Psychiatry Research 300 (2021) 113898

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

The impact of generalized anxiety disorder in obsessive-compulsive

disorder patients.
Prerika Sharma a, Maria C. Rosário b, Ygor A. Ferrão c, Lucy Albertella a, Euripedes C. Miguel d,
Leonardo F Fontenelle a, e, *
a
Turner Institute for Brain and Mental Health, Monash University, Victoria, Australia
b
Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), Brazil
c
Department of Psychiatry, Federal University of Health Sciences of Porto Alegre (UFCSPA)
d
Obsessive-Compulsive Spectrum Disorders Program (PROTOC), Department and Institute of Psychiatry, University of São Paulo (USP), Brazil
e
Obsessive, Compulsive, and Anxiety Spectrum Research Program. Institute of Psychiatry, Federal University of Rio de Janeiro & D’Or Institute for Research and
Education, Rio de Janeiro, Brazil

A R T I C L E I N F O A B S T R A C T

Key-words: Despite generalized anxiety disorder (GAD) being one of the most prevalent comorbidities in obsessive-
Obsessive-compulsive disorder compulsive disorder (OCD), few studies have researched its impact on the OCD phenotype. The present study
psychopathology investigated how the sociodemographic and clinical profile of people with OCD with comorbid GAD differs from
anxiety
people with OCD without comorbid GAD. We hypothesised that the phenotype of the comorbid group would be
closely related to GAD, in that it would more likely be female, have an earlier age at onset of OCD, and show an
increased severity of fear-related OCD symptoms (aggressive, sexual/religious, and contamination dimensions),
more avoidant behaviours, greater suicidality, more severe anxiety symptoms, and increased rates of comorbid
anxiety and mood disorders. The study included 867 participants with OCD, with GAD being comorbid in
33.56%. Mann-Whitney U tests, chi-square tests with continuity correction, and logistic regressions were per­
formed. Results showed that comorbid GAD was uniquely associated with an increased number of avoidant
behaviours, greater anxiety severity, panic disorder without agoraphobia, social phobia, specific phobia, and
type II bipolar disorder. These results illustrate the clinical severity associated with this comorbidity and high­
light markers that can aid diagnosis of GAD in OCD. Future studies should investigate whether this comorbidity
has an impact on the treatment of OCD.

1. Introduction previously classified elsewhere (e.g. body dysmorphic disorder)

Obsessive-compulsive disorder (OCD) is characterized by unwanted
thoughts, images, or urges that cause anxiety or distress (obsessions)
and/or repetitive behaviors or mental acts (compulsions) aimed at
decreasing distress (American Psychiatric Association, 2013). Until the
DSM-IV, OCD had been classified as an anxiety disorder, together with
panic disorder, agoraphobia, specific and social phobias, post-traumatic
stress disorder and generalized anxiety disorder (GAD) (American Psy­
chiatric Association, 2000). In the DSM-5, the recognition of the
uniqueness of OCD in terms of clinical and biological features has lead to
the removal of OCD from the anxiety disorders chapter and its inclusion
in a new group of entities entitled obsessive-compulsive and related
disorders (OCRDs), where OCD is listed with many other conditions
(American Psychiatric Association, 2013). Despite this change in the
way OCD is conceptualized, it remains undebatable that anxiety disor­
ders, including GAD, represent one of the most common psychiatric
disorders associated with OCD in both clinical and epidemiological
settings (Fontenelle and Hasler, 2008).
Additionally, the relationship between OCD and anxiety disorders,
particularly GAD, is recognized in many other domains. For example,
worry in GAD is similar to obsessions in OCD in that both refer to re­
petitive, unwelcome, and time-consuming thoughts (American Psychi­
atric Association, 2013). Plus, both disorders share “intolerance of
uncertainty” (Frost et al., 1997), which has been argued to engender
compulsive behaviour in OCD (Tallis, 1995; Tolin et al., 2003) and
worry in GAD (Dugas et al., 2004). These similarities have important

