Elsevier

Psychiatry Research

Volume 197, Issue 3, 30 May 2012, Pages 253-258
Psychiatry Research

Sensory phenomena associated with repetitive behaviors in obsessive-compulsive disorder: An exploratory study of 1001 patients

https://doi.org/10.1016/j.psychres.2011.09.017Get rights and content

Abstract

A substantial number of patients with obsessive-compulsive disorder (OCD) report compulsions that are preceded not by obsessions but by subjective experiences known as sensory phenomena. This study aimed to investigate the frequency, severity, and age at onset of sensory phenomena in OCD, as well as to compare OCD patients with and without sensory phenomena in terms of clinical characteristics. We assessed 1,001 consecutive OCD patients, using instruments designed to evaluate the frequency/severity of OC symptoms, tics, anxiety, depression, level of insight and presence/severity of sensory phenomena. All together, 651 (65.0%) subjects reported at least one type of sensory phenomena preceding the repetitive behaviors. Considering the sensory phenomena subtypes, 371 (57.0%) patients had musculoskeletal sensations, 519 (79.7%) had externally triggered “just-right” perceptions, 176 (27.0%) presented internally triggered “just right,” 144 (22.1%) had an “energy release,” and 240 (36.9%) patients had an “urge only” phenomenon. Sensory phenomena were described as being as more severe than were obsessions by 102(15.7%) patients. Logistic regression analysis showed that the following characteristics were associated with the presence of sensory phenomena: higher frequency and greater severity of the symmetry/ordering/arranging and contamination/washing symptom dimensions; comorbid Tourette syndrome, and a family history of tic disorders. These data suggest that sensory phenomena constitute a poorly understood psychopathological aspect of OCD that merits further investigation.

Introduction

Since the earliest reports, obsessions and compulsions have been considered the cardinal symptoms of obsessive-compulsive disorder (OCD), independent of cultural differences (Esquirol, 1838, Fontenelle et al., 2004). However, recent studies have demonstrated that many OCD features, including the nature of the symptoms, course of the disease, and treatment response, are quite variable. This heterogeneity might have confounded clinical and biological investigations, explaining why findings have been so inconsistent across different OCD studies.

Accordingly, various OCD subtypes have been proposed, including those based on age at OCD onset (de Mathis et al., 2008), on the presence of tics (Jaisoorya et al., 2008), on gender (Labad et al., 2008, Torresan et al., 2009), on symptom dimensions (Mataix-Cols et al., 2005, Ferrão et al., 2006, Leckman et al., 2010), and on treatment response (Ferrão et al., 2006, Fontenelle et al., 2006, Shavitt et al., 2006a, Raffin et al., 2009, Braga et al., 2010). Subtyping OCD on the basis of psychopathology could serve several purposes, perhaps allowing a more precise determination of the pathogenesis of OCD symptoms, a more accurate projection of future outcomes, and more efficacious treatments (Lochner and Stein, 2003, Miguel et al., 2005, Miguel et al., 2008).

A novel approach to studying the psychopathology of OCD is based on evaluating the phenomena that precede and/or accompany the repetitive behaviors. In individuals with OCD, repetitive behaviors and compulsions are classically defined as being produced in response to an obsession. However, a substantial number of patients report repetitive behaviors that are preceded not by obsessions but by uncomfortable, distressing subjective experiences known as “sensory phenomena,” a term that encompasses a variety of subjective experiences. Such experiences have previously been referred to as “premonitory urges”, “sensory tics,” “just-right perceptions,” “sensory experiences,” “feelings of incompleteness,” and “not just-right phenomena.” These sensory phenomena were initially described in Tourette syndrome but have also been associated with OCD (Leckman et al., 1994-95, Prado et al., 2008). Some authors have proposed that the presence and severity of sensory phenomena determine specific clinical characteristics of OCD (Miguel et al., 1997a, Miguel et al., 2000), hypothesizing that such phenomena represent specific pathological pathways and therefore contribute to the identification of OCD subgroups that are more specific (Miguel et al., 1997a). The investigation of these different forms of subjective experiences in OCD patients is important for various reasons. Like obsessions, such phenomena are disturbing and uncomfortable and can lead the patient to perform repetitive behaviors (compulsions), which cause considerable suffering (Cohen and Leckman, 1992). In addition, greater recognition of these subjective experiences can increase patient ability to suppress symptoms (Cohen and Leckman, 1992). Furthermore, pharmacological treatment and behavioral therapy can alter such subjective experiences (Leckman et al., 1992). Moreover, it is possible that the presence of subjective experiences is a predictor of response to such treatments (Miguel et al., 2000, Summerfeldt, 2004, Shavitt et al., 2006a, Katerberg et al., 2010).

The principal aim of this study was to investigate the frequency, severity, and age at onset of the different types of sensory phenomena described in the literature. A secondary objective was to compare OCD patients with and without sensory phenomena, in terms of clinical characteristics. On the basis of the findings reported in previous studies, we predicted that the frequency of sensory phenomena would be high in the OCD patients and that, as a group, those patients would have the following characteristics: a higher proportion of males; an earlier age of OCD onset; a higher prevalence of the symmetry/ordering/arranging dimension; a higher prevalence of tics, Tourette syndrome, skin picking, and trichotillomania; a stronger association with a family history of tics; and greater tic severity. This work is timely considering that the DSM-V task force has discussed whether the word “urge” (one of the described types of sensory phenomena) should replace the word “impulse” as a definition of obsession (Leckman et al., 2010).

Section snippets

Subjects

The dataset of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (BRC-OCSD) study comprises information on 1,001 consecutive OCD outpatients interviewed between August 2003 and August 2008 at seven university hospitals in six different Brazilian cities. Only patients with OCD, as defined in the DSM-IV, were included in the study. The diagnosis of OCD was confirmed by an OCD expert using the Structured Clinical Interview for DSM-IV Axis I disorders: clinical version

Description of sensory phenomena

Of the 1001 OCD patients evaluated, 651 (65.0%) reported at least one subtype of sensory phenomena preceding and/or accompanying repetitive behaviors and were collectively designated the OCD plus sensory phenomena (OCD + SP) group, whereas the remaining patients were collectively designated the OCD without sensory phenomena (OCD-noSP) group.

In the sample as a whole, “just-right” perceptions triggered by tactile, visual, or auditory input were observed in 519 patients (51.8%), physical sensations

Discussion

To our knowledge, this is the first study to systematically investigate the occurrence of different types of sensory phenomena in a large, multicenter sample of OCD patients. Subjects were thoroughly evaluated by experts in OCD and, in addition to the instruments commonly reported in the literature, the DY-BOCS, the YGTSS, and the USP-SPS were applied.

Our finding that 65% of the sample presented with at least one repetitive behavior preceded by sensory phenomena is in agreement with previous

Acknowledgements

We are grateful to all BRC-OCSD staff members, especially Albina Rodrigues Torres, Aristides Volpato Cordioli, Christina Hojaij Gonzalez, Kátia Petribú, Juliana Belo Diniz, Ricardo C. Torresan, Daniela T. Braga, Sonia Borcatto, Carolina Valério, Luciana N. Gropo, Carlos Alberto de Bragança Pereira, and Victor Fossaluza. This work was supported by a Projeto Instituto do Milênio (Millennium Institutes Project) grant from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq,

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