Acta Neuropsychiatrica 2007: 19: 118–121 # 2007 The Authors

All rights reserved Journal compilation # 2007 Blackwell Munksgaard

DOI: 10.1111/j.1601-5215.2006.00169.x
ACTA NEUROPSYCHIATRICA

Brief report

Obsessive compulsive disorder in adults with

rheumatic heart disease
Ashfaq-U-Rahaman, Janardhan Reddy YC, Prabhavathi, Pramod Ashfaq-U-Rahaman1, Y. C.
Kumar Pal. Obsessive compulsive disorder in adults with rheumatic Janardhan Reddy1, Prabhavathi2,
heart disease. Pramod Kumar Pal3
1
Department of Psychiatry, NIMHANS, Bangalore,
Objective: There are considerable data on the possible association India; 2Department of Cardiology, Sri Jayadeva
between streptococcal infection and obsessive compulsive disorder Institute of Cardiology, Bangalore, India; and
(OCD), particularly the relation between Sydenham’s chorea (SC) and 3
Department of Neurology, NIMHANS,
OCD. However, neuropsychiatric sequelae related to streptococcal Bangalore, India
infection are mainly reported in children. In this preliminary study, we
examined prevalence of OCD in a group of adult subjects with
established rheumatic heart disease (RHD). We hypothesized that the
rate of OCD would be higher than the known general population rates.
Method: One hundred adult subjects with RHD were evaluated for OCD
and other comorbid psychiatric disorders using well-known psychiatric
assessment tools. A qualified psychiatrist conducted the assessments. The
Keywords: comorbidity; obsessive compulsive
diagnoses were made according to DSM-IV criteria.
disorder; rheumatic heart disease
Results: The rate of clinical OCD and subclinical OCD was 10% and
3%, respectively (n ¼ 13), a rate much higher than the 1–3% rate Dr Y. C. Janardhan Reddy, Obsessive Compulsive
reported in general population. Of the 13 subjects, only three had Disorder Clinic, Department of Psychiatry, NIMHANS,
Bangalore 560029, India.
a history of SC (23%). Tel: 0091-80-26995278, 26995306;
Conclusions: OCD could be a long-term sequel in adults with a history Fax: 0091-80-26564822;
of rheumatic fever in childhood, even in the absence of frank chorea. E-mail: jreddy@nimhans.kar.nic.in,
The findings call for systematic research in this little explored area. ycjreddy@yahoo.com

The association between Sydenham’s chorea (SC), ment of basal ganglia is critical to the development
a classic postinfectious autoimmune basal ganglia of OCD [for detailed review, see Saxena and Rauch
disorder, and obsessive compulsive disorder (OCD) and Whiteside et al. (6,7)]. In the background of
is well documented (1). There is also considerable this knowledge, we hypothesized that the rate
interest in the Ôpediatric autoimmune neuropsychi- of OCD would be higher in adults with a history of
atric disorders associated with streptococcal infec- rheumatic fever (RF) in childhood than the rates
tions (PANDAS)’, a subtype of pediatric OCD with known in general population because of the long-
distinctive course but no obvious chorea (2). OCD term sequelae of potential autoimmune insult to
occurring in the context of streptococcal infections the basal ganglia even in the absence of history of
is attributed to autoimmunity (3) against basal SC. There is some evidence for increased preva-
ganglia (4). Support for autoimmune hypothesis lence of OCD in RF even in the absence of SC (8),
comes from the presence of autoantibodies that leading to the speculation that there could be
bind to basal ganglia proteins in both SC and a subthreshold autoimmune insult to the basal
PANDAS (5). ganglia, which results in behavioral sequelae
The role of basal ganglia involvement in OCD instead of frank chorea (9). However, neuropsy-
is well documented. Neuroimaging studies sug- chiatric sequelae related to streptococcal infection
gest involvement of orbitofrontal-subcortical cir- are mainly reported in children, with the exception
cuitry that involves orbitofrontal cortex, anterior of one recent study that found no evidence for
cingulum, basal ganglia (caudate in particular) and increased prevalence of OCD in adults with
thalamic structures (6,7). It appears that involve- a history of RF (10). This study examined the

