical correlations of the symptoms be explain the clinical appaerence and psychopathology of the disorder? 2.2 Citalopram neuroendocrine challenge test in patients with obsessive- compulsive disorder and healthy controls Is citalopram challenge test a valuable tool using as a neuroendocrine probe in obsessive compulsive disorder? Is there a difference between hormonal response in patients and

controls for the test? Are the hormonal responses similar to the response expereinced in depressive patients in citalopram test? 2.3 The impact of physical and sexual abuse on body image in eating disorders Are there any role of physical abuse in the etiopathogenesis of eating disorders? Is childhood physical abuse are more common than we thougt before and have these patients more serious body image distorsion? How is it in the different symptom subtypes of eating disorders? Which subtypes report the most frequent abuse? 2.4 The effectiveness of psychodramatic group therapy in eating disorders Is psychodrama a useful psychotherapeutic method in the treatment of eating disorders? Is there any effect of psychodramatic technique on the body image distorsion of these patients? Can this effect be meassured by body attitude tests? What kind of structural methods are effective in the teratment? 3. Methods 3.1 Differentiation on symptom subtypes of obsessive- compulsive disorder: a factor analytic study The purpose of our study was to examine the 13 a priori categories used to group types of obsessions and compulsions in the Yale-Brown Obsessive Compulsive Scale symptom checklist in our patients with obsessive-compulsive disorder (N=90). The goal of this analysis was to evaluate the correlational relationship of the symptom categories. A principal-components factor analysis (explorative) with varimax rotation was performed. A confirmative factor analysis were also done to identify the one, two, three or fourfactor-model. 3.2 Citalopram neuroendocrine challenge test in őatients with obsessive- compulsive disorder and healthy controls In the present study we investigated the neuroendocrine effects of intravenous administration of citalopram on serum cortisol and prolactin in 5 patients who met DSM- IV criteria for obsessive-compulsive disorder and 5 healthy subjects. We hypothesised that patients with obsessive-compulsive disorder exhibit lower hormonal responses which was found in other studies in depressive patients comparing to healthy controls and in turn it might correlate treatment outcome. Blood samples were obtained at 0, 30, 60 and 90 minutes for the determination of the concentrations of cortisol, prolactin with the simultaneous monitoring the blood pressure, heart rate, body temperature and side effects. In a six months follow up the treatment response to citalopram was also monitored. Statistical analysis meassured group correlations (Repeated Measures of ANOVA). 3.3 The impact of physical and sexual abuse on body image in eating disorders

The goal of our study was to test the hypothesis based on our clinical experience that physical abuse is more frequent in eating disorders than we thought before and the patients distorsion in body image is more severe in these cases. A standardised interview method was used to elicit details of physical and sexual abuse in a group of 63 patients with eating disorders. Four symprom sybtype were identyfied 1.) restrictive type anorexia: 23 patients; 2.) binge-purging type anorexia: 13 patients; 3.) bulimia nervosa: 16 patients; 4.) bulimia nervosa with the history of anorexia: 11 patients. The frequency of laxative use and the severity of body image distorsion was also examined with Body Attitude Test. These clinical data was analised by statistical methods (standard deviation, T-probe, odds ratio) on the whole sample and also on the subgroups of eating disorders. 3.4 The effectiveness of psychodramatic group therapy in eating disorders In this study we summerise our experience with psychodrama in the treatment of eight adult patients with eating disorders. The dramatic group sessions were settled on a weekly basis, every session was 1,5 hours long. The therapy lasted for three months. Body Attitude Test and Eating Disorder Inventory were performed before and after the therapy, and two years later a follow up was performed with an interview. After rewieving the literature we summerise the useful and effective structured dramatic methods in our practice: Body-Mirror, Eating around the Clock, Agression Trust exercise, Simple Body Image Feedback, Time-line Identity. 