Obsessive compulsive symptoms in Egyptian schizophrenic patients Aeida S. El Dawla, Tarek Assad, Mahmoud M. El Habiby, Eman M. Shorub and Rania Kasem

Original article 21 Obsessive compulsive symptoms in Egyptian schizophrenic patients Aeida S. El Dawla, Tarek Assad, Mahmoud M. El Habiby, Eman M. Shorub and Rania Kasem Neuropsychiatry Department, Institute of Psychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt Correspondence to Eman M. Shorub, MD, PhD, Neuropsychiatry Department, Institute of Psychiatry, Faculty of Medicine, Ain Shams University, Postal Code 22, Cairo 11657, Egypt Tel/fax: + 01003080305; e-mail: emanshorab@yahoo.com Received 3 May 2014 Accepted 27 October 2014 Middle East Current Psychiatry 2015, 22:21 26 Background Despite the growing body of evidence supporting the existence of an epidemiologic and biologic relation between obsessive compulsive disorder and schizophrenia, the association remains poorly understood. Patients and methods The sample consisted of 60 individuals, 30 healthy controls and 30 patients, of both sexes, recruited from the outpatient clinics and inpatient wards of the Institute of Psychiatry, Ain Shams University. The included patients had to fulfill the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., criteria for schizophrenia and had to be aged between 18 and 60 years. All participants were subjected to psychiatric assessment for obsessive compulsive symptoms on the basis of the Yale Brown Obsessive Compulsive Scale and to functional assessment on the basis of the Global Assessment of Function scale. Results The frequency of obsessive compulsive symptoms and obsessive compulsive disorder in the sample was estimated to be 23.3 and 13.3%, respectively. The most frequent obsessions were contamination (30%), religious obsession (26.7%), and sexual ideas (16.7%). The most common compulsions were cleaning (33%), checking (23.3%), and hoarding (16.7%). There was no significant correlation between Axis IV, admission times, and Yale Brown Obsessive Compulsive Scale s. Conclusion This study concluded that obsessive compulsive symptoms are prevalent among schizophrenic patients, especially among those with paranoia, and strongly affect the global functions of those patients. Keywords: Egyptian sample, obsessive compulsive disorder, obsessive compulsive symptoms, schizophrenia, Yale Brown Obsessive Compulsive Scale Middle East Curr Psychiatry 22:21 26 & 2015 Institute of Psychiatry, Ain Shams University 2090-5408 Introduction The connection between obsessive compulsive symptoms (OCS)/obsessive compulsive disorder (OCD) and schizophrenia has been of interest to clinicians and researchers since the beginning of this century [1,2]. OCS have been frequently studied in patients with schizophrenia, with the majority showing an increased rate of both OCS and OCD [3 7]. Recent studies have reported prevalence rates for OCD in schizophrenia ranging from 7.8 to 25%. OCS have been found in up to 60% of schizophrenic patients [8,9]. The term schizo-obsessiveness was coined by Hwang and Opler in 1994 and refers to a dual diagnosis of schizophrenia and OCD or OCS. Although large variance exists in the documented prevalence rates of schizo-obsessive disorder, higher than expected comorbidity rates for OCD and schizophrenia have ignited a controversy. It remains unclear whether this reflects a true comorbidity, more severe illness, or perhaps a unique diagnostic subcategory of schizophrenia [10]. Emerging neurobiological and genetic evidence suggests that persons with comorbid OCD and schizophrenia may represent a special category of the schizophrenic population. A different neuroanatomical profile has also been associated with schizophrenia and comorbid OCD. MRI studies have identified significantly reduced volumes in the left hippocampus, frontal lobes, and anterior horn of the lateral and third ventricle in schizophrenic patients with OCS when compared with their schizophrenic counterparts without OCS [11]. In addition, schizo-obsessive patients show more neurological signs, motor symptoms including catatonia, loss of motor ability or hyperactive motor activity, and extrapyramidal symptoms compared with schizophrenic patients, and more tics when compared with patients with OCD [12,13]. The presence of OCD in schizophrenic patients is reported to predict cognitive impairment, a severe course, greater social isolation, poor outcome, and greater resistance to treatment, compared with patients without 2090-5408 & 2015 Institute of Psychiatry, Ain Shams University DOI: 10.1097/01.XME.0000457268.13354.e8