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prevalence of OCD in a group of adult subjects (67%), with almost even distribution of subjects
with established rheumatic heart disease (RHD). from rural (51%) and urban (49%) backgrounds.
We chose subjects with RHD because presence A majority was Hindus (89%) and married (85%).
of established RHD is a definite proof of a history The mean number (SD) of years of education was
of RF. 6.19 (4.81) years.
A history of major Jones criteria other than
carditis was as following: polyarthritis in 41%, SC
Methods in 9%, subcutaneous nodules in 3% and erythema
marginatum in 1%. As determined by echocardi-
One hundred adult cases with RHD (.18 years)
ography, mitral stenosis was the commonest valv-
diagnosed by a senior cardiologist based on clinical
ular lesion (81%). Seventy-one subjects were on
and echocardiographic evidence formed the sample
regular penicillin prophylaxis, and 20 were not
of this study. We recruited consecutively the patients
taking penicillin regularly. The remaining nine
receiving treatment at the Sri Jayadeva Institute of
subjects were not on prophylactic penicillin.
Cardiology, Bangalore, India, over a period of 6
A lifetime diagnosis of clinical OCD or sub-
months. Informed consent was obtained from all the
clinical OCD was present in 13 subjects (13%), 10
patients. The study was conducted as per the ÔEthical
of them being female (77%): current clinical OCD
Guidelines for Biomedical Research Involving
in 9, current subclinical OCD in 3, and a history of
Human Subjects’ of the Ethics Committee of
OCD in 1 subject. The mean age of onset (SD) of
National Institute of Mental Health and Neuro-
RF and OCD was 12.76 (4.88) and 25.87 (9.58)
sciences. Doppler echocardiography has emerged as
years, respectively. In all the 13 subjects, OCD
a safe, sensitive and noninvasive method for the
postdated RF. Of the 13 subjects, only three had
diagnosis of RHD; its findings correlate very closely
a history of SC (23%). Six subjects with a history
to those of cardiac catheterization and, therefore,
of SC did not have OCD. Major depression was
considered adequate to diagnose RHD (11).
the commonest current comorbid condition (41%).
Psychiatric assessments were performed using
Comorbidity profile in the 100 subjects with RHD
the Mini International Neuropsychiatric Interview
and the symptom profile in the 13 subjects with
(MINI) (12), the Yale-Brown Obsessive Compul-
obsessional symptoms are given in Table 1.
sive Scale (Y-BOCS) (13) and the tics and attention
The subjects with lifetime diagnosis of clinical
deficit disorder subsections of the Schedule for
OCD or subclinical OCD (n ¼ 13) did not differ
Tourette and other Behavioral Syndromes (14).
from those without with regard to age, gender,
A detailed clinical neurological examination was
religion, urban/rural background, occupational
also performed. The MINI is a short structured
status and years of education. However, those
diagnostic interview for diagnosing major axis-I
with OCD had significantly higher rates of current
psychiatric disorders according to the current
major depression (77 vs. 36%, p ¼ .007) than those
classificatory systems. The Y-BOCS has a symptom
without OCD.
checklist, and a 10-item clinician administered scale
widely used for assessing severity of OCD. The
Schedule for Tourette and other Behavioral Syn-
dromes has an exhaustive checklist of motor and Discussion
phonic tics and assesses Ôworst ever’ and current In the assessment of psychiatric morbidity, the
severity of tics. It also has a 21-item questionnaire most striking finding was the increased prevalence
that helps in diagnosing attention deficit hyperac- of OCD (10%) in the patients with RHD
tivity disorder as per DSM-IV criteria. compared with the reported general population
All psychiatric diagnoses were made according prevalence of about 1–3% in various epidemiolog-
to DSM-IV criteria. The principal author was ical studies (15–17). The overrepresentation of
trained to administer the instruments and per- female subjects in those with OCD is somewhat
formed all the detailed psychiatric assessments. consistent with the epidemiological data but is also
The final diagnoses were made by the consensus reflective of the female preponderance in the
opinion of the two authors (AUR and YCJR). sample. The 10% rate of OCD in this sample of
patients with RHD is five-fold higher than the
general population rate suggesting, a possible
Results etiological relationship between RHD and OCD.
The mean age [standard deviation (SD)] of the The existing literature on neuropsychiatric com-
subjects was 33.09 (9.22) years. The sample plications of RF is largely confined to acute phases
consisted of predominantly female subjects of RF in children with the exception of a recent