4. Results 4.1 Differentiation on symptom subtypes of obsessive- compulsive disorder: a factor analytic study A principal-components factor analysis (explorative) with varimax rotation was performed and four factors emerged in our data set: 1.) worried obsessions and checking; 2.) symmetry and ordering; 3.) cleanliness and washing; 4.) hoarding and collecting. The confirmative factor analysis identified the three-factor-model. Our findings identified different symptom dimensions and confirm the hypothesis that obsessive-compulsive disorder is a multidimensional and heterogeneous condition. 4.2 Citalopram neuroendocrine challenge test in obsessivecompulsive disorder and healthy controls Comparing to controls 10 mg citalopram infusion induced a lower and moderate hormone response in patients with obsessive-compulsive disorder, but there was no significant difference comparing to the healthy subjects, although the tendency was opposite. The most pronounced response was found in prolactine secretion during the first postinfusion hour after administration of 10 citalopram in patients with obsessive-compulsive disorder, but these response was not found in healthy controls. The amount of side effects and the treatment response in the follow up correlated positively but there was no correlation with the hormone response, but the difference was not significant. At those patients who responded well for the citalopram treatment we found a slight decrease in body temperature after the infusion of citalopram. In opposite as it was expected we did not find

a blunted hormonal reaction in patients but we found higher responses of prolactin and cortisol in patients comparing to controls. 4.3 The impact of physical and sexual abuse on body image in eating disorders The sexual abuse was 29% in the whole sample, the physical abuse 57%, the use of lacatives 46%. We found significantly more severe body image distorsion in those patients who had physical abuse and/or laxative abuse in their history (p<0.05). The physical abuse and the laxative abuse was more frequent in the subgroup of binge-purge type anorexia nervosa (92% and 69%). According to our results the presence of sexual abuse was not associated with more severe body image distorsion in eating disordered patients. 4.4 Evészavarban szenvedők pszichodramatikus csoportterápiájának hatásvizsgálata és tapasztalatai The basic elements of psychodramatic therapy such as doubling, mirroring and role reversal were found to be effective in the treatment of alexithymic patients with eating dosirders, who usually split between their emotional and rational pronlem areas The psychodramatic group therapy resulted the decrease of the EDI and BAT scores with the average of one third. The follow up also reported favourable results 5. Conclusions 5.1 Differentiation on symptom subtypes of obsessive- compulsive disorder: a factor analytic study Our findings identified different symptom dimensions and confirm the hypothesis that obsessive-compulsive disorder is a multidimensional and heterogeneous condition.this study independently replicates recent reports and opens the possibility for future neurobiological and treatment response studies. 5.1 Citalopram neuroendocrine challenge test in obsessivecompulsive disorder and healthy controls This study was the first in the literature to use citaopram challenge test in obsessivecompulsive disorder. The effect of citalopram test can be a promising tool in the investigation of serotonergic function in OCD but the neuroendocrine response must be differ from the results in depressed patients. In citalopram challenge test the change in body temperature and the amount of side effects can have a predictive value for treatment outcome in patients with OCD. 5.3 The impact of physical and sexual abuse on body image in eating disorders This research effort was the first to emphasise the importance of physical abuse in the etiopathogenesis of eating disorders. The childhood physical abuse seems to be a more important factor in the development of body image distorsion than we thought before, its importance must be greater than sexual abuse. The physical abuse, the laxative abuse and

the binge-purge subtype anorexia nervosa is a considerable risk factor for the severity of the distorsion in body image, and their presence makes the prognosis of the eating disorder worse. Further studies of the nature of these relationships are warranted. 5.4 The effectiveness of psychodramatic group therapy in eating disorders I probe the basic elements of psychodrama therapy such as doubling, mirroring and role reversal which were found to be effective in the treatment of alexithymic patients with eating dosirders, who usually split between their emotional and rational problem areas. The psychodramatic therapy was found very useful in the treatment of eating disorders and body image disturbances. Psychodrama can be also suggested as a cost effective treatment in everyday psychotherapy practice for eating disorders. Acknowledgements I am very gratefully acknowledge the work of the following collegues: Prof. János Füredi, Erika Szádóczky, Attila Németh, Sándor Rózsa, György Bagdy, Nagy Sándorné, Ozoróczyné Ilona Szász, Mihály Arató, Erika Vandlik, Zsolt Fábián, Zsófia Sáfrán, László Varga, Tamás Kurimay, Eszter Lukács, Kenéz Mórotz, István Boncz, Péter Gaszner. 