22 Middle East Current Psychiatry OCS [9]. The aim of this work was to investigate the frequency of OCS in an Egyptian sample of schizophrenic patients and evaluate the association between OCS and schizophrenia. Patients and methods This was designed as a cross-sectional case control study. It was conducted in the outpatient clinics and the inpatient ward of the Institute of Psychiatry, Ain Shams University Hospitals, located in Eastern Cairo, which serves a catchment area of about a third of greater Cairo. It serves both urban and rural areas, including areas around greater Cairo as well. Patients Thirty patients fulfilling the diagnosis of schizophrenia using the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria were chosen in a convenient manner from among the outpatients and inpatients of the Institute of Psychiatry, Ain Shams University Hospitals. Thirty healthy volunteers were included as a control group. Both cases and controls were matched for sex and age to avoid selection bias. The study was performed from November 2012 until July 2013. Inclusion criteria (1) Patients aged 18 60 years. (2) Patients of either sex. (3) Patients on medication or not. Exclusion criteria (1) Having major physical illness (major cardiac, hepatic, or renal problems). (2) Agitated patients. Procedures The study was conducted in the outpatient clinics and inpatient department of the Institute of Psychiatry, Ain Shams University Hospitals. All individuals who signed a written informed consent form according to the rules of the ethical committee involved in the study were assessed using the following tools: (1) A detailed psychiatric sheet stressing on the following: demographic information, medication history, physical history, and physical examination. (2) Structured clinical interview for DSM-IV Axis I Disorders (SCID-I): It is a clinician-administered semistructured interview for use in psychiatric patients. It is used for the diagnosis of both schizophrenia and OCD. It provides a broad coverage of psychiatric diagnosis according to DSM-IV and consists of nine diagnostic modules (mood episode, psychotic symptom, psychotic disorder differential, mood disorder differential, substance use, anxiety, somatoform disorder, eating disorder, and adjustment disorder). It was designed to be more efficient and simpler to use than other existing instruments and, consequently, to require less time for training and administration [14]. (3) The Yale Brown Obsessive Compulsive Scale (YBOCS): The Arabic version was used to specifically measure the types and severity of symptoms of OCD. OCD patients seeking treatment usually obtain s of 17 or higher. It has five items on obsessions and five items on compulsions, each with a ranging from 0 to 4, where 0 = no symptom, 1 = mild symptoms, 2 = moderate symptoms, 3 = severe symptoms, and 4 = extreme symptoms; the maximum total is 40. The total ranges of severity for patients who have both obsessions and compulsions are as follows: 0 7 = subclinical, 8 15 = mild, 16 23 = moderate, 24 31 = severe, and 32 40 = extreme. The cutoff for clinically significant symptoms is greater than 16 [15,16]. (4) DSM-IV Axis IV: Global Assessment of Function Scale (GAF): This is a numeric scale used by psychiatrists to subjectively rate the social, occupational, and psychological functioning of adults on a hypothetical continuum of mental health illness and do not include impairment in functioning due to physical (or environmental) limitations [17]. Statistical analyses The computer software package SPSS (version 19; SPSS Inc., Chicago, Illinois, USA) for Windows was used for the data analysis. Continuous variables such as age were expressed as mean ± SD, whereas categorical variables such as sex were presented as frequencies (%). The independent-samples T-test was used to assess the statistical significance of the difference between the mean values of two study groups and the w 2 -test was used to examine the relationship between two qualitative variables. One-way ANOVA was used to assess the statistical significance of the difference between the mean values of more than two study groups. Pearson s correlation test (r) was used whenever a linear relationship between two quantitative data was to be tested. An r of 1.0 indicates that all the plotted points lie on a straight line and that the dependent variable can be predicted from the independent variable with 100% accuracy. Significance level was set at P values less than 0.05. Results Demographic and clinical characteristics across groups The two study groups were matched for age, sex, and education, with no significant differences. The mean age of the patient group was 32.83 ± 7.7 years and that of the control group was 34.47 ± 11.4 years. The majority of respondents were male (76.7%), single (63.3%) and working (20 patients, 66.7%). Meanwhile, there was significant difference between patients and controls regarding marital status and working status because of the burden of the disease on patients.

