(ocd) sample of patients - Centro de Documentacion e Informacion
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1. 1038 1048 2004 SPSS Inc SPSS Base 10 0 for Windows Users Guide Chicago 1999 TRIVEDI MH Functional neuroanatomy of obsessive com pulsive disorder J Clin Psychiatry Suppl 8 57 26 35 1996 WILSON KD Issues surrounding the cognitive neuroscience of obsessive compulsive disorder Psychonomic Bulletin Review 5 161 172 1998 ZIELINSKI CM TAYLOR MA JUZWIN KR Neuro psychological deficits en obsessive compulsive disorder New ropsychiatry Neuropsychology Behavioural Neurology 4 110 126 1991 Salud Mental Vol 30 No 1 enero febrero 20072. aXe Fig 3 Execution as according to factorial punctuation of each one of the for groups in each one of the three factors Salud Mental Vol 30 No 1 enero febrero 2007 GROUP 4 N 37 represented 64 of the sample In these 37 patients it was found that 54 showed obsessions and aggression as prevalent while 41 pre sented washing compulsions Surprisingly the former were combined in 20 with washing compulsion while the latter were combined with different kinds of ob sessions The four patients who were strictly obsessive were placed in this group Data suggests that indepen dently from clinic characteristics and subtype this would be the typical execution pattern of this sample of OCD Performance shows that in both tests their execution was regular but slower in the TMTB Table 1 shows for each group the average values of punctuations in obsessions and compulsions obtained through the Yale Brown scale This scale also shows the outstanding similarity of severity present in obses sions as well as in compulsions in the four groups In group 3 apparently compulsions are dominant al though it must be remembered that only two subjects integrated this group No relevant correlations were found when the co efficient of correlation of Pearson was used to find out if there was an association between perseverative answers and errors to maintain category of the WCST 5 TABLE 1 Average values of the obsessions and com
3. related with certain compulsions of recurrent nature and with Salud Mental Vol 30 No 1 enero febrero 2007 the incapability to change a given response on behalf of another more adequate and adaptative 1 3 35 At the same time obsessions are predominately as sociated to the anterior cingulum the basal part of the striate body and its connections with the limbic sys tem giving place to incapability in selecting relevant surrounding information a fact that causes the sub ject to perceive harmless stimuli as threatening to physical integrity 35 40 In this manner it is proposed a model that may be applied to OCD in which the anterior sector of the cingulum is in charge of detecting errors in the sur roundings through selective attention and at the same time inhibits the behaviours taking place at that very moment and indicates to the dorsal lateral prefron tal cortex to participate in solving the problem that is present 2 9 Some clinic subtypes have also been identified such as contamination washing ageressiveness verification accumulation symmetry order which in turn have been related with different patterns of genetic trans mission co morbidity and response to treatment Dif ferent patterns of increase or decrease have also been found either of cerebral metabolism or blood stream in the frontal striated circuits according to the clinic subtype 33 37 On the other hand using functional mag
4. what has been mentioned in different researches which constantly have found deficiencies in this cortical subcortical cir cuit 1 4 6 7 17 27 29 32 33 37 where the striated body appears as a structure related with habits or semi automatic actions that allow the species survival as would be the case of personal hygiene 7 17 In patients of this group 41 of washing com pulsions were observed in such a way that the ac tion of cleaning would appear as uninhibited and pathological resulting from a dysfunction in this area The fact that this group is the largest of the sample suggests that independently from any clini cal characteristic or subtype that would be the ex ecution pattern more representative of this OCD sample On the other hand at first it was considered also the possibility of finding the relationship between the disorder s severity and the different kinds of neuro psychological failures Nevertheless when analyzing the results it was found that most of the sample had been formed by patients with similar severity for both symp toms only 4 of the 58 patients 3 were exclusively obsessive and thus it is not possible to establish such relationship Besides the fact that in this type of patients the WCST vatiables form only one factor that is they do not discriminate between processes associated with the cin gulum and with the dorsal lateral cortex may also be attributed to the sample being formed by
