How Common Are Obsessive-Compulsive Symptoms in Schizophrenia and Bipolar Disorder?

What you need to know

• Obsessive-compulsive symptoms are common in people with schizophrenia, schizoaffective disorder, and bipolar disorder, affecting about 23% of patients.
• Having obsessive-compulsive symptoms was associated with more severe psychiatric symptoms like hallucinations, delusions, and aggressive behavior.
• Automated tools to detect obsessive-compulsive symptoms in medical records could help improve recognition and treatment of these symptoms in patients with severe mental illness.

Understanding Obsessive-Compulsive Symptoms

Obsessive-compulsive symptoms (OCS) involve unwanted, intrusive thoughts (obsessions) and/or repetitive behaviors or mental acts (compulsions) that a person feels compelled to perform. When these symptoms are severe and time-consuming enough to significantly interfere with a person’s daily life, they may be diagnosed with obsessive-compulsive disorder (OCD).

While OCS and OCD are often thought of as separate conditions, they frequently occur alongside other psychiatric disorders. Previous research has found that people with schizophrenia, schizoaffective disorder, or bipolar disorder are more likely to experience OCS compared to the general population. However, estimates of how common these symptoms are have varied widely between studies.

A Large-Scale Look at Obsessive-Compulsive Symptoms

To get a clearer picture of how prevalent OCS are in people with severe mental illness, researchers analyzed the electronic health records of over 21,000 patients diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder who received care from a large mental health system in London.

The researchers used natural language processing - a type of artificial intelligence that can analyze written text - to scan through clinical notes and identify mentions of obsessive-compulsive symptoms or diagnoses. This allowed them to efficiently review huge amounts of clinical data that would be impractical to analyze manually.

How Common Are Obsessive-Compulsive Symptoms?

The study found that 23% of patients - nearly 1 in 4 - had documentation of obsessive-compulsive symptoms in their medical records. Specifically:

• 24.6% of patients with schizophrenia had OCS
• 25.3% of patients with schizoaffective disorder had OCS
• 22.6% of patients with bipolar disorder had OCS

Additionally, 11.9% of patients had a formal diagnosis of obsessive-compulsive disorder recorded in their charts.

These rates are considerably higher than OCD prevalence in the general population, which is estimated to be around 2-3%. The findings confirm that obsessive-compulsive symptoms frequently co-occur with severe mental illnesses like schizophrenia and bipolar disorder.

Who Is More Likely to Experience OCS?

The study found that certain demographic and clinical factors were associated with a higher likelihood of having obsessive-compulsive symptoms:

• Male gender
• Non-white British ethnicity
• Living in more socioeconomically deprived neighborhoods
• Being single/unmarried
• Having co-occurring diagnoses of alcohol use disorder, opioid use disorder, or major depressive disorder

This suggests there may be shared risk factors or vulnerabilities that predispose some individuals to developing both OCS and other psychiatric conditions.

Impact on Psychiatric Symptoms and Functioning

One of the key questions the researchers wanted to explore was whether having obsessive-compulsive symptoms was associated with more severe psychiatric symptoms or worse overall functioning in patients with schizophrenia, schizoaffective disorder, or bipolar disorder.

To assess this, they looked at clinician ratings of various symptoms and behaviors using a standardized assessment tool called the Health of the Nation Outcome Scales (HoNOS). After accounting for demographic factors, they found that patients with OCS were more likely to have:

• Aggressive behavior
• Cognitive problems (e.g. difficulties with memory, concentration, decision-making)
• Hallucinations and delusions
• Physical health problems or disabilities

This suggests that the presence of obsessive-compulsive symptoms may be a marker of more severe or complex illness in people with schizophrenia spectrum disorders or bipolar disorder.

Interestingly, the association between OCS and hallucinations/delusions was strongest for patients with bipolar disorder. This highlights how the interplay between different psychiatric symptoms can vary depending on a person’s primary diagnosis.

Why Are These Findings Important?

Understanding the prevalence and impact of obsessive-compulsive symptoms in severe mental illness is crucial for several reasons:

1. Improving detection and diagnosis: OCS may be overlooked or misdiagnosed in patients with schizophrenia or bipolar disorder. Raising awareness of how common these symptoms are could help clinicians better recognize and assess for them.

2. Tailoring treatment approaches: The presence of OCS may influence how well patients respond to certain medications or psychological therapies. Identifying OCS could help guide more personalized and effective treatment plans.

3. Predicting outcomes: Co-occurring OCS appears to be associated with more severe symptoms overall. Screening for OCS could potentially help identify patients at higher risk of poor outcomes who may need more intensive support.

4. Advancing understanding of mental illness: The frequent co-occurrence of OCS with other psychiatric symptoms provides clues about potential shared underlying mechanisms or risk factors that warrant further research.

Leveraging Technology to Improve Care

A noteworthy aspect of this study was its use of natural language processing to efficiently analyze thousands of patient records. This type of “big data” approach allows researchers to study psychiatric symptoms and outcomes at a scale that wasn’t previously feasible.

The authors suggest that similar automated tools could potentially be used in clinical practice to help flag patients who may have unrecognized obsessive-compulsive symptoms. This could prompt further assessment and ensure that OCS are properly addressed as part of a patient’s overall treatment plan.

Limitations and Future Directions

It’s important to note some limitations of the study. Since it relied on symptoms documented in medical records, it may have underestimated the true prevalence of OCS. Clinicians may not always thoroughly assess for or record these symptoms, especially if they seem less severe than a patient’s primary psychiatric condition.

Additionally, the study design didn’t allow researchers to determine whether obsessive-compulsive symptoms developed before, after, or around the same time as schizophrenia or bipolar disorder. Understanding the timing and trajectory of symptom development could provide valuable insights.

Future research could address these limitations by:

1. Directly assessing patients for OCS using standardized measures, rather than relying solely on medical records
2. Following patients over time to track how OCS and other psychiatric symptoms change and interact
3. Investigating whether early identification and treatment of OCS in people with schizophrenia or bipolar disorder leads to better outcomes

Conclusions

• Obsessive-compulsive symptoms are common in people with schizophrenia, schizoaffective disorder, and bipolar disorder, affecting nearly 1 in 4 patients.
• The presence of OCS is associated with more severe psychiatric symptoms and may be a marker of more complex illness.
• Improved recognition and assessment of obsessive-compulsive symptoms in patients with severe mental illness is needed to ensure comprehensive treatment.
• Automated analysis of electronic health records shows promise as a tool for large-scale mental health research and potentially for improving clinical care.