* Corresponding author at: Turner Institute for Brain and Mental Health, Monash University, 770 Blackburn Road, Clayton, VIC 3168, Australia
E-mail address: lfontenelle@gmail.com (L.F. Fontenelle).

https://doi.org/10.1016/j.psychres.2021.113898
Received 31 October 2020; Accepted 20 March 2021
Available online 23 March 2021
0165-1781/© 2021 Elsevier B.V. All rights reserved.
P. Sharma et al.
clinical and diagnostic implications. For instance, when OCD lacks overt
(“motor”) symptoms, and “mental” compulsions are not identified by
the diagnostician, OCD may end up being mislabelled as GAD (Williams
et al., 2011).
Nonetheless, OCD and GAD also present with distinctive features.
For instance, obsessions are more likely to include bizarre themes (Lee
and Kwon, 2003) and to be considered ego-dystonic (Nestadt et al.,
2001) while GAD worries are more commonly about realistic and daily
problems (Breitholtz et al., 1998). People with OCD also employ greater
efforts to control thoughts than those with GAD (Morillo et al., 2007).
Indeed, Abramowitz and Foa (Abramowitz and Foa, 1998) found that
people with OCD with comorbid GAD reported more generalised worry
than those without, but no difference in the severity of OCD symptoms.
These findings, paired with the distinctive features of the two disorders,
imply that GAD’s comorbidity will have a perceptible effect on the OCD
phenotype. However, insuficient research on this frequently comorbid
disorders has left this effect unclear, leaving the clinical and de­
mographic presentation of someone with OCD and comorbid GAD
unknown.
Although it is beyond the scope of this paper to discuss the differ­
ences between OCD and GAD, their undeniable similarities have lead
many clinicians to speculate whether they represent the same disorder
along a single spectrum of severity. For instance, if OCD associated with
GAD simply represents a more “malignant” type of GAD, one could
expect OCD associated with GAD to be characterised by many typical
GAD features, including greater prevalence of female individuals (de
Mathis et al., 2009; Vesga-López et al., 2008), earlier age at onset [as in
an “anxious temperament” (Akiskal, 1998; Taylor, 2011)], increased
severity of fear/doubt-related symptoms (i.e. aggressive, sexual/reli­
gious, and contamination dimensions) (Coleman et al., 2011a; Fergus
and Wu, 2010), and greater number of avoidant behaviors (Andrews
et al., 2010; McGuire et al., 2012). In addition, OCD associated with
GAD may be characterised by greater suicidality (Angelakis et al., 2015;
Sommer et al., 2019), more severe anxiety symptoms (Abramowitz and
Foa, 1998), and increased rates of comorbid anxiety and mood disorders
(Lochner et al., 2014; Nutt et al., 2006). To test these hypotheses, we
investigated the sociodemographic and clinical correlates of comorbid
GAD in a large OCD sample.
2. Method
2.1. Participants
The present study was a secondary analysis of an existing databank,
the Brazilian Research Consortium on Obsessive–Compulsive Spectrum
Disorders (Miguel et al., 2008). All participants in the original study
were recruited from seven centres. The original databank recruited 1001
(M= 34.85 years, S.D= 12.99 years) participants who were seeking
treatment, and had OCD as their primary diagnosis according to the
DSM-IV criteria. Attending physicians ordered blood tests, neuro­
cognitive tasks, and brain scans if an underlying neurological and/or
medical condition was suspected to be causing obsessive-compulsive
symptoms. Exclusion criteria included intellectual disability, schizo­
phrenia, developmental disorders, “organic” OCD or any other condition
that interfered with proper participation (n= 8), or refusal to participate
(n= 40). Ethics approval for the original study was obtained by the
Research Ethics Committees of all centres, and ethics approval for the
present study was obtained by the Monash University and the Monash
University Human Research Ethics Committee.
After data cleaning (described below), the final sample for the pre­
sent study included 867 participants (504; 58.1% females). The age
ranged from 18 to 65 years (M= 35.61 years, S.D = 11.89 years). The
study group comprised participants who presented with current co­
morbid GAD, according to the Structured Clinical Interview for DSM IV-