5. LINDO G PAEZ F TIRADO E WOLF M Evaluaci n neuropsicol gica de pacientes con trastorno obsesivo compulsivo evidencia de alteraciones en el sistema nervioso central Salud Mental 16 8 13 1993 GOODMAN WK PRICE LH RASMUSSEN SA MA ZURE C FLEISCHMANN RL The Yale Brown Obsessive Compulsive Scale I Development Use and Reliability Arch Gen Psychiatry 46 1006 1011 1989 HANSEN ES PRICHEP LS BOLWIG TG JOHN ER Quantitative electroencephalography in OCD patients treat ed with paroxetine Clin Electroencephalogr 34 70 74 2003 HEATON RK CHELUNE GJ TALLEY JL KAY GG CURTISS G Wisconsin Card Sorting Test Manual Psychologi cal Assessment Resources Inc Los Angeles 1993 HOLLANDER E SCHIFFMAN E COHEN B Signs of central nervous system dysfunction in obsessive compulsive disorder Arch Gen Psychiatry 47 27 32 1990 JOSEPH R Neuropsychiatry Neuropsychology and Clinical Neuro science Williams amp Wilkins Baltimore 1996 JOSEPH R Frontal lobe psychopatholgy Mania depression confabulation catatonia perseveration obsessive compulsions and schizophrenia Psychiatry 62 Summ 138 172 1999 KEEFE RS The contributon of Neuropsychology to Psy chiatry Aw J Psychiatry 152 1 6 15 1995 LEZAK M Neuropsychological Assessment Oxford University Press New York 1995 MARTINOT JL ALLILAIRE JF MAZOYER BM Obses sive compulsive disorder a clinical neuropsychological and positron emission tomography study Acta Psy
6. NEUROPSYCHOLOGICAL CHARACTERIZATION IN CLINICAL SUBTYPES OF AN OBSESSIVE COMPULSIVE DISORDER OCD SAMPLE OF PATIENTS Elsa Tirado Dur n Josefina Ricardo Garcell Ernesto Reyes Zamorano Cristina L yzaga Mendoza SUMMARY Since the decade of the seventies several neuropsychological abnormalities in very different cognitive domains have been de scribed among patients with Obsessive compulsive disorder OCD Due to the nature of these abnormalities it was con cluded that possibly the main dysfunction for this disorder was located in the right hemisphere especially in the frontal cortex nevertheless this particular brain region was found to be involved in other psychiatric disorders so neuropsychological results were considered to be of limited precision and it was thought that the diversity in results was not due to the malfunction of one particu lar brain region So it became evident that a new research methodology based in the information processing model with highly specific neuropsy chological paradigms of frontal functioning was needed as well as considering a subtypology based in the cognitive characteris tics in patients with the same disorder and similar phenomenol ogy Regarding OCD it is well known that the dorsolateral prefron tal cortex is in charge of the regulation of complex actions ex ecutive functions and the elaboration of logical strategies in a prob lem solving task so its dysfunction causes a fai
7. and basal ganglia volumes in tic obsessive compulsive and attention deficit hyperactivity disorders Arch Gen Psychi atry 57 364 372 2000 PHILLIPS ML MARKS IM SENIOR C LYTHGOE D O DWYER AM A differential neural response in obsessive compulsive disorder patients with washing compared with checking symptoms to disgust Psychol Med 30 1037 1050 2000 PRICHEP LS MAS F HOLLANDER E LIEBOWITZ M et al Quantitative electroencephalographic subtyping of ob sessive compulsive disorder Psychiatry Res 50 25 32 1993 PURCELL R MARUFF P KYRIOS M Cognitive deficits in obsessive compulsive disorder on test of frontal striatal func tion Biol Psychiatry 43 348 357 1998 RAUCH SL SAVAGE CR Neuroimaging and neuropsychol ogy of the striatum Psychiatric Clinics North America 20 741 768 1997 34 35 36 37 38 39 40 41 RAUCH SL DOGHERTY DD SHIN LM ALPERT NM MANZO P Neural correlates of factor analyzed OCD symp tom dimensions A PET Study CNS Spectrums 3 37 43 1998 ROSENBERG DA KESHAVAN MS Toward a neurodevelop mental model of obsessive compulsive disorder Biol Psychia try 43 623 640 1998 SAVAGE CR BAER L KEUTHEN N Organizational strat egies mediate non verbal memory impairment in obsessive compulsive disorder Bio Psychiatry 45 905 916 1999 SAXENA S BRODY AL MAUDMENT KM SMITH EC ZOHRABIN Cerebral glucose metabolism in obsessive com pulsive hoarding Am J Psychiatry 161
