Mi foto
CD. DE MEXICO, D.F., Mexico




lunes, 22 de octubre de 2012


Original Article
Neuropsychopharmacology (2012) 37, 2730–2739; doi:10.1038/npp.2012.138; published online 8 August 2012
White Matter Abnormalities in Pediatric Obsessive-Compulsive Disorder
Patricia Gruner1,2, An Vo3, Toshikazu Ikuta1,2, Katie Mahon1,2, Bart D Peters1,2, Anil K Malhotra1,2,4,5, Aziz M Uluğ3,5 and Philip R Szeszko1,2,4,5
1Center for Psychiatric Neuroscience, Feinstein Institute for Medical Research, Manhasset, NY, USA
2Psychiatry Research, Zucker Hillside Hospital, North Shore-LIJ Health System, Glen Oaks, NY, USA
3Susan and Leonard Feinstein Center for Neurosciences, Feinstein Institute for Medical Research, Manhasset, NY, USA
4Department of Psychiatry, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
5Department of Molecular Medicine, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA

Obsessive-compulsive disorder (OCD) is a prevalent and often severely disabling illness with onset generally in childhood or adolescence. Although white matter deficits have been implicated in the neurobiology of OCD, few studies have been conducted in pediatric patients when the brain is still developing and have examined their functional correlates. In this study, 23 pediatric OCD patients and 23 healthy volunteers, between the ages of 9 and 17 years, matched for sex, age, handedness, and IQ, received a diffusion tensor imaging exam on a 3T GE system and a brief neuropsychological battery tapping executive functions. Patient symptom severity was assessed using the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Patients with OCD exhibited significantly greater fractional anisotropy compared to matched controls in the left dorsal cingulum bundle, splenium of the corpus callosum, right corticospinal tract, and left inferior fronto-occipital fasciculus. There were no regions of significantly lower fractional anisotropy in patients compared to controls. Higher fractional anisotropy in the splenium was significantly correlated with greater obsession severity on the CY-BOCS in the subgroup of psychotropic drug-naïve patients. Among patients, there was a significant association between greater fractional anisotropy in the dorsal cingulum bundle and better performance on measures of response inhibition and cognitive control. The overall findings suggest a pattern of greater directional coherence of white matter tracts in OCD very early in the course of illness, which may serve a compensatory mechanism, at least for response inhibition functions typically subserved by the cingulum bundle.
Keywords: obsessive-compulsive disorder; child; white matter; diffusion tensor imaging; functional correlates; response inhibition

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by recurrent and persistent obsessions or compulsions that are recognized as excessive or unreasonable, cause marked distress, are time consuming, and/or interfere with normal functioning (American Psychiatric Association, 1994). The disorder can be severely disabling and usually begins in childhood (Pauls et al, 1995), with prevalence rates among children and adolescents reported to be as high as 2–4% (Kiejna et al, 2002). Despite the prevalence and severity of the disorder, neuroimaging and neuropsychological research in OCD is limited and few studies have examined the disorder in children and adolescents close to illness onset.
Neurobiological models of OCD propose aberrations in frontal–striatal–thalamic–cortical loops in the pathogenesis of OCD in adults and children, including abnormalities of the anterior cingulate cortex, orbitofrontal cortex, thalamus, and basal ganglia (Harrison et al, 2009; Insel, 1992; Maia et al, 2008). Although structural and functional abnormalities of the gray matter nodes comprising these circuits have been repeatedly implicated, findings have been inconsistent regarding the precise locations of neuroanatomical abnormalities as well as the direction of findings. A review of pediatric studies (Huyser et al, 2009) concluded that several studies of children and adolescents with OCD indicate abnormalities of the putamen, globus pallidus, and thalamus (eg, Rosenberg et al, 1997b; Szeszko et al, 2004), whereas studies of adults tend to implicate the caudate nucleus and orbitofrontal cortex (eg, Robinson et al, 1995; Szeszko et al, 1999). The results of two recent meta-analyses, including adult and pediatric samples, however, both implicated less anterior cingulate gray matter in OCD; one study reported smaller volumes in bilateral anterior cingulate/dorsal medial frontal gyri and greater volumes of bilateral lenticular nuclei (Radua and Mataix-Cols, 2009) and the other study identified smaller volume in the left anterior cingulate and bilateral orbitofrontal cortex, and greater volumes of the bilateral thalami. (Rotge et al, 2009).