TR Axis I Disorders, while the comparison group comprised participants
with OCD without GAD. A total of 291 (33.56%) participants had
2
Psychiatry Research 300 (2021) 113898
comorbid GAD.
2.2. Instruments
The Structured Clinical Interview for DSM IV-TR Axis I Disorders (SCID-
I). The SCID-I (First et al., 2002) was used to confirm the presence of
OCD and assess the presence of comorbid Axis I disorders according to
the DSM-IV, including GAD. The SCID has been validated to Brazilian
Portuguese (Del-Ben et al., 2001) and has shown good inter-rater reli­
ability in the present sample (Miguel et al., 2008). Only mood and
anxiety disorders were compared between the two groups.
The Dimensional Yale-Brown Obsessive-Compulsive Scale (D-YBOCS).
The D-YBOCS was used to measure differences between the two groups
in terms of global and dimensional severity. As we were interested in
measuring the GAD-like symptoms, only the fear/doubt-related sub-
scales (i.e. aggressive, sexual/religious, contamination/cleaning) were
included in the analyses (Rosario-Campos et al., 2006). The D-YBOCS
has been found to be valid and reliable (Rosario-Campos et al., 2006). It
has also been used to rate the presence of compulsive and avoidant
behaviors, as reported on its symptom checklist, (e.g. “I avoid certain
actions ... to prevent obsessions and compulsions of ...”). The total
number of compulsive and avoidant symptoms was computed by us
through these items. Only current scores were used for the present study.
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). The Y-BOCS
(Goodman et al., 1989a) was used to rate the severity of obsessions and
compulsions in both groups. The original Y-BOCS shows high reliability
(Goodman et al., 1989b) and validity values (Goodman et al., 1989a).
Scores range from 0 to 20 for obsessions and compulsions each. Thus,
the total score varies from 0 to 40.
OCD Natural History Questionnaire (OCD-NHQ). The OCD-NHQ
(Leckman, 2002) was used to measure the different aspects of the nat­
ural history of OCD, including circumstances related to onset of obses­
sions and compulsions, course of symptoms, ameliorating and
worsening factors, the effects of medication, and factors associated with
the worst phase of symptom severity. For the purposes of this study, only
age at onset of OCD (operationalised as the age at which an individual
first perceived their obsessions and compulsions) was extracted.
Beck Depression (BDI) and Beck Anxiety Inventory (BAI). The severity
of depression and anxiety symptoms were measured with the BDI (Beck
et al., 1961) and the BAI (Beck et al., 1988), respectively. Both scales
show good psychometric properties in Brazilian Portuguese (Cunha,
2001) and are scored from 0 to 63.
Suicidality. The questions used to assess suicidality were the same
employed by Torres et al. (2011) and have been used in subsequent
studies investigating suicidality from the same group (e.g. Velloso et al.,
2016). Only five of the original questions were asked, including whether
the person has ever a) thought life was not worth living, b) wished to be
dead, c) thought about killing themselves, d) made suicidal plans, and e)
attempted suicide. Answers were recorded as ‘yes’ or ‘no’.
2.3. Procedure
All data was retrieved from an existing data bank with OCD patients
from seven university centers (Miguel et al., 2008). In the original study,
participants were informed of the aims and methods of the research, and
were told that refusal to participate would not impact their treatment.
Then, they freely signed a consent form. Personnel from the centres were
trained to ensure a standardised administration of all assessment mea­
sures, which occurred between 2003 and 2009. Leaders from each
centre examined at least six patients with the SCID and D-YBOCS, and an
inter-rater reliability of 96% was obtained. They were responsible for
training researchers within their own centres. Additional details on the
procedure of the original study are presented in Miguel et al. (2008).
In the present study, relevant data such as the aforementioned in­
struments and demographic characteristics was retained from the
databank and subsequently analysed. All analyses were performed with
P. Sharma et al. Psychiatry Research 300 (2021) 113898