7. Related publications Scientific articles Treuer T.: A rögeszmés-kényszeres zavar. (1990). Diplomamunka, konzultáns: dr. Faludi Gábor, opponens: Prof. Tringer László, 5 (jeles) SOTE Pszichiatriai Klinika, 1990. március, Semmelweis Orvostudományi Egyetem, megtekinthető a Klinika könyvtárában, 1-56 oldal. Treuer T..: A kényszerbetegség és kezelése. (1996). In.: Háziorvosi Továbbképző Szemle, 1996. No. 1. 98-101. Treuer T.: Egy bulimiás páciens pszichoterápiás kezelése (1996). In.: Hírmondó, az Integratív Pszichoterápiás Egyesület folyóirata, 1996/8. szám 65-87. Németh A., Lukács E., Vandlik E., Mórotz K., Juranovics J., Arató M., Treuer T.: Trichotillománia - 12 beteg adatainak feldolgozása alapján (1996). In.: Psychiatria Hungarica, 1996, 11(5): 527-536. Németh A., Lukács E., Mórotz K., Treuer T., Vandlik E., Boncz I.: Kóros játékszenvedély - 12 beteg adatainak feldolgozása alapján (1996). In.: Psychiatria Hungarica, 1996, 11(5): 537-546. Németh A., Arató M., Treuer T., Vandlik E.: Treatment of Fluvoxamine-Induced Anorgasmia With a Partial Drug Holyday. (1996). In.: American Journal of Psychiatry, letter, 153:10, October 1996, p1365. Treuer T.: Szorongásos zavarok: pánikbetegség, a fóbiák és a kényszer. (1997). In.: Praxis, Vol. 6. No. 10. 37-41. oldal, 1997

Treuer T.: A pszichoszomatikus zavarokról (1997) In.: Medinfo, (1997). Volume I. No. 4. p19-20. Treuer T.: Az evészavarok kezelése (1997). In.: Diéta, II. évf. 8. szám, 32-33. Treuer T., Fábián Zs.: Információátviteli és feldolgozási sajátosságok a különböző pszichiátriai zavarokban: a pszichoterápiás és biológiai megközelítések szintézisének egyik lehetősége (1998). Pszichoterápia, 1998, VII. évf., 249-254. Fábián Zs., Treuer T.: Információ és a lelki működések: Információelmélet egy lehetséges szemlélet a pszichiátriában (1998).. Psychiatria Hungarica, 1998, 13:1, 71-80. Treuer T., Németh A., Füredi J.: Hungarian psychotherapist about psychotherapy: a result of a survey (2000). In.: Psychotherapy and Psychosomatics, 2000, 69:163-164. Treuer T., Németh A., Rózsa S., Füredi J.: A kényszerbetegség tüneti altípusainak elkülönítése faktoranalízis segítségével (2001). In.: Psychiatria Hungarica, 2001, 16 (3): 269-278. Treuer T., Fábián Zs., Füredi J.: Internet addiction associated with features of impulse control disorder: is it a real psychiatric disorder? (2001). In.: Journal of Affective Disorders, ed. let, 2001, 66 (2-3): 283. Treuer T., Fábián Zs., Füredi J.: Fizikai abúzus, szexuális abúzus és testképzavar összefüggése evészavarokban (2001). In.: Pszichoterápia, 2001, 10 (4): 248-252. Treuer T., Sáfrán Zs.,: Evészavarban szenvedők pszichodramatikus csoportterápiájának hatásvizsgálata és tapasztalatai - Szakirodalmi áttekintés és módszerbemutatás (2001). In.: Pszichoterápia, 2001, 10 (5): 342-350. Treuer T., Németh A., Rózsa S., Füredi J.: Dimensionality of the Obsessive Compulsive Disorder: Factorial Validity of Yale-Brown Obsessive Compulsive Scale Symptom Checklist. (2001) In.: Psychopathology (submitted for publication). Treuer T., Koperdák, M., Fábián Zs, Füredi J.: The impact of physical and sexual abuse on body image in eating disorders (2001) In.: Psychosomatic Medicine (submitted for publication). Treuer T., Németh A., Bagdy Gy.: Citalopram challenge test in obsessive-compulsive disorder and in healthy controls. (2001) In.: Psychiatry Research (submitted). Gerevich J., Treuer T., Danics Z., Herr J.: A kényszeres szexuális viselkedés nem parafíliás formájaként jelentkező szexuális addikció diagnosztikai és pszichodinamikus vonatkozásai. Psychiatria Hungarica, 2001, 16 (3): 269-278. Lectures related to this work Treuer T., Németh A., Kurimay T., Vandlik E., Füredi J.:Kényszerbetegek családjának vizsgálata McMaster Családfelmérő Kérdőív segítségével (1996). Előadás a Magyar Pszichiátriai Társaság V. Vándorgyűlésén, Gyula, 1996. február 28-március2. Treuer T., Juranovics J., Németh A., Arató M., Bagdy Gy.: Citalopram challenge test in obsessive-compulsive disorder. (1997) European Congress of Neuropsychopharmacology, Vienna Sept. 13-17. 1997. Vandlik E., Németh A., Treuer T.: A szkizo-obszessziv spektrum (1996). Előadás a Magyar Pszichiátriai Társaság V. Vándorgyűlésén, Gyula, 1996. február 28-március 2. Németh A., Lukács E., Vandlik E., Juranovics J., Arató M., Mórotz K., Treuer T., Zieber É.: Trichotillománia (1996). Magyar Pszichiátriai Társaság V. Vándorgyűlése, Gyula, 1996. február 28-március 2. Németh A., Lukács E., Treuer T., Vandlik E.: Kóros játékszenvedély (1996). Magyar Pszichiátriai Társaság V. Vándorgyűlése, Gyula, 1996. február 28-március 2.