8. chiatr Scand 82 233 242 1990 MATATX COLS D ALONSO P PIFARRE J MENCHON M VALLEJO J Neuropsychological performance in medi cated vs unmedicated patients with obsessive compulsive dis order Psychiatry Research 109 255 264 2002 MATAIX COLS D WOODERSON S LAWRENCE N BRAMMER MJ et al Distinct neural correlates of washing checking and hoarding symptoms dimensions in obsessive compulsive disorder Are Gen Psychiatry 61 564 576 2004 NEURONIC SA Diagn stico Neuropsicol gico Automatizado DI ANA Manual del usuario La Habana 1997 NEZIROGLU FN PENZEL FI VAZQUEZ J YARYURA TOBIAS JA Neuropsychological studies in obsessive com pulsive Psychopharmachol 96 356 1988 NIELEN MM DEN BOER JA Neuropsychological perfor mance of OCD patients before and after treatment with flu oxetine evidence for persistent cognitive deficits Psychological Medicine 33 5 917 925 2003 OHARA K ISODA H SUZUKI Y TAKEHARA Y Proton magnetic resonance spectroscopy of lenticular nuclei in ob sessive compulsive disorder Psychiatry Research Neuroimaging Section 92 83 91 1999 28 29 30 31 32 PERLMUTTER SJ GARVEY MA CASTELLANOS X MITTLEMAN BB GIEDD J A case of pediatric autoim mune neuropsychiatric disorders associated with streptococ cal infections Am J Psychiatry 155 11 1592 1598 1998 PETERSON BS LECKMAN JF TUCKER D SCAHILL L STAIB L Preliminary findings of antistreptococcal antibody titers
9. e la m s ca racter stica y su desempe o en ambas pruebas regular pero m s lento en TH Cada uno de estos grupos de funcionamiento neu ropsicol gico se relacion con los distintos subtipos de obsesio nes y compulsiones mas no con su gravedad 2 Encontrar subtipos neuropsicologicos de TOC asociados a sin tomatolog a cl nica distinta presta apoyo al modelo de organiza ci n modular de los diferentes circuitos neurales que intervienen en la manifestaci n sintom tica de este padecimiento Palabras clave Trastorno obsesivo compulsivo Test de Clasifi caci n de Tarjetas de Wisconsin Trazado con Hitos subtipos cl nicos de TOC Escala de severidad de Yale Brown INTRODUCTION Since 1970 as a part of the neurosciences neuropsycho logy has contributed to the study of cognitive alter ations in obsessive compulsive disorder OCD by proposing the frontal left region as the dysfunctional area in this entity 11 Following this particular finding several researches were published which pointed out failures in different areas such as motor and tactile functions psychomo tor coordination 16 visual information processing 5 8 12 16 visuo spatial perception 10 25 41 and handling of spatial information in relation to one s on body 5 On the other hand it was found in the mnesic activity a deficit in visual memory regarding retention as well as recognition 8 10 12 16 reasoning 25 intellectual process
10. el sistema l mbico dando lugar a la incapaci dad para seleccionar la informaci n relevante del entorno Esto genera que el individuo perciba los est mulos inocuos como ame nazantes para la integridad f sica Tambi n se han identificado subtipos cl nicos de obsesiones y compulsiones tales como contaminaci n lavado agresividad com probaci n atesoramiento simetr a y de orden entre otros que se han relacionado con distintos patrones de transmisi n gen tica comorbilidad y respuesta a tratamiento Adem s se han docu mentado distintos patrones de aumento o disminuci n ya sea de metabolismo cerebral o de flujo sangu neo en los circuitos fron to estriados Con la resonancia magn tica funcional tambi n se han encontrado distintos patrones de activaci n en los circuitos neuronales entre distintos subtipos cl nicos mediante la exposi ci n de im genes que se relacionan con el contenido de la obse si n o bien con la acci n de la compulsi n Ante esta evidencia se decidi averiguar si en pacientes con este trastorno eta posible encontrar mediante distintos paradig mas neutopsicol gicos de funcionamiento frontal dichos patro nes diferenciales considerando tanto el subtipo cl nico como la gravedad de las obsesiones y compulsiones En este estudio participaron 58 pacientes con este diagn stico pertenecientes a la Cl nica de TOC del Instituto Nacional de Psi quiatr a Ram n de la Fuente de los que 24 eran