Table 1 considered ‘absent’, and only clinically diagnosed disorders were used
Sociodemographic and clinical characteristics of OCD participants with and for analyses. For presence of a given OCD dimension, ‘evident presence’
without GAD. and ‘ambigious presence’ were classified into one category. To calculate
OCD without GAD OCD with GAD the total number of avoidant items endorsed on the D-YBOCS, items
(n= 576) (n= 291) were allocated to ‘obsessive’ thoughts (n= 40), ‘avoidant’ behaviors (n=
Gender- n (%) 9) or ‘compulsive’ behaviors (n= 36), and some items were ignored for
Male 237 (41.1) 126 (43.3) ambiguity (n= 3) (see Appendix). Finally, outliers (n= 90) were
Female 339 (58.9) 165 (56.7) removed using z-scores (+/- 3.29), as transformations would have led to
Age (years)- median (range) 34 (47) 32 (47)
difficulties in interpretation (Tabachnick and Fidell, 2014). The age
Ethnicity- n (%)
Caucasian 479 (83.2) 233 (80.1) range was restricted to between 18 and 65 years (instead of 9 to 82 years
African 22 (3.8) 14 (4.8) in the original dataset).
Asian 7 (1.2) 6 (2.1) Analyses used. Univariate analyses were first performed to highlight
Mixed 66 (11.5) 38 (13.1) any significant differences between the two groups. Due to non-normal
Other 2 (0.3) 0
Religion- n (%)
data, Mann-Whitney U tests were used to investigate differences in age
Religious 511 (88.7) 266 (91.4) at onset of OCD; number of avoidant and compulsive items endorsed in
Non-religious 65 (11.3) 25 (8.6) the D-YBOCS; and scores on the DYBOCS, Y-BOCS, BDI, and BAI. A chi-
Marital status- n (%) square test with Yates’ correction for continuity was used to investigate
Married/ stable partner 233 (40.5) 110 (37.8)
differences in gender, prevalence of suicidality phenomena, and some
Single 292 (50.7) 159 (54.6)
Widowed 10 (1.7) 1 (0.3) comorbid Axis I disorders (see Table 1). A logistic regression was finally
Divorced 41 (7.1) 21 (7.2) performed using all significant (p > .05) variables found in the pre­
Employment status- n (%) liminary univariate analyses, to find predictors of having comorbid GAD
Working outside the home 249 (43.2) 145 (49.8) in OCD. Multicollinearity was inspected via variance inflation factor
Working inside the home 69 (12.0) 28 (9.6)
(VIF) and tolerance statistics. Although the total D-YBOCS and Y-BOCS
Student 78 (13.5) 37 (12.7)
Unemployed 101 (17.5) 44 (15.1) scores were found significant in the univariate analyses, only their sub-
Retired 70 (12.2) 29 (10.0) scales were computed in the regression, to avoid multicollinearity.
OCD age at onset- median (range) 11 (42) 10 (51)
D-YBOCS - median (range)
3. Results
Aggressive 5 (15) 7 (15)
Sexual/religious 1.5 (15) 3 (15)
Symmetry 8 (15) 9 (15) 3.1. Sample characteristics
Contamination 6 (15) 8 (15)
Hoarding 0 (15) 0 (15) Table 1 shows the sociodemographic and clinical characteristics of
Miscellaneous 8 (15) 10 (15)
participants with and without GAD.
Global severity 22 (30) 23 (30)
Number of avoidant items endorsed 1 (7) 2 (7)
Number of compulsive items endorsed 6.5 (24) 8 (25) 3.2. Univariate analyses
Y-BOCS – median (range) 26 (33) 27 (33)
Obsessions 13 (19) 13 (17)