There is now increasing evidence that the white matter pathways comprising cortical–striatal–thalamic–cortical loops may also be abnormal in OCD. The majority of diffusion tensor imaging (DTI) studies in OCD to date have investigated white matter tract coherence in adults (see Fontenelle et al (2009) for a review), but these studies of adults with OCD have been inconsistent, with some studies reporting lower (Garibotto et al, 2010; Nakamae et al, 2011; Saito et al, 2008; Szeszko et al, 2005) or higher (Li et al, 2011; Yoo et al, 2007) fractional anisotropy (FA) in patients, while other studies reported significant variation depending on the specific white matter bundle or region of interest examined (Cannistraro et al, 2007; den Braber et al, 2011; Menzies et al, 2008).
The inconsistency in adult white matter findings in OCD may be associated with confounding factors, such as cohort effects, drug exposure, illness duration, and treatment history. For example, Yoo and colleagues (2007) found greater white matter integrity (higher FA) in adult OCD patients compared to controls in the corpus callosum, the internal capsule, and the white matter superolateral to the right caudate that was no longer evident following 12 weeks of citalopram treatment. A potential advantage of using child cohorts to examine the neurobiology of OCD is that it limits confounds such as medication history and illness duration. Moreover, the use of child cohorts permits the examination of potential abnormalities early in the course of the illness when the brain is still under considerable development. To date, however, only one study has examined a pediatric OCD sample using DTI. Zarei and colleagues (2011) examined adolescents with OCD compared to age-matched controls and reported higher FA in patients in multiple white matter tracts, including the left inferior longitudinal fasciculus, right inferior front-occipital fasciculus, corpus callosum splenium and genu, the left cingulum bundle, and bilateral corticospinal tract.
Executive functioning deficits, such as response inhibition and set shifting, are often reported in adults with OCD (Abramovitch et al, 2011; Bannon et al, 2002; Chamberlain et al, 2006; Penades et al, 2007) and have been linked to aberrations in frontal–subcortical circuitry, especially in the anterior cingulate. Response inhibition, in particular, may deserve particular attention in OCD, as an inability to inhibit recurrent, intrusive thoughts and/or repetitive behaviors appears to be a core illness feature (Bannon et al, 2002). It should be acknowledged, however, that not all studies have implicated response inhibition deficits in OCD (Beers et al, 1999; Ciesielski et al, 2011; Krishna et al, 2011). Specifically, Beers and colleagues (1999) found no cognitive impairments in psychotropic medication-naïve children with OCD compared to age-matched controls, and Krishna and colleagues (2011) found no significant difference in performance between psychotropic medication-naïve adults with OCD and matched controls on the majority of neuropsychological tests, including measures of set shifting and response inhibition. Moreover, little research has been directed at discerning the functional correlates of white matter pathology in OCD.
In this study, we examined white matter abnormalities in OCD in a child and adolescent cohort of patients using DTI and the relationship between abnormal white matter integrity and their clinical and neuropsychological correlates. We hypothesized that patients with OCD would have greater fractional anisotropy (FA) in white matter bundles comprising frontal–striatal–thalamic–cortical circuitry, including the cingulum bundle and internal capsule, and that these white matter aberrations would be correlated with symptom severity and executive functioning in patients.