11. es 12 and performance of inter ference tasks that imply selective attention 21 Due to the nature of the mentioned alterations it was concluded that probably the dysfunction present in this disorder could be found in the right hemisphere with predominance in the frontal cortex Nevertheless this cerebral sector is also involved in other psychiatric diseases and thus these findings were interpreted as scarcely accurate and it was considered that the diver sity of alterations was not caused by the ill function ing of a particular structure 36 39 Therefore it was needed to create another research methodology that would start from the model of the information process with specific neuropsychological paradigms of frontal functioning that should include a series of subtypes based on the cognitive characteris tics present in patients with the same psychiatric disor der and a similar phenomenology 19 In the case of OCD it is known that dorsal lateral prefrontal cortex DLPC is in charge of regulating complex actions and of elaborating logical strategies in problem solving in a way that its dysfunction causes failures in creating response patterns and also produces persistence due to the incapability to change patterns when another alternative for responding is required Besides its connection with the dorsal lateral part of the caudate nucleus a region where behavioural fixed patterns are associated causes this circuit to be
12. ing benzo diazepines Procedure After the diagnose received at the first time visit was confirmed by the psychiatrists assigned to the OCD clinic patients were referred to a neuropsycholo gist experienced in computer evaluations who applied to them the neuropsychological battery called Diagn stico Neuropsicologico Automatizado DIANA 24 and who had no information either regarding the classification of OCD s subtype or of the severity of obsessions and compulsions obtained through the Se verity scale of Yale Brown 13 These tests were done in one only session Instruments applied Two paradigms were applied to confirm the research objective Trail Making Test B TMTB and the Wisconsin Card Sorting Test WCST 1 The TMTB explores the frontal striated system func tioning Specifically it evaluates visual search mental flexibility and motor function In this paradigm are shown diverse circles with letters and numbers in the inner part and the task consists in joining these circles with lines in such a way that the alternating sequence continues successively between number and letter 1 A 2 B 3 C etc until ending with the circles that appear on the screen during a time limit of three minutes The following variables are considered time of performance number of wrong answers and num ber of asserts 20 24 2 The WCST created by Berg and Grant in 1948 15 to evaluate abstract reasoning is composed by a se
13. ive disorder Am J Psychiatry 156 777 779 1999 5 BEHAR D RAPOPORT JL BERG CJ Computarized to mography and neuropsychological test measures in adoles cents with obsessive compulsive disorder Am J Psychiatry 1141 363 369 1984 6 BERTHIER ML KULOVESKY J GIRONELL A HERAS JA Obsessive compulsive disorder associated with brain le sions Neurology 47 353 361 1996 Salud Mental Vol 30 No 1 enero febrero 2007 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 BOOKS VILLARREAL G BRAWNA MINTZER O Neu roimaging in Obsessive Compulsive Disorder En Rama Krishnan K R Doraiswamy P eds Brain Imaging in Clinical Psychiatry Marcel Dekker 463 476 New York 1997 BOONE KB ANANTH J PHILPOTT L Neuropsycholog ical characteristics of nondepressed adults with obsessive compulsive disorder Neuropsychiatry Neuropsychology Behavioural Neurology 4 2 96 109 1991 CARTER C Executive function Am J Psychiatry 157 1 3 2000 CHRISTENSEN KJ WON KS DYSKEN MW Neuropsy chological performance in obsessive compulsive disorder B o Psychiatry 31 4 18 1992 FLOR HENRY P Psychopathology and hemispheric special ization left hemispheric dysfunction in schizophrenia psy chopathy hysteria and the obsessional syndrome En Boller F Grafman J eds Handbook of Neuropsychology Vol 3 Elsevier Science Publishers 477 494 Amsterdam 1989 GA