Results of the Mann-Whitney U test and chi-square test with Yates’
Compulsions 13 (20) 13 (20)
Suicidality- n (%) continuity correction are displayed in Tables 2 and 3, respectively. The
Ever thought life wasn’t worth living 334 (58.0) 190 (65.3) two groups significantly differed on their scores on the BDI, BAI, D-
Ever wanted to be dead 261 (45.3) 144 (49.5) YBOCS aggressive subscale, and Y-BOCS obsession sub-scale. While the
Ever thought of committing suicide 200 (34.7) 118 (40.5) D-YBOCS global severity and Y-BOCS total severity were both found to
Ever planned committing suicide 114 (19.8) 68 (23.4)
Ever tried committing suicide 50 (8.7) 45 (15.5)
be significantly different between the two groups, these were not
BDI scores- median (range) 15 (53) 20 (52) computed in the following regression as the presence of their sub-scales
BAI scores- median (range) 12 (51) 21 (53) in the regression would have led to multicollinearity. The two groups
Mood disorders- n (%) also significantly differed on ever having thought life wasn’t worth
Major depressive disorder 165 (28.6) 130 (44.7)
living and having tried suicide; endorsement of avoidant and compul­
Bipolar disorder
Type I 10 (1.7) 10 (3.4) sive items on the D-YBOCS; and presence of multiple comorbid
Type II 11 (1.9) 18 (6.2) disorders.
Anxiety disorders - n (%)
Separation anxiety disorder 20 (3.5) 18 (6.2) 3.3. Multivariate analysis
Panic with agoraphobia 32 (5.6) 29 (10.0)
Panic without agoraphobia 14 (2.4) 24 (8.2)
Agoraphobia without panic 22 (3.8) 16 (5.5) Using the significant variables found from the preliminary analyses,
Social phobia 152 (26.4) 131 (45.0) a logistic regression was performed to predict the probability of some­
Specific phobia 148 (25.7) 116 (39.9) one with OCD having comorbid GAD. The assumption of multi­
Post-traumatic stress disorder 49 (8.5) 41 (14.1)
collinearity was not violated by any variables, as found by tolerance
Note. n= number of participants; OCD= Obsessive compulsive disorder; GAD= values well above 0.1 and VIF values well below 5 (Allen et al., 2014).
Generalised anxiety disorder; DYBOCS= Dimensional-Yale Brown Obsessive- None of the interaction terms for the continuous variables (Allen et al.,
Compulsive Scale; YBOCS= Yale Brown Obsessive-Compulsive Scale; BDI= 2014) were significant, thus complying with the assumption of logit
Beck Depression Inventory; BAI= Beck Anxiety Inventory. linearity.
* denotes significance at α = .05.
The omnibus model for the regression was statistically significant, χ2
(df= 15, N= 876) = 141.23, p < .001, Cox and Snell R2 = .15, Nagel­
SPSS Version 21. kerke R2 = .21. The model was 71.9% accurate in predicting GAD.
Homer and Lemeshow test showed that the model was a good fit for the
2.4. Data analysis data, χ2 (df = 8, N = 876) = 8.72, p = .37. Coefficients for the model’s
predictors are presented in Table 4. Eventually, the significant pre­
Data cleaning. All missing data were removed. Recoding was per­ dictors of GAD were type II bipolar disorder (OR = 3.11), panic disorder
formed for a few variables: All disorders labelled ‘subclinical’ were without agoraphobia (OR= 2.89), social phobia (OR = 1.92), specific