OCS in Egyptian schizophrenic patients El Dawla et al. 23 Obsessive compulsive disorder prevalence and Yale Brown Obsessive Compulsive Scale s Table 1 shows that the majority of patients had paranoid schizophrenia (56.7%), followed by undifferentiated schizophrenia (26.7%). The prevalence of OCD in the sample on the basis of SCID-I was 13.3% (N = 4). Among the schizophrenic patients, 23.3% (N = 7) had clinically obsessive symptoms; their mean s on the GAF was 55 ± 15.9. Comparison between patients and controls as regards Yale Brown Obsessive Compulsive Scale items Total YBOCS s ranged from 17 to 36. Among the patients, as shown in Tables 2 and 3, the most frequent obsessions were for contamination (30%), religious ideas (26.7%), and sexual obsessions (16.7%) and the most common compulsions were cleaning/washing (33.3%), checking (23.3%), repeating (16.7%), and hoarding (16.7%). As can be seen in Table 4, on the YBOCS Egyptian schizophrenic patients d higher on degree of indecisiveness, pervasive slowness, pathological doubting, global severity, reliability, obsession sub, and total YBOCS, whereas there was a highly statistical significance between cases and controls regarding avoidance (P = 0.008) and insight (P = 0.006). With regard to the diagnosis of patients using one-way ANOVA, cases of paranoid schizophrenia had significantly higher prevalence of obsessions and compulsions with Table 1 Demographic and clinical characteristics Variables Participants [N (%)] Cases (n = 30) Control (n = 30) P-value Age (mean ± SD) 32.83 ± 7.7 34.47 ± 11.4 0.52 Sex Male 23 (76.7) 23 (76.7) 1 Female 7 (23.3) 7 (23.3) Educational level 0.6 Illiterate preparatory 7 (23.3) 6 (20) Secondary 16 (53.3) 14 (46.7) University 7 (23.3) 10 (33.3) Occupation 0.014* Occupied 20 (66.7) 29 (96.7) Unoccupied 10 (33.3) 1 (3.3) Marital status 0.004** Single 19 (63.3) 10 (33.3) Married 8 (26.7) 20 (66.7) Divorced 3 (10) Schizophrenia subtypes Paranoid 17 (56.7) Undifferentiated 8 (26.7) Disorganized 4 (13.3) Catatonia 1 (3.3) OCD (SCID-I) Present 4 (13.3) 2 (6.7) Absent 26 (86.7) 28 (93.3) YBOCS total Subclinical 23 (76.7) 26 (86.7) 0.31 Clinical 7 (23.3) 4 (13.3) Axis IV GAF (mean ± SD) 55 ± 15.9 GAF, Global Assessment Function Scale; OCD, obsessive compulsive disorder; SCID-I, Structured Clinical Interview for DSM-IV Axis I Disorders; YBOCS, Yale Brown Obsessive Compulsive Scale. **Highly significant. higher global severity compared with other types of schizophrenia. Meanwhile, the disorganized schizophrenic patients had less reliability compared with both paranoid and undifferentiated schizophrenic patients. Correlations On using Pearson s correlation, no significant correlation was found between Axis IV, admission times, and the YBOCS items, as seen in Tables 5 and 6. Discussion Co-occurrence of OCS and psychotic illness was recently revived because of increased recognition of higher than expected comorbidity rates and observations of the emergence or exacerbation of OCS during treatment of psychosis with atypical antipsychotics [18 20]. Despite growing knowledge about OCD and schizophrenia, little is known about the links between them, and, to our knowledge, only a few studies have investigated the relationship between OCS and OCD in Egyptian schizophrenic patients. Therefore, the aim of the study was to ascertain the frequency of OCS among patients with schizophrenia in an Egyptian patient sample and assess the relation between the two disorders. In this study, the frequency of OCS and OCD among Egyptian schizophrenic patients was estimated to be 23.3 and 13.3%, respectively. This is consistent with the results of other studies, which have revealed comorbidity rates for OCS in the schizophrenia population of 10 52% [7,21,22] and for OCD of 7.8 26% [23 27]. In addition, In Malaysia, Abdul Hamid and Abdul Razak [28] reported that 15% of their schizophrenic sample met the criteria for OCD. In another study conducted in Iran on 100 schizophrenic patients (in whom antipsychotics were stopped for at least 1 week and who were studied during the first 10 days of hospitalization), 10% had OCD, of whom 6% had OCD before the onset of schizophrenia [29]. These results indicate that schizophrenic patients have a higher possibility of developing OCD when compared with the normal population. However, the