14. lure in the creation of response patterns and perseverations due to the inability to change a pattern when an alternative response is needed On the other hand obsessions are associated mainly with the anterior cingulated cortex and the basal region of the corpus stria tum and its connections with the limbic system giving place to incapacity to select the relevant information from the environ ment which makes the individual perceive irrelevant stimuli as threatening for physical integrity By the way some clinical subtypes have also been identified contamination washing ageressiveness checking hoarding sym metry order There is also some evidence of different patterns of brain activation to several visual stimuli related to the obses sive or compulsive object in the clinical subtypes as shown by functional magnetic resonance image in some regions of the frontal lobe either dorsolateral medial or basal and its connections with the basal ganglia and in some cases thalamus or limbic system In the face of all this evidence the goal of the present study was to find if within this disorder it was possible through several neuropsychological paradigms of frontal functioning to find dif ferent patterns of execution considering the clinical subtype and the severity of obsessions and compulsions Fifty eight patients with a diagnosis of OCD were studied all patients were under treatment at the OCD clinic of the National Institute of Ps
15. mujeres y 34 hom bres Una vez que los psiquiatras adscritos a dicha cl nica confirma ban el diagn stico obtenido en la cita de primera vez refer an a los pacientes al programa para computadora de Diagn stico Neuro psicol gico Automatizado DIANA Se aplicaron en una sola se si n las siguientes pruebas 1 Trazado con Hitos TH y 2 Test de Categorizaci n de Tarjetas de Wisconsin TCTW Con posterioridad a la aplicaci n de las pruebas a todos los pacientes se revis cada uno de los expedientes de la cl nica de TOC para obtener el subtipo cl nico En el an lisis estad stico de los datos se realiz primero un an lisis factorial para disminuir el n mero de variables y luego un an lisis de conglomerados para ver si se formaban grupos conforme a la ejecuci n de los sujetos en las pruebas aplicadas De acuerdo con la ejecuci n de los pacientes se observ que los sujetos se agruparon en cuatro grupos distintos de desempe o cognoscitivo el primero tuvo una ejecuci n muy deficiente en ambas pruebas El segundo exhibi un desempe o regular en las dos pruebas pero fue mas r pido para terminar el TH El tercero s lo estuvo constituido por dos pacientes que tuvieron un desem pe o muy diferente al del resto al presentar una ejecuci n sobre saliente en WCST pero con gran cantidad de errores en el TH En tanto en el cuarto de estos grupos donde se concentraba la ma yor a de la muestra se consider que su ejecuci n fu
16. netic reso nance in different clinic subtypes and through expo sure to images related to the object of obsession or compulsion different patterns of activation in the neu ral circuits have been reported which involve differ ent regions of the frontal lobe either dorsal lateral median or basal and its connections with the basal gan glia the thalamus or the limbic system The former suggests that this disorder should be considered within a multiple and diverse scope of overlapping syndromes instead of taking it as a unitary nosology entity 22 23 30 Facing this evidence the objective of our work was to investigate the probable existence of neuropsycho logical subtypes by using different paradigms of fron tal functioning in a group of patients with OCD at tending to their clinic subtype as well as to the severity of their obsessions and compulsions MATERIAL AND METHOD Subjects The study was done with a sample of 58 patients with ODC diagnose who attended the Clinic for this disorder of the Instituto Nacional de Psiquiatria Ramon de la Fuente The sample was integrated by 24 women and 34 men with an average age of 11 98 SD 2 92 Two weeks before evaluation average time Salud Mental Vol 30 No 1 enero febrero 2007 for appointment all patients had already started phar macological treatment mainly with inhibitors of serotonine recapture N 46 and tricyclics N 12 From the total of patients only 17 were tak