Treuer T., Németh A. Füredi J.: Pszichoterapeuták a pszichoterápiáról: egy kérdőíves felmérés tanulságai (1996). Előadás a Magyar Pszichiátriai Társaság Nemzeti kongresszusán, Siófok, 1997. január 28. Treuer T.: A kényszerbetegség tüneti alcsoportjai (1999). Az MPT Vándorgyűlése, Debrecen, előadás, 1999. Január, 26-29. Treuer T., Varga L., Fábián Zs.: Testkép-Öndestruktivitás-Női identitás: evészavarban szenvedők pszichodramatikus csoportterápiájának hatásvizsgálata és tapasztalatai. (1999). Előadás és módszerdemonstrációs workshop. A Magyar Pszichiátriai Társaság VIII. vándorgyűlésén, 2000. január 26-29. Győr. Treuer T., Németh A. Füredi J.: Hungarian psychotherapists about psychotherapy: a result of a survey. (1999). Előadás a World Congress of Psychotherapy konferencián, Bécs, 1999. Június 8. Treuer T., Fábián Zs., Füredi J.: Fizikai abúzus, szexuális abúzus és testképzavar összefüggése evészavarokban (2001). Előadás. A Magyar Pszichiátriai Társaság IX. vándorgyűlésén, 2001. január 26-29. Miskolc. Citable abstracts related to the topic Treuer T., Nyilas Zs., Tar A., Zádor Gy., Sineger E., Gaszner P.: Antidepressive Therapy with a Well Proved Antidepressant: Five Years Experience with Fluvoxamine (Fevarin). (1993). In.: Neuropsychopharmacology, Vol. 9. No. 25. 1993. Supplement, Raven Press. Treuer T., Juranovics J., Németh A., Arató M., Bagdy Gy.: Citalopram challenge test in obsessive-compulsive disorder. (1997) Poster: ECNP Congress, Vienna Sept. 13-17. 1997. In.: European Neuropsychopharmacology, supplement, 1997, Volume 7., S23. Németh A., Szádóczky E., Treuer T., Vandlik E., Papp Zs.: Epidemiology of OCD in Hungary. Poster: ECNP Congress, Vienna Sept. 13-17. 1997. In.: European Neuropsychopharmacology, supplement, 1997, Volume 7., S234. Vandlik E., Németh A., Treuer T., Arató M.: Pure OCD - does it exist? Study of comorbidity in OCD. European Neuropsychopharmacology 7 (1002) (1997) pp. S240-S240. Treuer T., Németh Attila, Vitrai József, Füredi János: Identifying Symptom Subtypes of Obsessive Compulsive Disorder: a Factor Analytic Study. (1998) Poster: ECNP Congress, Paris Nov. 13-17. 1998. In.: European Neuropsychopharmacology, supplement for ECNP, 1998, Volume 7., S220 Chapters in Handbooks Gaszner P., Treuer T.: The Pharmacological Treatment of Depression. In: New Aspects of Antidepressants in Depression - New Perspectives. Edited by Radu Vrasti, B.I.C. ALL Bucuresti, Temesvar, Roumania, p199-218. 1992. Tankönyvfejezet. Németh A., Treuer T.: A kényszerbetegség (2001). A Pszichiátria Magyar Kézikönyve, Bővített, átdolgozott II. kiadás, szerk.: Füredi-Németh-Tariska, Medicina Könyvkiadó, Budapest, 447-462. oldal. Treuer T., Fábián Zs.: Információátvitel és feldolgozás a pszichiátriai zavarokban (2001). A Pszichiátria Magyar Kézikönyve, Bővített, átdolgozott II. kiadás, szerk.: Füredi-Németh-Tariska, Medicina Könyvkiadó, Budapest, 447-462. oldal.