JOURNAL READINGOBSESSIVE – COMPULSIVE SYMPTOMS IN FIRST

EPISODE PSYCHOSIS AND IN SUBJECTS AT ULTRA HIGH RISK FOR DEVELOPING PSYCHOSIS; ONSET AND RELATIONSHIP TO PSYCHOTIC SYMPTOMS

Pembimbing : dr. Elly Noerhidajati, SpKJPresented by : Afifatul Hakimah (01.209.5822)

Introduction it has been noted that co-occurrence of

obsessive – compulsive symptoms (OCS) and obsessive – compulsive disorder (OCD) is frequently seen in patients with schizophrenia and related disorders

Introduction Recent studies reveal high co-morbidity

rates for OCS in schizophrenia patients varying from 7.8% to 46.6%

Prevalence rates for OCD reported in schizophrenia populations vary from 7.8% to 26%

Estimated prevalence figures for OCS in the general population are similar (21 – 24%), but clearly lower for OCD (2 – 3%)

Introduction The wide range of reported co-

occurrence rates of OCS in schizophrenia patients is probably due to differences in definitions of obsessive –compulsive features and sample characteristics (i.e. Age of subjects, inpatient-outpatient, stage of illness)

Earlier studies concluded that patients with schizophrenia can develop OCS as a sign of emerging reality testing of psychotic symptoms and stated that the presence of OCS could be an indicator of good prognosis

However, subsequent studies reported poorer outcome and higher levels of positive and negative symptoms in schizophrenia patients with OCS

Hypotheses concerning the association of OCS in schizophrenia :

OCS in schizophrenia might be considered as a subtype of schizophrenia

Second, the occurrence of OCS in schizophrenia patients may be associated with the treatment with second generation antipsychotic medications

OCS in schizophrenia might be considered as a subtype of schizophrenia OCS can either begin prior, during or after the first

episode of psychosis (FEP). If OCS typically occurs prior to FEP, it would be likely that OCS together with schizophrenia can be seen as above

mean age at onset of OCS in patients with first episode schizophrenia reported by Poyurovsky et al is 16.6 years (SD 8.7) and the mean age at onset of psychosis is 23.4 (SD 5.9) years, this would also support the hypothesis

high incidence of OCS in patients at ultra high risk (UHR) of developing psychosis [18], suggesting that OCS could be a part of the prodromal phase of schizophrenia.

The occurrence of OCS in schizophrenia patients may be associated with the treatment with second generation antipsychotic medications

Byerly et al . [19] report in their study that OCS predominantly concurs with, or develops after the onset of the psychotic disorder in patients with schizophrenia or a schizoaffective disorder

Purpose to assess the prevalence of OCS and OCD

among all referrals with a FEP or with a potential UHR

determined the time of onset of OCS related to the time of onset of FEP: prior, during or after first episode psychosis

Materials and methods Participants

Subjects with FEP and subjects who are at ultra high risk of developing psychosis, located in the Academic Medical Centre from 1 July 2006 until 1 July 2008.

Sampling technique : consecutive

Instruments and procedure

All cases were discussed in a weekly meetingwith three senior psychiatrists and all residents andResearchers are involved

patients were

interviewed by

psychiatrist or a

psychologist with

extensive clinical

experience In this approximately 2-h face-to-face interview, subjects were asked about their premorbid history of complaints, psychotic symptoms, OCS and general characteristics.Diagnosis of psychotic disorders was established using the Comprehensive Assessment ofSymptoms and History (CASH) schedule

All cases were discussed in a weekly meeting with three senior psychiatrists and all residents and researchers involved

Diffi culties in assessing symptom status or diagnostic criteria were discussed and resolved by reaching agreement between all professionals involved

In referrals to the diagnostic facility of our clinic with no evident psychosis, the Structured Interview for Prodromal Syndromes (SIPS) was administered

Patients were alsoclassified as being UHR when they had a genetic risk and reduced functioning or brief limited intermittent psychotic symptomsin a separate interview the parents or guardians were asked about the premorbid emergence and presence of symptoms and signs of the patientpatients whose obsessional thoughts or compulsions are elated exclusively to psychotic content of thoughts are not included in the OCS or OCD group

After the diagnostic procedure the presence of OCS was assessed independently by two of the authors (B.S.,K.L.), taking longitudinal, clinical, and heteroanamnestic information into account

all patients were screened for the presence of OCS and if present, we determined the time of onset of OCS

To determine ethnicity we used the classification used by the Dutch Central Bureau of Statistics

Statistical analyses All statistical analyses were performed

using SPSS 16.02 software. By using chi-square tests and logistic

regression we compared different variables (gender, ethnicity, living in Amsterdam or not) in patients with OCS to patients without OCS.

Results

Results

Results

Discussion In this study 9.3% of the patients with

recent onset schizophrenia, schizophreniform or schizoaffective disorder had OCS, when a strict definition of OCS used. 1.5% also met the criteria for OCD

These prevalence figures for OCS and OCD are not as high as reported prevalence rates in other recent studies that examined OCS and OCD in schizophrenia and related disorders

In contrast with the relatively low prevalence rates for OCS and OCD in schizophrenia and related disorders in our sample, we did find relatively high rates of OCS (20.7%) and OCD (3.4%) in UHR patients, although this finding should be interpreted with caution, since the sample size of this UHR group was reasonably small (N 29) and predominantly male.