17. patients who had obsessions as well as compulsions whose severity was similar This would explain the absence of a sig nificant correlation between these WCST variables and the values in the severity scale of Yale Brown The findings in this sample in a neuropsychological sense are similar to those of Prichep who demons trated the existence of two electroencephalographic subgroups in a sample of patients with OCD homo geneous from the clinic point of view one is typified by an excess of theta relative potency particularly in frontal and frontal temporal regions and the other by an increase of alpha relative potency 31 Salud Mental Vol 30 No 1 enero febrero 2007 In this manner our findings acquire relevance by considering the type of dysfunction prevailing in each patient either in prefrontal PFDL or orbit frontal OF regions as a means for selecting the more conve nient pharmacological treatment making an accurate prognosis and considering therapeutic alternatives within a cognitive behavioural approach In this sense it has been observed that inhibitors of serotonine re capture ISR have a better effect in patients with a dysfunction in sector PFDL differently from those with OF alteration 26 These results are not due to pharmacological effects as it has been possible to confirm that neuropsycho logical alterations appear with or without pharmaco logical handling and on the other hand are not sec onda
18. pulsions punctuations Yale Brown Scale obtain in each group Group Yale O Yale C 11 6 12 1 2 12 6 11 4 3 8 5 11 5 4 12 9 12 8 with the severity of obsessions and compulsions ob tained through the Yale Brown scale table 2 DISCUSSION First of all it is concluded that in a sample of 58 pa tients with OCD different groups of neuropsycho logical deficit were found a fact that in turn indicates a neurobiological dysfunction which is different within the same psychopathological entity Of the four groups that were formed the first one showed relevant difficulties to execute both tasks as compared to the other three groups This could be re lated to the fact that this pattern may be due to failures in operation of the prefrontal dorsal lateral sector as well as of the frontal striated circuit It must be stressed that this group had a larger percentage of individuals with contamination obsessions 75 and washing compulsions 50 Probably this coexistence of cog nitive deficit is related with the incapability to respond to these tasks and denotes a greater dysfunction that implies an alteration in self regulation combined with incapability for premise reasoning and gives place for associated compulsion and obsession Still this can be related to the fact that some actions that are partly au tomatic such as cleaning are not inhibited and the subject is unable to regulate them The second group attained a regular pe
19. re distributed equally in the four groups Figure 1 shows percentages of each symptom sub types either for obsessions part A or compulsions part B As the same patient could present three sub types of obsessions and compulsions percentages were calculated based on the frequency of each subtype in respect to the total sample On the other hand no significant differences were found between punctuations obsessions and compul sions with the Severity scale of Yale Brown 4 40 00 4 Aggression Contamination Sexual Religious Symmetry Somatic 20 00 Hoarding 30 00 4 ZJOAOUAWn pa la Obsessions 10 00 40 0 4 Cleaning washing Checking Repeating Counting Ordering Hoarding treasuring Mental rituals 30 0 4 Motor rituals Prevention OID PWNYP 20 0 4 lb Compulsions 1 2 3 4 5 6 7 8 Fig 1 Percentage with respect to total of the main obses sions and compulsions obtain through the Target Symptoms List of the patients in sample Through the factorial analysis three factors were obtained which explained 80 of the variance the first corresponded to the WCST and included the follow ing variables number of cards presented perserverative errors number of errors and errors to maintain cat egory From the TMTB two factors were obtained one for the number of wrong answers and the other for the time of execution fig 2 According to the patients pe
20. rformance and through the analysis of conglomerates it was observed that subjects formed four groups and according to the fac torial values obtained it was considered that their per formance had been deficient regular and adequate fig 3 GROUP 1 N 8 represented 14 of patients In six of these eight patients contamination obsessions were prevalent 75 while in four 50 washing compulsions prevailed This group performed errone ously in the WCST at the same time had mote errors in TMTB and took longer to perform In short per formance was deficient in both tests GROUP 2 N 11 constituted 19 of the sample and showed dominance of obsessions of aggressive type in 55 This group had a regular performance in Salud Mental Vol 30 No 1 enero febrero 2007 Wisconsin Card Sorting Test Trails of Categories Completed Correct answers Incorrect answers Fig 2 Evaluated variables in each test and how they were grouped afterwards in a factor analysis both tests in comparison to the rest nevertheless it was the faster to finish the TMTB GROUP 3 N 2 included 3 of the patients Ap parently these two patients did not have common chat acteristics but were quite different from the rest of the sample in the sense that they obtained an outstand ing performance in the WCST although they were slow and made more mistakes in the TMTB TCTW TH Errors TH Time 921 le fo