3
P. Sharma et al. Psychiatry Research 300 (2021) 113898

Table 2
Results of Mann-Whitney U test showing differences in the age at onset of OCD; fear/doubt-related dimensional and total severity scores on the D-YBOCS; total
endorsement of avoidant and compulsive items on the D-YBOCS; obsession, compulsion, and total severity on the Y-BOCS; and BDI and BAI scores.
Measure OCD without GAD OCD with GAD

Mean rank n (%) Mean rank n (%) U z p

576(66.4) 291(33.6)
Age at onset of OCD 438.70 424.70 81102.00 -0.78 0.44
Symptom severity (D-YBOCS)
Aggressive 417.67 466.33 74400.50 -2.78 .006*
Sexual/religious 428.98 443.93 80918.00 -0.88 .38
Contamination 423.03 455.71 77489.00 -1.85 .07
Global severity 412.76 476.05 71571.50 -3.52 <.001*
Number of avoidant items endorsed (D-YBOCS) 411.37 478.80 70771.00 -3.83 <.001*
Number of compulsive items endorsed (D-YBOCS) 414.16 473.27 72380.50 -3.29 .001*
Symptom severity (Y-BOCS)
Obsessions 415.84 469.94 73349.00 -3.02 .003*
Compulsions 428.61 444.66 80705.50 -0.89 .37
Total 422.21 457.34 77017.50 -1.95 .05*
BDI 398.17 504.92 63169.00 -5.93 <.001*
BAI 381.20 538.51 53394.50 -8.74 <.001*

Table 3 Table 4
Results of chi-square test with Yates’ continuity correction showing gender, Predictor coefficients for the logistic regression model predicting comorbid GAD
suicidality phenomena, and comorbid disorders related to having comorbid GAD with OCD.
with OCD.
Predictor b SE p Exp (B) [95%
Comorbid disorder df χ2 p ϕ (b) CI]

1 D-YBOCS
Gender (female) 0.29 .59 -.02 Aggressive -.002 .02 .91 1.00 [0.97,
Suicidality 1.03]
Ever thought life wasn’t worth living 4.02 .05* .07 Number of avoidant items .18 .06 .004* 1.20 [1.06,
Ever wanted to be dead 1.19 .28 .04 endorsed 1.36]
Ever thought of committing suicide 2.58 .11 .06 Number of compulsive items .02 .02 .45 1.02 [0.98,
Ever planned committing suicide 1.28 .26 .04 endorsed 1.06]
Ever tried committing suicide 8.44 .004* .10 Obsession severity (Y-BOCS) .03 .02 .22 1.03 [0.98,
Mood disorders 1.08]
Major depressive disorder 21.42 < .001* .16 Suicidality
Bipolar disorder Thought life wasn’t worth living -.08 .18 .68 0.93 [0.65,
Type I 1.78 .18 .05 1.32]
Type II 9.65 .002* .11 Tried suicide .46 .25 .07 1.58 [0.97,
Anxiety disorders 2.59]
Separation anxiety disorder 2.78 .10 .06 BDI -.01 .01 .49 0.99 [0.97,
Panic with agoraphobia 5.09 .02* .08 1.01]
Panic without agoraphobia 14.25 < .001* .13 BAI .05 .01 < 1.05 [1.03,
Agoraphobia without panic 0.93 .34 -.04 .001* 1.07]
Social phobia 29.67 < .001* .18 Major depressive disorder .17 .20 .38 1.19 [0.81,
Specific phobia 17.66 < .001* .15 1.74]
Post-traumatic stress disorder 5.89 .02* .09 Type II Bipolar disorder 1.14 .42 .01* 3.11 [1.37,
7.07]
Note. ϕ = Phi measure of effect size; OCD= Obsessive compulsive disorder; Panic with agoraphobia .04 .31 .89 1.04 [0.57,
GAD= Generalised anxiety disorder 1.89]
*
denotes significance at α = .05 Panic without agoraphobia 1.06 .38 .006* 2.89 [1.37,
6.12]
Social phobia .65 .17 < 1.92 [1.37,
phobia (OR = 1.46), DYBOCS avoidance scores (OR= 1.20), and BAI .001* 2.67]
scores (OR= 1.05). Specific phobia .38 .17 .03* 1.46 [1.04,
2.05]
4. Discussion Post-traumatic stress disorder -.02 .26 .94 0.98 [0.59,
1.63]

