Resistant obsessive compulsive disorder (ROC): predictive factors and links with soft bipolarity

Background

In the collaborative survey of AFTOC (French Association of patients suffering from OCD) in which 612 OCD patients were included, we observed a high rate of soft bipolar comorbidity in OCD: 30% with hypomanic episodes and 50% with cyclothymia, "Cyclothymic OCD" appeared as a distinct form with a different clinical picture, episodic course of illness; higher rate of recurrent depression; suicide attempts and psychiatric admissions; and less favorable response to anti-OCD drug therapy (Hantouche et al., 2003).

Materials and methods

Following these data, a new survey of AFTOC was implemented with the aim of exploring ROC, Resistant OCD.

Results

The new survey of AFTOC "TOC and ROC" have selected a sample of 360 patients, who are members of the association. The rate of ROC was 44.2%, 25.3% of Good responders (GR), and 30.5% in between. Inter-group comparisons (vs GR) showed in the ROC group significant higher rates of psychiatric admissions (49% vs 28%), suicide attempts (26% vs 13%), cases with slow and continuous course of illness (69% vs 48%, p = 0.001); higher numbers of doctors consulted (5.5 vs 3.2), compulsions (4.6 vs 3.4), and psychiatric comorbidity (2.8 vs 2.0, especially agoraphobia, depression and worry about appearance). Rate of worsening under SRI drugs was higher in ROC (21% vs 10% (p = 0.0115), and also of mood switching (42% vs 27%, p < 0.001). Cyclothymic Temp (63% vs 43%, p = 0.003), depressive Temp (72% vs 53%, p = 0.004), and Irritable Temp (21% vs 9%, p = 0.02) were more represented in ROC. Logistic regression analyses (Stepwise method) showed that the most powerful factors were slow and continuous course of illness (OR = 2.2), worsening under SRIs (OR = 2.9) age above 40 yrs (OR = 2.7), psychiatric admission (OR = 2.2), and worry about appearance (OR = 2.8).

Discussion

We submit the hypothesis that cases with ROC should be explored through specific comorbidity (obsession of appearance, and Cyclothymic depression), and especially worsening with serotonergic antidepressants. More vigilance is needed toward suicide risk in this condition.