21. rformance in both paradigms comparable to the last group s although it was faster at the task of tracing lines from target to target thus implying motor response and visual follow ing in a partly automatic sequence In this sense there was more evidence of a dysfunction at a prefrontal dor sal lateral level due to the failure in self regulation of which this sector is in charge which is associated with a greater impulsivity to carry out the task Besides it was found that 55 of the patients had obsessions of aggressiveness which leads us to think that this dysfunction could also be related with the at tempts of such sector to inhibit the operation of these impulses 17 18 The third group was formed by two patients with a very different performance from that attained by the other three groups in such a way that it would be dif ficult to draw conclusions TABLE 2 Pearson s correlation coefficient values obtain bet ween obsessions and compulsions severity Yale Brown Scale and the number of perseverative errors and failures to maintain set Wisconsin Card Sorting Tests Obsessions Compulsions Perseverative errors 0 171 0 206 Failures to maintain set 0 076 0 013 In contrast the last group which included the ma jority of patients had a regular performance in both tests though it was slower in carrying out the TMTB a fact that would involve a greater commitment of the frontal striated circuit This agrees with
22. ry to symptoms Therefore they are considered as a trait of the disorder or as a phenotypic character istic 23 26 Besides on average patients had initiated treatment two weeks before the application of DIANA therefore it is more difficult to attribute such failures to medical therapy Finally to typify cognitive deficits may shed light on neuroanatomic localization and on therapeutic ap proach and if combined with functional images it can contribute to attain more accuracy in regard to the brain s topography through an adequate selection of frontal paradigms and of their correlation with other studies of paraclinic nature Acknowledgments To Gabriela Galindo y Villa Molina for her valuables com ments REFERENCES 1 ABBRUZZESE M FERRI S SCARONE S The selective breakdown of frontal functions in patients with obsessive compulsive disorder and in patients with schizophrenia A double dissociation experimental finding Neuropsychologia 35 907 912 1997 2 BARCH D The anterior cingulate and response conflict Am J Psychiatry 156 12 1999 3 BAXTER LR SAXENA S BRODY AL ACKERMANN RF et al Brain mediation of obsessive compulsive disorders symptoms Evidence from functional brain imaging studies in the human and nonhuman primate Semin Clin Neuropsychi atry 1 32 47 1996 4 BEER SR ROSENBERG DR DICK EL Neuropsycholog ical Study of frontal lobe function in psychotropic naive chil dren with obsessive compuls
23. t of cards that have three characteristics which in turn have four values each a type of image triangle star cross and circle b colour red yellow green and blue number of figures from one to four Each card must be assigned by the subject to one of the four model cards represented by a red triangle two green stars three yellow crosses and four blue circles 20 The subject must complete successfully ten items according to either one of the three finished categories colour form and number This sequence is repeated twice in this order From this test the fol lowing results were taken cards presented concluded categories preseverative errors number of errors and errors to maintain category Two specific measure ments were also considered in the same test the num ber of perseverative errors and the errors to main tain category The first one is a cognitive flexibility measure realized by the dorsal lateral prefrontal sec tor and the second is useful to explore working 3 memory associated with the anterior part of the cin gulum 15 20 Following the application of tests the files of all the patients in the OCD Clinic were revised in order to obtain the clinic subtype We used the Target symp toms list where the patient informs verbally which are the three obsessions and the three compul sions most important to him or her Obsessions ate classified as aggression contamination sexual accu m