observations of the emergence of new OCS with atypical antipsychotic treatment for schizophrenia [18 20,30] raise the possibility that some of these comorbid OCD cases are medication induced. Guillem et al. [31] also reveal a strong positive relationship between psychosis and OCS, which suggests that they share common mechanisms. The most frequent obsessions were contamination (30%), religious obsession (26.7%), and sexual ideas (16.7%). The most common compulsions were cleaning (33%), checking (23.3%), and hoarding (16.7%). Patients with schizophrenia had higher degree of indecisiveness, pervasive slowness, pathological doubting, global severity, and reliability s. In previous studies also the types of obsessions and compulsions experienced by patients with schizophrenia were similar to those found in our results [26,29]. Türkcan et al. [32] have reported contamination and sexual obsessions, cleaning

24 Middle East Current Psychiatry Table 2 Different types of obsessions among cases and controls n (%) Obsessions Cases (n = 30) Controls (n = 30) Total (n = 60) w 2 P-value Aggressive Absent 27 (90) 27 (90) 54 (90) 1 0 Present 3 (10) 3 (10) 6 (10) Contamination Absent 21 (70) 25 (83.3) 46 (76.7) 1.4 0.22 Present 9 (30) 5 (26.7) 14 (23.3) Sexual Absent 25 (83.3) 30 (100) 55 (91.7) 5.45 0.02* Present 5 (16.7) 0 0 Hoarding Absent 27 (90) 30 (100) 57 (95) 3.15 0.07 Present 3 (10) 0 3 (5) Religious Absent 22 (73.3) 23 (76.7) 45 (75) 0.089 0.766 Present 8 (26.7) 7 (23.3) 15 (25) Need for symmetry Absent 27 (90) 26 (86.7) 53 (88.3) 0.162 0.68 Present 3 (10) 4 (13.3) 7 (11.7) Somatic Absent 27 (90) 27 (90) 54 (90) 1 0 Present 3 (10) 3 (10) 6 (10) Miscellaneous Absent 24 (80) 26 (86.7) 50 (83.3) 0.48 0.48 Present 6 (20) 4 (13.3) 10 (16.7) Total obsession Absent 14 (46.7) 21 (70) 35 (58.3) 3.36 0.067 present 16 (53.3) 9 (30) 25 (41.7) Table 3 Different types of compulsions among cases and controls n (%) Compulsions Cases (n = 30) Controls (n = 30) Total (n = 60) w 2 P-value Cleaning Absent 20 (66.7) 24 (80) 44 (73.3) 1.36 0.24 Present 10 (33.3) 6 (20) 16 (26.7) Checking Absent 23 (76.7) 24 (80) 47 (78.3) 0.09 0.75 Present 7 (23.3) 6 (20) 13 (21.7) Repeating Absent 25 (83.3) 26 (86.7) 51 (85) 0.13 0.78 Present 5 (16.7) 4 (13.3) 9 (15) Counting Absent 28 (93.3) 30 (100) 58 (96.7) 2.06 0.15 Present 2 (6.7) 0 2 (3.3) Arranging Absent 28 (93.3) 24 (80) 52 (86.7) 2.3 0.12 Present 2 (6.7) 6 (20) 8 (13.3) Hoarding Absent 25 (83.3) 30 (100) 55 (91.7) 5.45 0.02* Present 5 (16.7) 0 5 (8.3) Miscellaneous Absent 25 (83.3) 29 (96.7) 54 (90) 2.96 0.085 Present 5 (16.7) 1 (3.3) 6 (10) Total compulsion Absent 15 (50) 18 (60) 33 (55) 0.6 0.43 Present 15 (50) 12 (40) 27 (45) compulsions, and repetitive rituals in schizophrenic patients. In addition, in the study by De Haan et al. [33] the obsessions found were similar to ours but checking, arranging, repetition, and washing compulsions had higher prevalence. The differences in types of symptoms in different studies can be due to the characteristics of the disorder, personality background, psychopathology, and chronicity of schizophrenia, course of the disorder, and culture impact. With regard to the diagnosis of the patients, paranoid schizophrenia had significantly higher prevalence of obsessions and compulsions with higher global severity compared with other types of schizophrenia, which may be

OCS in Egyptian schizophrenic patients El Dawla et al. 25 Table 4 Comparison between cases and controls regarding the Yale Brown Obsessive Compulsive Scale YBOCS Patients group (mean) Controls group (mean) Mean difference T P-value Insight 0.6 0 0.6 34.04 0.006** Avoidance 0.3 0 0.3 46.58 0.008** Degree of indecisiveness 0.33 0.03 0.3 36.12 0.012* Overvalued sense of responsibility 0.23 0.1 0.13 6.61 0.22 Pervasive slowness 0.27 0.07 0.2 16.55 0.032* Pathological doubting 0.37 0.07 0.3 19.32 0.035* Global severity 0.57 0.23 0.3 8.39 0.045* Reliability 0.33 0.03 0.29 34.59 0.01* Obsessive sub 2.23 0.8 1.4 13.79 0.02* Compulsive sub 1.96 0.83 1.13 10.66 0.05 Total YBOCS 4.2 1.63 2.56 12.98 0.0358* T, Student s T-test; YBOCS, Yale Brown Obsessive Compulsive Scale. **Highly significant. Table 5 Pearson s correlations between Axis IV and Yale Brown Obsessive Compulsive Scale Variables Axis IV Admission times Insight Avoidance Degree