Unike Byerly et al . [19], we found no significant difference between the time of onset of OCS prior to or after the time of onset of first-episode psychosis

Also we did not confirm the finding that OCD precedes the onset of schizophrenia in co-morbid patients as found at a trend level in the meta-analysis by Devulapalli and colleagues

An explanation of these differences might be the heterogeneity and possible selection bias (i.e. Chronically ill and older age at assessment) in the study samples included in this meta-analysis. We specifically studied a young, recent-onset population

The equal distribution of the time of onset of OCS related to the time of onset of first-episode psychosis suggests that OCS and schizophrenia are two separate disorders which have their onset in adolescence

However, it could still be that both hypotheses, OCS as a schizophrenia-subtype and OCS induced by antipsychotic medication, are true. It is not ruled out that maybe a small number of the patients with OCS occurrence prior to FEP suffer from a ‘ schizo-obsessive ’ disorder, and possibly another subgroup of patients with OCS occurrence after FEP, developed OCS associated with the effects of antipsychotic medication.

We found prevalence rates of OCS and OCD in patients with schizophrenia that are almost the same, or even lower, as the rates of OCS and OCD found in the general population.

More importantly, these findings show lower prevalence rates of OCS and OCD in schizophrenia than many other studies.

This difference might be caused by several reasons: Our criteria for defining OCS were strict: obsessive –

compulsive symptoms needed to be unrelated to the psychotic content.

The symptoms of schizophrenia or related disorders in our patients were probably not as severe as chronic schizophrenia patients as described in other studies.

Most patients were not using antipsychotic medication yet or had only recently started antipsychotic medication.

It has been suggested by other authors that the use of low dose of antipsychotic medication may reduce OCS in schizophrenia and schizophrenia related disorders

Limitations The sample size might be still insufficient to

comprehensively evaluate the prevalence of OCS and OCD and the association of occurring OCS with the onset of first-episode psychosis.

There might be a reporting bias On the other hand, OCS might have been over

reported due to the possible presence of referral bias

Although we suppose that we were able to include almost all FEP in contact with mental health care in Amsterdam, we probably have missed several cases.

The relatively small sample of UHR subjects precludes more definitive conclusions to be drawn.

Conclusion we found a relatively low prevalence of OCS and OCD in a

large consecutively diagnosed cohort of patients with a first episode of schizophrenia or related disorder.

OCS either developed prior, during, or after the onset of FEP, which may have implications for understanding the relationship of the two conditions and their association with each other.

We found a relatively high incidence of OCS in subjects who met UHR criteria, possibly prodromal for FEP, suggesting that OCS might be a part of the prodromal phase of first-episode psychosis.

The predictive validity of OCS for transition to psychosis in UHR subjects warrants further investigation.

CRITICAL APPRAISAL

Identitas Jurnal Title : Obsessive – compulsive

symptoms in first episode psychosis and in subjects at ultra high risk for developing psychosis; onset and relationship to psychotic symptoms

Author : Bouke Sterk , Kay Lankreijer , Don H Linszen , Lieuwe de Haan

Pubisher : Australian and New Zealand Journal of Psychiatry

• Tahun terbit : 2011

PICO Patients : first episode psychosis patients

and ultra high risk subjects Intervention : Obsessions and compulsions

were defined in accordance with DSM-III-R criteria and assessed by clinicians

Comparison : previous studies Outcome : prevalence of OCS and OCD

among all referrals with a FEP or with a potential UHR

Critical Appraisal

Title :consists more than 12 wordscontent : describe enough the content of the study, interesting enough, without abbreviation

Author :Bouke Sterk , Kay Lankreijer , Don H Linszen , Lieuwe de Haan

The authors are psychiatrists from Department of Psychiatry, Academic Medical Centre, University of Amsterdam and their journal was published at Australian and New Zealand Journal of Psychiatry

Publisher :Australian and New Zealand Journal of Psychiatry

the publisher is one of well-known publisher among Netherlands and Europe.

Abstract :(+): Di dalamnya terdapat Tujuan, Bahan dan

Metode, Hasil Diskusi, kesimpulan Kata kunci dicantumkan dan tepat

(-): jumlah kata>321

Result :dijelaskan dengan lengkap

methods:Metode tidak dijelaskan secara ekplisit tetapi dapat diketahui bahwa study ini merupakan observational study.

Sampling:subjects that qualified with Comprehensive Assessment of Symptoms and History (CASH) schedule, Structured Interview for Prodromal Syndromes (SIPS), The Scale of Prodromal Symptoms (SOPS), and Structured Clinical Interview for DSM-III-R

Sampling technique : consecutive sampling

Conclusion :Kesimpulan menjawab tujuan dari penelitian

Reference :Referensi yang digunakan sesuai tetapi beberapa diantaranya diterbitkan tahun 1990an.

ValidITYQuestion Were subjects chosen randomly?

No

Were the observation long enough and detailed?

No

Were randomized subjects analyzed?

No

Were subjects and clinician blinded in medication, besides medication that examined?

No

Were the therapeutic group and controlled group homogen?

Unknown

Application Question are there any differences in our patients compared with this study so that the findings cannot be applied to our patients?

Unknown

Was the therapy applicable to our patients?

No

Were the patients have beneficial or harmful potention whether the therapy being applied?

Unknown

Conclusion

Clinical evidence : not valid cannot be applied