The aim of the present study was to investigate the impact of co­
morbid GAD on the OCD phenotype by comparing the sociodemo­
graphic and clinical profile of participants with OCD with and without
GAD. We predicted that OCD with GAD would be associated with a
range of phenotypical aspects more closely related to GAD, such as fe­
male gender, earlier age at onset, increased severity of fear-related OCD
symptoms, more avoidant strategies, greater suicidality, increased rates
of axis I comorbid anxiety disorders, and more severe anxiety symptoms.
Only part of our hypotheses were confirmed, i.e., a diagnosis of GAD
(present in almost 34% of the OCD sample) was uniquely associated with
a greater number of avoidant symptoms, greater severity of anxiety
symptoms, and comorbidity with type II bipolar disorder, panic disorder
without agoraphobia, social phobia, and specific phobia. These findings
indicate that comorbid GAD “shapes” the phenotype of an OCD sample.
The facts that both a greater number of avoidant OCD behaviors and
increased BAI scores were independently associated with the presence of
GAD are consistent with each other and also with earlier studies showing
OCD with GAD to be associated with more pathological responsibility
and indecisiveness (Abramowitz and Foa, 1998). We also speculate that
GAD-associated worries and anxiety may result in more OCD-related
avoidance to modulate distress, a mechanism that can represent a
cross-talk between these different disorders. While earlier studies have
already reported checking behaviors in GAD (Coleman et al., 2011b;
Schut et al., 2001), a recent investigation also described avoidance of
saying or doing things that are worrisome as one of the most relevant

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P. Sharma et al. Psychiatry Research 300 (2021) 113898