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Table 1. Clinical characteristics of the sample It is postulated that children might exhibit only
Psychiatric comorbidity (N ¼ 100)
tics or OCD if the dose of a presumed etiologic
Major depressive disorder, current 41 agent was not sufficient to cause frank chorea (9).
Major depressive disorder, past 9 This hypothesis implies that neuropsychiatric
Dysthymia 1 manifestations are dose dependent and that the
OCD, current 9
OCD, past 1
manifestations lie on a continuum of impairment,
Subclinical OCD 3 ie psychiatric manifestations such as OCD occur at
Panic disorder, current 2 lower doses and SC occurs at higher doses. Our
Agoraphobia without panic disorder, current 4 study does not support this hypothesis unequivo-
Social phobia, current 1
Generalized anxiety disorder, current 1 cally. For example, three patients had both SC and
Bipolar disorder 1 OCD, whereas the other six subjects who had SC
Psychosis 1 did not have OCD. However, our finding is
Tics disorder 1
supportive of the speculation that there could be
Attention deficit hyperactivity disorder 3
Profile of obsessive compulsive symptoms* (N ¼ 13) basal ganglia damage even in the absence of frank
Obsessions, n (%) chorea and that OCD could be a long-term sequel
Aggressive 1 (8) of such damage (9). It has been suggested that
Contamination 7 (54)
Sexual 0
immunologic stress may result in compromised
Religious 2 (15) blood-brain barrier that results in influx of
Symmetry, ordering 4 (31) antineuronal antibodies into the central nervous
Hoarding 1 (8) system (20). Imaging studies of children with
Somatic 3 (23)
Miscellaneous 7 (54)
PANDAS have shown reduced caudate nucleus
Compulsions, n (%) volumes in those with chronic OCD, suggesting
Washing, cleaning 5 (38) that repeated bouts of inflammation could be the
Checking 1 (8) cause of shrinkage in the volume of caudate nuclei
Repeating 3 (23)
Counting 2 (15)
(4). It is possible that repeated bouts of infections
Ordering, arranging 3 (23) could result in further damage to caudate nuclei in
Hoarding 1 (8) subjects with RHD too resulting in increased risk
Miscellaneous 3 (23) for OCD. Considering that basal ganglia involve-
Y-BOCS score in current OCD, mean (SD) 18.00 (3.71)
Y-BOCS score in subclinical OCD, mean (SD) 10.00 (4.58) ment is crucial in the current neuroanatomic model
of OCD (6,7), we speculate that RF results in the
*Symptom profile in the subjects with clinical and subclinical OCD (clinical ¼ 10, development of antibodies that cross-react with
subclinical ¼ 3).
basal ganglia proteins and increase the vulnerabil-
ity to develop OCD in the long run.
study that reported high rates of OCD and related The study provides preliminary clinical evidence
spectrum disorders in a sample of nonacute that OCD could be a sequel of RF. The study
subjects with RF that consisted mainly children has several shortcomings including the absence of
(18). Literature on long-term neuropsychiatric a control group and unblind assessments. It could
complications in adults with a history of RF is also be argued that a high prevalence of major
scarce. This is surprising considering that RF has depression in the subjects with OCD may have
long-term complications related to other systems confounded the assessment of OCD. Despite its
such as heart and joints. A recent study examined limitations, the study explores a little studied area
OC symptoms in a small sample of adults with and provides directions for more systematic
a history of RF and found no increased propensity studies in the future. The findings of the study
for OCD in adulthood (10). The study concluded need to be replicated by studies with a more
that the neuropsychiatric manifestations possibly robust methodology including a larger sample,
occur only in acute RF phases. However, in a matched medically ill control group with
support of our hypothesis, there is an intriguing commensurate rate of depression and, if feasible,
case report of an adult who developed OCD blind assessments. Further, it would be prudent for
following a group-A beta hemolytic streptococcal future studies to collect immunological, neuro-
infection after a latent period of 3 years (19). The imaging and family genetic data to validate the
case report has two main implications relevant to concept.
this study. First, the case report shows that
poststreptococcal neuropsychiatric disorders are
not limited to children. Second, the report shows Acknowledgements
that they can develop even after a relatively long This study was conducted as a part fulfillment toward the
latent period. completion of MD course in Psychiatry by the first author. The