24. ulation religious symmetry and somatic Compul sions could be cleanliness and washing revision count ing arrangement keeping or collecting mental rituals motor rituals and means to avoid damage The punctuations of the Yale Brown scale were ob tained also This scale was applied once the patient was considered as part of the OCD Clinic Data analysis To explore if there were significant differences between the different punctuations obsessions and compul sions in the Severity scale of Yale Brown the test for related samples was employed Through the Statistics package for social sciences SPSS 38 a factorial analysis was done with the vari ables selected in the WCST and in the TMTB with the purpose to decrease them Afterwards a conglomer ates analysis was done to find out if from the factors found the groups were formed according to the sub jects performance in the tests applied The Kruskal Wallis test was used to find out if there were differences regarding age and schooling in the groups that were formed Finally to find out if there was an association be tween perseverative answers and errors to maintain the category of WCST and the severity of obsessions and compulsions obtained by the Yale Brown scale the Pearson correlation coefficient was calculated RESULTS No differences were found as to age and schooling by applying the Kruskal Wallis test Besides ages of evo lution as well as gender we
25. ychiatry Ramon de la Fuente in Mexico City Two neuropsychological tests were administered 1 Trail Mak ing Test TMT and 2 Wisconsin Card Sorting Test WCST From the Target Symptom List the clinical subtype was obtained After the statistical analysis we found no differences between the severity of obsessions and the severity of compulsions as measured by the Yale Brown Scale Also we observed three fac tors concerning the neuropsychological tests and patients were grouped in four different groups each one with a distinct cogni tive performance Through the interpretation of results it was concluded that in a sample of 58 patients with OCD different groups of neuropsy chological functioning where distinguished In their own these groups where associated with different clinical subtypes These results are in accordance with the neurobiological modular orga nization model of OCD which sustains the existence of inde pendent systems of cognitive dysfunction that regulate different symptomatic expressions Key words Obsessive compulsive disorder Wisconsin Card Sort ing Test Trail Making Test OCD clinical subtypes Yale Brown Severity Scale RESUMEN La metodolog a de investigaci n a partir del modelo del procesamiento de informaci n con paradigmas neuropsicol gicos de funcionamiento del l bulo frontal permite un estudio m s espec fico de los trastornos psiqui tricos con fenomenolog a parecida lo que a su ve
26. z permite crear modelos basados en una subtipolog a de ndole cognoscitiva y por ende lleva al 2 Unidad de Neuropsicolog a Divisi n de Servicios Cl nicos Instituto Nacional de Psiquiatr a Ram n de la Fuente Calz Mexico Xochimilco 101 San Lorenzo Huipulco Tlalpan 14370 M xico D F e mail etirado imp edu mx Coordinaci n de la Cl nica de Trastorno Obsesivo Compulsivo Divisi n de Servicios Cl nicos INPRE Instituo de Neurobiologia UNAM Campus Juruquilla Quer rtaro Para este art culo tambi n colabor mediante la referencia de pacientes de la Cl nica de TOC del INPRE el doctor Jorge Gonz lez Olvera Recibido 21 de febrero de 2006 Aceptado 3 de agosto de 2006 Salud Mental Vol 30 No 1 enero febrero 2007 conocimiento de los circuitos neurales involucrados en la manifestaci n cl nica de estos padecimientos En el caso del trastorno obsesivo compulsivo TOC la corte za prefrontal dorsolateral se encarga de regular las acciones com plejas las funciones ejecutivas y la elaboraci n de estrategias l gi cas en la resoluci n de problemas de tal manera que su mal fun cionamiento ocasiona fallas en la creaci n de patrones de respuesta y perseveraciones por incapacidad de cambiar de patr n cuando se requiere otra alternativa de respuesta Por otra parte las obsesiones se relacionan predominantemen te con el cingulo anterior y la parte basal del cuerpo estriado y de sus conexiones con
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