maladaptive behaviours associated with GAD (Mahoney et al., 2018) Table A1

Panic disorder without agoraphobia, social phobia, and specific The following table shows the items on the D-YBOCS that were categorised as
phobia were each associated with 2.89, 1.92, and 1.46 times the likeli­ either ‘avoidant’ or ‘compulsive’. This was used to explore how the coping
hood of having comorbid GAD, respectively. Actually, both OCD and strategies changed on each OCD dimension between the two groups.
GAD are highly comorbid with these disorders (Brakoulias et al., 2017; OCD dimension Item number categorised as Item number categorised as
Kessler, 2000; Turner et al., 1992), which also tend to share several ‘avoidant’ ‘compulsive’
Aggressive 13 3, 7,12, 14, 15
characteristics with both OCD and GAD, such as intolerance of uncer­
Sexual/Religious 21, 27 20, 25, 26, 28, 29, 30
tainty (Boelen and Reijntjes, 2009; Gorka et al., 2014) and social Symmetry 42 33, 34, 35, 36, 37 38, 39, 41
avoidance (American Psychiatric Association, 2013). As these condi­ Contamination 54 49, 50, 52, 53
tions are all characterized by significant fearful components (involving Hoarding 61 59, 60
more panic attacks or situations that would be difficult to escape, social Miscellaneous 65, 68, 73 63, 64, 74, 75, 77, 79, 80,
83, 86, 87, 88
interactions and situations that involve the possibility of being scruti­
nized, and circumscribed objects or situations), these findings suggest Items removed for ambiguity: 69, 70, 85
that GAD in OCD may be a marker of a more fearful/anxiety OCD All other items were categorised as ‘obsessive’.
phenotype. The finding that major depressive disorder was not found to
be a significant predictor of this comorbidity, despite its high prevalence investigation. Lastly, the inclusion of a GAD group without comorbid
with each disorder individually (Hoffman et al., 2008; Lochner et al., OCD could allow us to clarify whether the sociodemographic profile and
2014), lends further support to this later hypothesis. clinical expression of OCD comorbid with GAD is more similar to that of
Given the cross-sectional design of our study, it is difficult to estab­ OCD or to GAD. Future longitudinal studies can elucidate the causal
lish with certainty whether (1) a diagnosis of GAD in OCD patients relationships between OCD, GAD, and the significant findings of this
showing these “fearful” disorders is a by-product or artifact of increased study, to inform which variables or disorders to target first to improve
anxiety and/or distress levels; (2) increased anxiety leads to greater prognosis.
rates of “fearful” disorders; (3) both mechanisms work in parallel, or (4) The present study aimed to investigate the differences in the socio­
that these disorders all represent an unique fearful phenotype that ex­ demographic and clinical profile between those with OCD with comor­
presses as different diagnoses. Hybrid presentations of these disorders bid GAD and those of OCD without comorbid GAD. The comorbidity
are supportive of the latter interpretation, as typical behaviors (e.g. with GAD was associated with worse clinical outcomes. Comorbid GAD
avoidance of social interactions) may emerge not as a fear of being in OCD was associated with higher anxiety according to the BAI scores,
scrutinized (as in social phobia) but also as a consequence of typical greater number of avoidant behaviors, and higher comorbidity rates of
obsessions (e.g. OCD shameful thoughts) or multiple worries (as in social and specific phobia, panic disorder without agoraphobia, and type
GAD). II bipolar. With further replication, these results can assist clinicians
Type II bipolar disorder was also independently associated with the administering treatments to people with this comorbidity.
presence of GAD in participants with OCD. Someone with OCD and
comorbid type II bipolar disorder was 3.11 times more likely to be 5. Financial Support
diagnosed with GAD than someone with OCD without type II bipolar. In
fact, previous studies indicate that both OCD and GAD seem to have This work was supported by the Conselho Nacional de Desenvolvi­
stronger relationships with type II than type I bipolar disorder. For mento Científico e Tecnológico (L.F., grant number 302526/2018-8),
instance, type II bipolar disorder is reported to be a more common co­ Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro, (L.F.,
morbidity in OCD than bipolar I (Masi et al., 2018), and comorbid grant number CNE E 26/203.052/2017); the D’Or Institute of Research
anxiety disorders are also more prevalent in type II than in type I bipolar and Education (L.F., no grant number available); and the David Winston
disorder (Bauer et al., 2005; Zutshi et al., 2007). Compared to Turner Endowment Fund. (L.F, no grant number available); The funding
non-comorbid OCD, OCD with bipolar disorders has a more episodic sources had no role in study design, data analysis, and result
course of OCD symptoms that worsen during depression and improve interpretation.
during mania/hypomania (Amerio et al., 2014). A longitudinal study of
413 young patients with bipolar disorders (I, II or not otherwise speci­
Data availability statement
fied) has described a “bidirectional” interaction between bipolar and
anxiety disorders, i.e. while anxiety disorders frequently antedates the
Dataset is not available for sharing.
onset of bipolar disorder, bipolar symptoms may also result in residual,
“interepisodic” anxiety (Sala et al., 2012).
Our findings in relation to comorbidity patterns in OCD associated Authorship contribution statement
with GAD have a range of therapeutic implications. Firstly, therapists
need to be mindful that OCD patients with GAD may be more likely to P.S. and L.F.F were responsible for conception and design of the
engage in avoidance/preventative safety behaviours, which may in­ study, for the analysis and interpretation of data, and for the preparation
crease treatment resistance (Goetz et al., 2018). Further, medications for of manuscript. L.A. was involved in the conception and design of study
both OCD and GAD (e.g. serotonin reuptake inhibitors) can often and in the analysis and interpretation of data. M.C.R., Y.A.F., E.C.M. and
exacerbate mania, whereas mood stabilisers seem to be less effective for L.F.F were responsible for the recruitment of subjects and data, and for
bipolar disorders in the context of OCD (Zutshi et al., 2007). These ob­ the preparation of manuscript. All authors approved the final version of
servations illustrate the challenges faced by clinicians who treat this the manuscript and agree to be accountable for all aspects of the work.
comorbid “triad”. We suggest that an individual presenting OCD and
GAD should be screened for type II bipolar disorder. This can enable
early identification and control, which may also improve outcomes. Declaration of Competing Interest
Admittedly, our study has a number of limitations. Firstly, since that
our patients was receiving treatment in specialized clinics, the rates and None.
correlates of GAD may not be generalisable to other settings. Further
research can inform clinical and treatment investigations in general and Appendix
less severe populations. Secondly, our measure for the total number of
avoidant items on the D-YBOCS is novel and requires further Table A1

5
P. Sharma et al. Psychiatry Research 300 (2021) 113898

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