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thesis was submitted to the National Institute of Mental Health fever, Sydenham’s chorea and type I diabetes mellitus:
and Neurosciences (deemed university). preliminary results. Acta Psychiatr Scand 2005;111:
159–161.
11. SANYAL SK. Longterm sequelae of the first episode of acute
rheumatic fever during childhood. In: MOSS AJ, ADAMS
References FH, EMMANOUILIDES GC, eds. Heart disease in infants,
1. SWEDO SE, RAPOPORT JL, CHESLOW DL, LEONARD HL, children and adolescents. Lippincott Williams & Wilkins,
AYOUS EM, HOSIER DM. High prevalence of obsessive- 1995; 1416–1440.
compulsive symptoms in patients with Sydenham’s chorea. 12. SHEEHAN DV, LECRUBIER Y, SHEEHAN KH et al. The Mini
Am J Psychiatry 1989;146:246–249. International Neuropsychiatric Interview (MINI): the
2. SWEDO SE, LEONARD HL, GARVEY MA et al. Pediatric development and validation of a structured diagnostic
autoimmune neuropsychiatric disorders associated with interview for DSM-IV and ICD-10. J Clin Psychiatry
streptococcal infections: clinical description of the first 50 1998;59 (Suppl. 20):20–23.
cases. Am J Psychiatry 1998;155:264–271. 13. GOODMAN WK, PRICE LH, RASMUSSEN SA et al. The Yale-
3. KIM SW, GRANT JE, KIM SI et al. A possible association of Brown Obsessive-Compulsive Scale. I: development, use,
recurrent streptococcal infections and acute onset of and reliability. Arch Gen Psychiatry 1989;46:1006–1011.
obsessive-compulsive disorder. J Neuropsychiatry Clin 14. PAUL DL, HURST CR. Schedule for Tourette and
Neurosci 2004;16:252–260. Behavioral syndromes: adult form version A3-Yale Family
4. GIEDD JN, RAPOPORT JL, GARVEY MA, PERLMUTTER S, Genetic Study of Tourette Syndrome. New Haven,
SWEDO SE. MRI assessment of children with obsessive- Connecticut: Yale Child Study Center, 1996.
compulsive disorder of tics associated with streptococcal 15. JENKINS R, BEBBINGTON P, BRUGHA T et al. The National
infection. Am J Psychiatry 2000;157:281–283. Psychiatric Morbidity Surveys of Great Britain–strategy
5. MURPHY TK, SAJID MW, GOODMAN WK. Immunology of and methods. Psychol Med 1997;27:765–774.
obsessive-compulsive disorder. Psychiatr Clin North Am 16. KARNO M, GOLDING JM, SORENSON SB, BURNAM MA.
2006;29:445–470. The epidemiology of obsessive-compulsive disorder in
6. SAXENA S, RAUCH SL. Functional neuroimaging and the five US communities. Arch Gen Psychiatry 1988;45:
neuroanatomy of obsessive-compulsive disorder. Psychiatr 1094–1099.
Clin North Am 2000;23:563–586. 17. WEISSMAN MM, BLAND RC, CANINO GJ et al. The cross-
7. WHITESIDE SP, PORT JD, ABRAMOWITZ JS. A meta-analysis national epidemiology of obsessive-compulsive disorder.
of functional neuroimaging in obsessive-compulsive dis- J Clin Psychiatry 1994;55 (Suppl. 3):5–10.
order. Psychiatry Res 2004;132:69–79. 18. HOUNIE AG, PAULS DL, MERCADANTE MT et al. Obsessive-
8. MERCADANTE MT, BUSATTO GF, LOMBROSO PJ et al. The compulsive spectrum disorders in rheumatic fever with and
psychiatric symptoms of rheumatic fever. Am J Psychiatry without Sydenham’s chorea. J Clin Psychiatry 2004;65:
2000;157:2036–2038. 994–999.
9. SWEDO SE. Sydenham’s chorea. A model for childhood 19. BODNER SM, MORSHED SA, PETERSON BS. The question of
autoimmune neuropsychiatric disorders. JAMA 1994; PANDAS in adults. Biol Psychiatry 2001;49:807–810.
272:1788–1791. 20. DINN WM, HARRIS CL, MCGONIGAL KM, RAYANARD RC.
10. ASBAHR FR, RAMOS RT, COSTA AN, SASSI RB. Obsessive- Obsessive-compulsive disorder and immunocompetence.
compulsive symptoms in adults with history of rheumatic Int J Psychiatry Med 2001;31:311–320.

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