EDITORIAL

Two Times Four Is Four: OCD Dimensions,

Classes, and Categories
MARCO A. GRADOS, M.D., M.P.H.,

Recent research on the phenomenology, etiology, and

pathophysiology of pediatric obsessive-compulsive disorder
(OCD) signals a renewed interest in pediatric neuropsychiatric disorders. Pediatric OCD is one of the few
disorders that mimic the adult form of the disorder in
its breadth and depth; that is, it appears in a full-blown
form even in prepubertal ages. This is not the case for
schizophrenia, bipolar disorder, or major depression.
Following the paradigm of early-onset diabetes and other
pathophysiologically better understood diseases, pediatric
OCD is plausibly more biologically driven or more genetic
than its adult-onset form. This greater biological relevance
is demonstrated by family studies that find higher rates
of familial OCD when child OCD probands are used.1
In this vein, one of the most active research domains in
OCD, is the search for biologically meaningful subphenotypes that would facilitate etiological research, including
gene discovery.
In this issue of the Journal, Mataix-Cols et al.2 and Stewart
et al.3 examine the symptom architecture of pediatric OCD
using data reduction techniques that have been widely used in
the adult OCD literature. Mataix-Cols et al.2 consider
whether symptom dimensions in pediatric OCD are
preserved with respect to symptoms dimensions in adult
OCD samples. In the adult OCD literature, four factors are
commonly reported to explain variance using principal
components analysis (PCA): contamination/cleaning, aggressive/sexual/religious obsessions, ordering/symmetry, and
hoarding.4,5 The statistical technique used by Mataix-Cols
et al. on a sample of 238 children and adolescents takes a

Accepted March 10, 2008.

Drs. Grados and Riddle are with the Department of Psychiatry and Behavioral
Sciences, Johns Hopkins University School of Medicine.
Correspondence to Dr. Marco A. Grados, 600 N. Wolfe Street, CMSC 346,
Baltimore, MD 21287; e-mail: mjgrados@jhmi.edu.
0890-8567/08/4707-0731*2008 by the American Academy of Child and
Adolescent Psychiatry.
DOI: 10.1097/CHI.0b013e318173f720

J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 47:7, JULY 2008

AND

MARK A. RIDDLE, M.D.

similar approach to those previously reported, namely,

semiquantitative data (symptom counts within particular
categories) submitted to PCA with varimax rotation. The four
derived factors are comparable to adult PCA symptom
dimension factors, with the exception that hoarding is
comingled with checking symptoms in the child sample.
Interestingly, in this child sample, hoarding was correlated
with OCD-related measures of slowness, responsibility,
indecisiveness and doubt, and higher depression severity
and was more common in girls compared to boys, highlighting a particularly vulnerable subset of children with
OCD.
In turn, Stewart et al.2 report on a confirmatory factor
analysis (CFA) of three age group samples: children,
adolescents, and adults with OCD. This ambitious article
is a tour de force in OCD symptom data reduction.
Although the limitations of the methods and sampling leave
some questions unanswered, this study does advance
research in the field. Using cross-sectional samples, modelfitting methods are applied to measure fit of these data to the
Summerfeldt et al.4 four-factor solution. Summerfeldt et al.4
had applied CFA testing of three-, four- and five-factor
models, concluding that the four-factor model best fit OCD
category symptom, but not item-level, data in adults. This
category symptom analysis assumes that the 60+ symptoms
listed in the Yale-Brown Obsessive Compulsive Scale are
grouped correctly into 13 categories. In Stewart et al.,3
categorical data on the three different age samples are used to
test the fit of the data to the Summerfeldt et al.4 four-factor
solution. The results show that, in fact, the four-factor
solution continues to best fit OCD categorical symptom
data in each of the three samples across ages using multiplegroup CFA.
In summary, the analyses by Mataix-Cols et al.2 and
Stewart et al.3 of OCD symptom structure in youths yield
four-factor solutions similar to those in Summerfeldt et al.4
The authors note that although there is similarity in symptom
structure across ages, this is suggestive but not confirmatory of
symptom stability. Taken together, these results, although

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consistent, should be tempered with the following observations: PCA is not an ideal method to derive factors from
categorical or semiquantitative data; factor analyses that
derive categories from the individual items rather than
assuming that the items are categorized accurately by the YaleBrown Obsessive Compulsive Scale now suggest a five-factor
model as the best solution6; the adult sample in Stewart et al.3
had been used to derive the four-factor solution; there is a
high factorYfactor correlation between OCD factors in the
four-factor model.
Most important, the variance explained by the four-factor
models published to date are usually in the range of 50% to
60%, leaving a large amount of variance unexplained in all
of the published solutions. Thus, the debate continues about
whether factor dimensions in OCD have extensive research
or clinical utility,7 beyond the fact that they can be used to
simplify clinical data. The hoarding dimension is often
considered to identify a unique subgroup of OCD, given
treatment and neuroimaging studies,8,9 but there is only one
question in the Children`s Yale-Brown Obsessive Compulsive Scale or Yale-Brown Obsessive Compulsive Scale that
addresses hoarding, limiting the utility of any factor analysis.
Another symptom dimension that is mentioned as heuristic
is the contamination/cleaning factor,10 but the identification
of children who are washers or have other contamination
fears and cleaning rituals is generally not problematic. That
is, this factor does not reduce clinical data substantially.
Thus, the immediate clinical utility of factor-analytic data
is not readily apparent, but holds promise, given the
statistical attraction of having a quantitative variable for
use in biological research. Furthermore, linkage and/or
association studies using OCD factors will become more
common in the near future. For example, Hasler and
colleagues11 recently reported on the association of the
serotonin transporter variant SS with high scores on
the ordering/symmetry factor and on the familiality of the
hoarding and taboo factors.12
However, compared to factor analysis, methods that explore
symptom or comorbid disorderYlevel data in OCD may be
more germane for clinical and research purposes. Latent class
analysis (LCA), for example, provides a model-fitting technique
that focuses on person-centered variables. This can be
extremely useful in OCD, a disorder that has a large panoply
of disorder-specific symptoms and frequent comorbidities.
Using this method, different classes of individuals can be
identified, which, at face value, may have different pathophysiological substrates and treatment needs. The co-occurrence of
attention-deficit/hyperactivity disorder, in particular, may
differentiate groups of children with OCD, distinguishing
OCD linked to neurodevelopmental disorders such as
attention-deficit/hyperactivity disorder and tic disorders13
from OCD linked to anxiety disorders. In adult samples,