of indecisiveness Overvalued sense of responsibility Pervasive slowness Pathological doubting Global severity Reliability Obsessive Compulsion R 0.067 0.093 0.200 0.286 0.236 0.166 0.347 0.256 0.214 0.116 0.214 P-value 0.726 0.624 0.290 0.126 0.209 0.380 0.061 0.171 0.256 0.543 02.57 Table 6 Pearson s correlations between admission time and Yale Brown Obsessive Compulsive Scale Variables Admission times Axis IV insight avoidance Degree of indecisiveness Overvalued sense of responsibility Pervasive slowness Pathological doubting Global severity Reliability Obsessive Compulsion R 0.067 0.043 0.012 0.097 0.019 0.186 0.007 0.143 0.253 0.119 0.099 P-value 0.726 0.823 0.950 0.609 0.922 0.352 0.972 0.449 0.177 0.531 0.601 due to the participation of more paranoid schizophrenic patients (n = 17) in the study. Meanwhile, disorganized schizophrenic patients had a lower reliability compared with both paranoid and undifferentiated schizophrenic patients, which may be related to the presence of formal thought disorder and the fact that they are more disturbed. Similar to our results, in India, Jaydeokar et al. [34] found that OCS were more prevalent among paranoid schizophrenic patients, with the frequent obsessions being those for contamination and sexual and aggressive thoughts, and frequent compulsions being the need to ask or confuse. Rajkumar et al. [35] studied the clinical profile of schizophrenic patients with and without comorbid OCD. They found that schizo-obsessive patients were more likely to have paranoid symptoms and first-rank symptoms of schizophrenia [35]. There was no significant correlation between admission times (as a reflection of the duration of illness) and YBOCS. These results are in accordance with those of Hosseini et al. [29], who reported no significant relationship between demographic factors, rank of hospitalization, duration of symptoms, age, and severity of schizophrenia in the group with OCS, but are in contrast to the results of Hemrom et al. [36] and Jaydeokar et al. [34], who suggested that schizophrenic patients with OCS had significantly longer duration of illness. These symptoms were more prominent in patients with more than 5 years of total duration of illness. With regard to DSM-IV Axis IV (GAF), in our study the Axis IV was higher among those diagnosed clinically with OCS compared with those who were not (60 ± 16.3 vs. 54.48 ± 15.8); yet, no statistical significance was found between the two groups (P = 0.17). In contrast, Nolfe et al. [37] found that the average GAF s were higher in patients without OCS compared with patients with OCS. This discrepancy may be attributed either to the small number of our sample or to the fact that OCS in schizophrenia has a protective effect on functioning. Therefore, the GAF should be applied on a larger sample of patients for further validation. The present study has several limitations. The small sample size might have affected the accuracy of the prevalence rate and factors associated with OCS in schizophrenic patients and prevented us from conducting further analyses comparing subgroups based on diagnosis. Moreover, the cross-sectional nature of the study limited our ability to draw causal inferences on OCS or OCD and schizophrenia. Further, we did not investigate the drug

26 Middle East Current Psychiatry history of the patients in a way that could be included in a research to reveal the effects of antipsychotic medications on OCS. Despite these limitations, the current findings are important in clarifying the relation between OCS and schizophrenia, and provide guidance for future research. In conclusion, OCS are prevalent among schizophrenic patients, especially among those with paranoia, and strongly affect the global functions of those patients. Recommendation Detailed assessment of schizophrenic patients is required to evaluate probable comorbid OCS as subsyndromal symptoms as it may require treatment for a longer duration and possibly require additional interventions. Acknowledgements The authors thank patients and controls for their participation and cooperation. Conflicts of interest There are no conflicts of interest. References 1 Hwang MY, Hollander E. Schizo-obsessive disorders. Psychiatr Ann 1993; 23:401. 2 Zohar J. 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