ReviewThe obsessive compulsive spectrum in schizophrenia, a meta-analysis and meta-regression exploring prevalence rates
Introduction
After modifying the diagnostic hierarchical DSM-rules that excluded co-morbid conditions in schizophrenia with the introduction of DSM-IIIR in 1987, the remarkably high co-occurrence of obsessive compulsive spectrum disorders in schizophrenia has resulted in a growing interest in the topic. Co-morbidity of schizophrenia and obsessive compulsive symptoms (OCS) or obsessive compulsive disorder (OCD) has clinical implications, as this type of co-morbidity is associated with greater dysfunction, poorer quality of life, more suicide attempts and a smaller social network (Lysaker and Whitney, 2009). Most studies also report an association between co-morbid OCS and higher levels of positive, negative and depressive symptoms, although a meta-analysis found this association in OCS and not in OCD (Cunill et al., 2009). Adequate recognition of OCS in schizophrenia is of great clinical importance. OCS is a condition causing additional suffering but may respond well to treatment. Research suggests that successful treatment of OCS with, for instance, serotonergic antidepressants leads to a significant reduction of psychotic symptoms as well (Reznik and Sirota, 2000).
Reported prevalence rates however show a striking variation. OCS, defined as the presence of obsessions and compulsion not severe enough to meet the diagnostic criteria of OCD may occur as high as in 64% (Kayahan et al., 2005) of patients with schizophrenia. Reported OCD co-morbidity ranges between 0% and 59% across studies (Bland et al., 1987, Fabisch et al., 2001). Overall, these prevalence rates are much higher than in the general population where the lifetime prevalence for OCD is 1.6% (Kessler et al., 2005a). Interestingly, even though patients with schizophrenia often have co-morbid conditions(Buckley et al., 2009), the difference between the prevalence of OCS in schizophrenia patients and the community is much more pronounced than with other anxiety disorders and depression(Bijl et al., 1998, Achim et al., 2011). The reason for this high co-occurrence of OCS in schizophrenia is still not fully understood. A number of factors are potentially associated with the prevalence estimate of OCD/OCS in schizophrenia. These include measurement issues such as the instruments and diagnostic thresholds used to define OCS and OCD, sampling methods, as well as patient characteristics such as age, gender, cultural background, severity and chronicity of psychotic disorder, and treatment setting. The importance of these factors is shown by the fact that two earlier reviews that addressed the issue of anxiety disorders in schizophrenia found substantially differing figures. Buckley et al. (Buckley et al., 2009) calculated a weighted average from 36 studies providing prevalence rates and estimated the prevalence of OCS to be 25% and OCD to be 23%. Achim et al. (2011) also performed a meta-analysis of all anxiety disorders in schizophrenia but found a mean prevalence of 12.1% for OCD and provided no information on OCS.
The current study will focus specifically on the whole OCS spectrum, including OCS prevalence rates at specific Y-BOCS cut-off points. It aims to provide a best estimate of both OCS and OCD prevalence in schizophrenia patients. Second, this study intends to identify the variables associated with a higher OCS/OCD prevalence rate through meta-regression analysis.
Section snippets
Literature search and study selection and data retrieval
Studies were selected by performing an online OVID database search, including PsychInfo, Embase and Medline up to December 2009. The following keywords were used: “psychosis or schizophrenia”, “obsessive compulsive”. All potentially relevant articles were screened manually by title and, if necessary, by abstract. All reviews and relevant articles were checked for references. All articles reporting on the prevalence of OCS/OCD in patients with schizophrenia spectrum disorder were assessed by two
Study selection
The literature search yielded 2895 articles; an additional 15 articles were identified by hand search. We identified 70 studies that reported original data on OCD or OCS in patients diagnosed with schizophrenia spectrum disorders. Fig. 1 shows the process of identifying and selecting relevant articles. Three studies were excluded because their subject selection was likely to influence the OCS prevalence. One study included only non-disabling OCS, excluding patients suffering severe symptoms (
Main findings
To our knowledge, this is the first meta-analysis and meta-regression specifically addressing the whole spectrum of OCS/OCD in schizophrenia. Unlike earlier reviews, we distinguish between OCD and OCS, also addressing different thresholds used on the Y-BOCS. By focusing on obsessive–compulsive psychopathology rather than the full spectrum of anxiety disorders, and by using strict study selection criteria as well as meta-regression of variables potentially affecting prevalence estimates, our aim
Conclusion
Our results show that OCD is fairly common in schizophrenia, with a 13.6% prevalence estimate after meta-regression and a higher prevalence in chronic populations. The prevalence estimate of OCS, defined as any obsession or compulsion is 30.3% after meta-regression. Our results indicate that OCS/OCD should be diagnosed in a more uniform way to improve the identification and evaluation of treatment of this type of co-morbidity. Assessment of OCS should be routine in the intake of any patient
Role of funding source
The Arkin Mental Health Centre of Amsterdam has partially funded the salary of some of the authors and provided the statistical software.
Contributors
M. Swets performed the literature search, the analyses and wrote the first draft of the manuscript.
R schoevers helped design the study and write the protocol. He wrote the second draft.
F. Smit and G Smid helped design and conduct the meta-regression analyses.
K van Emmerik-van Oortmerssen, L de Haan and J Dekker contributed to the writing of the final manuscript.
Conflict of interest
None of the authors have any conflict of interest regarding this manuscript.
Acknowledgement
We thank the Arkin Mental Health Centre for its practical support during the preparation for our manuscript.
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