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comorbid depressive, anxiety, and grooming disorders may

differentiate OCD classes. Although few LCAs of OCD have
been published to date,14 newer studies are expected to fill
this gap.
Finally, latent profile analysis may constitute a hybrid
method that marries exploratory factor analysis/CFA to
LCA methods. In this approach, factor scores are used to
classify individuals as hoarders, washers, and so forth, and
then these classified individuals are submitted to LCA. In a
preliminary unpublished analysis by our group, three
classes of individuals emerged from a latent profile analysis:
one with high contamination/cleaning and sex/aggressive/
religious factor scores, one with high ordering/symmetry
and repeating/counting factor scores, and one in which all
four factor scores were high. Thus, this yet-to-be-explored
approach may yield a classification of OCD that uses
information from both exploratory factor analysis/CFA
and LCA.
Phenomenological subtyping will play an important role
in research designed to elucidate the etiology of OCD, and
the worthy efforts of Mataix-Cols et al.2 and Stewart et al.3
in this issue of the Journal are a welcome addition to the
literature. However, the field is still under development and
future research will determine whether symptom dimensions, OCD classes, or merely the categorical diagnosis of
OCD best describe and are correlated with etiological,
pathophysiological, and treatment-need pathways in pediatric OCD.
Disclosure: Dr. Riddle has consulted to Shire and Johnson & Johnson;
served as a scientific advisor to Jazz; has received funding from
NIMH and NICHHD; has participated in not-for-profit organization activities for the University of Florida, the University of
Maryland, and Long Island Jewish Health System; and offered expert
opinions to the Gleason Flynn law firm. Dr. Grados reports no
conflicts of interest.
REFERENCES
1. Hanna GL, Himle JA, Curtis GC, Gillespie BW. A family study of
obsessive-compulsive disorder with pediatric probands. Am J Med Genet
B Neuropsychiatr Genet. 2005;134:13Y19.
2. Mataix-Cols D, Nakatani E, Micali N, Heyman I. The structure of
obsessive-compulsive symptoms in pediatric OCD. J Am Acad Child
Adolesc Psychiatry. 2008;47:773Y778.
3. Stewart SE, Rosario MC, Baer L, et al. Four-factor structure of obsessivecompulsive disorder symptoms in children, adolescents, and adults. J Am
Acad Child Adolesc Psychiatry. 2008;47:763Y772.
4. Summerfeldt LJ, Richter MA, Antony MM, Swinson RP. Symptom
structure in obsessive-compulsive disorder: a confirmatory factor-analytic
study. Behav Res Ther. 1999;37:297Y311.
5. Leckman JF, Grice DE, Boardman J, et al. Symptoms of obsessivecompulsive disorder. Am J Psychiatry. 1997;154:911Y917.
6. Pinto A, Eisen JL, Mancebo MC, Greenberg BD, Stout RL, Rasmussen
SA. Taboo thoughts and doubt/checking: a refinement of the factor
structure for obsessive-compulsive disorder symptoms. Psychiatry Res.
2007;151:255Y258.

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7. Mataix-Cols D, Rosario-Campos MC, Leckman JF. A multidimensional
model of obsessive-compulsive disorder. Am J Psychiatry. 2005;162:
228Y238.
8. Saxena S, Brody AL, Maidment KM, et al. Cerebral glucose metabolism in obsessive-compulsive hoarding. Am J Psychiatry. 2004;161:
1038Y1048.
9. Mataix-Cols D, Wooderson S, Lawrence N, Brammer MJ, Speckens A,
Phillips ML. Distinct neural correlates of washing, checking, and
hoarding symptom dimensions in obsessive-compulsive disorder. Arch
Gen Psychiatry. 2004;61:564Y576.
10. Stein DJ, Arya M, Pietrini P, Rapoport JL, Swedo SE. Neurocircuitry of
disgust and anxiety in obsessive-compulsive disorder: a positron emission
tomography study. Metab Brain Dis. 2006;21:267Y277.

J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 47:7, JULY 2008

11. Hasler G, Kazuba D, Murphy DL. Factor analysis of obsessivecompulsive disorder YBOCS-SC symptoms and association with 5HTTLPR SERT polymorphism. Am J Med Genet B Neuropsychiatr
Genet. 2006;141:403Y408.
12. Hasler G, Pinto A, Greenberg BD, et al. Familiality of factor analysisderived YBOCS dimensions in OCD-affected sibling pairs from the
OCD Collaborative Genetics Study. Biol Psychiatry. 2007;61:617Y625.
13. Grados MA, Mathews CA. Latent class analysis of Gilles de la Tourette
syndrome using comorbidities: clinical and genetic implications. Biol
Psychiatry. 2008;March 20 e-pub ahead of print.
14. Nestadt G, Addington A, Samuels J, et al. The identification of OCDrelated subgroups based on comorbidity. Biol Psychiatry. 2003;53:
914Y920.

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