In all, 23 pediatric patients with a DSM-IV diagnosis of OCD and 23 healthy controls matched for sex, age, handedness, and IQ participated in this study. All participants were between the ages of 9 and 17 years. Demographic and clinical characteristics for the sample are illustrated in Table 1. Diagnoses were based on the Schedule for Affective Disorders and Schizophrenia for School-Age-Children, Present and Lifetime Version (K-SADS-PL) (Kaufman et al, 1997). All pediatric OCD patients underwent a detailed clinical assessment by a licensed psychologist experienced in the assessment of OCD. Four patients had a comorbid major depressive disorder, four had comorbid anxiety disorders (two had social anxiety disorder and two had panic disorder), and five met the criteria for attention deficit hyperactivity disorder. Nine patients were psychotropic drug-naïve at the time of the scan, two were free of treatment with psychotropic drugs for at least 30 days before the scan, and the remainder were being treated with selective serotonin reuptake inhibitors (SSRIs) (n=12). All healthy controls were assessed using the K-SADS-PL and were determined to be free of any current or past psychiatric disorder. Exclusion criteria for all participants included: (1) MRI contraindications; (2) significant medical illness; (3) prior psychosurgery; (4) DSM-IV diagnosis of Tourette syndrome, schizophrenia, schizoaffective disorder, delusional disorder, brief reactive psychosis, bipolar disorder, substance-use disorder, or mood disorder with psychotic features; (5) DSM-IV mental retardation; and (6) pregnancy. All procedures were approved by the North Shore-LIJ Institutional Review Board and written informed consent was obtained from all parents along with written assent from participants.
All children with OCD were interviewed using the Children's Yale-Brown Obsessive-Compulsive Scale (Scahill et al, 1997). All participants also completed the Multidimensional Anxiety Scale for Children to evaluate general anxiety symptoms and severity. Handedness was assessed using the Edinburgh Handedness Inventory. Intellectual ability was estimated using the Wechsler Abbreviated Scale of Intelligence. All participants were administered a brief neuropsychological battery tapping executive functions, including the Stroop Color Word Test, the Wisconsin Card Sorting Test (WCST-64), the Controlled Oral Word Association Test (COWAT), and the Trail Making Test (TMT). Neuropsychological data were unavailable for one patient; one control subject was missing data from the TMT and one control subject was missing data from the WCST.
We converted all scores to z-scores based on the reference group of 23 healthy volunteers. To minimize Type 1 error, we first computed a global executive functioning score for each subject based on the z-scores from the full battery of tests. This global executive functioning score was comprised of the interference score from the Stroop Color Word Test, categories completed on the WCST, total fluency score on the COWAT, and time to completion on Trails B of the TMT. To assess specifically response inhibition and cognitive control, we also computed a cluster score comprised of performance on the two measures requiring stimulus–response selection despite competing streams of information, the Stroop Color Word Test, and Trails B of the TMT. All tasks were given equal weight in the equations. We used Pearson's product moment correlations to examine the clinical and neuropsychological correlates of FA measures with α set to 0.05 (two-tailed).
DTI Procedures
All participants received an MR imaging exam on a GE Signa HDx 3.0 T system. Participants were scanned using anatomical sequences for segmentation and sequences for DTI. The DTI sequence included volumes with diffusion gradients applied along 31 non-parallel directions and five volumes without diffusion weighting (TR=14 000 ms, TE=min, matrix=128 × 128, FOV=240 mm). Each volume consisted of 51 contiguous 2.5-mm axial slices acquired parallel to the anterior–posterior commissural line using ramp sampled, spin-echo, single-shot echo-planar imaging. Data acquisition used parallel imaging with an acceleration factor of 2.
DTI Processing
Images were corrected for Eddy current-induced distortions and head motion using the Eddy current correction routine in FSL. Using the brain extraction tool in the FMRIB software library (Smith, 2002), non-brain tissue was removed from the images. Diffusion tensor components for each brain pixel were then calculated and FA maps were determined for all subjects using FSL. We used the DTIFIT tool with the weighting option in FSL to fit a diffusion tensor model to the raw diffusion data at each voxel. The FA maps were then registered to the Montreal Neurological Institute template (MNI-152: 1 × 1 × 1 mm3) using a 12-parameter affine transformation (FLIRT) (Jenkinson et al, 2002). Images were smoothed using an 8 × 8 × 8 mm3 kernel, and compared group-wise (OCD vs healthy volunteers) using SPM5 ( Our statistical approach involved using the p-value based on the spatial extent of the nearest cluster (Friston, 1997). Thus, in this study we used a voxel-level threshold of p<0"">
Fractional Anisotropy
Patients with OCD exhibited significantly higher FA compared to matched healthy volunteers in four white matter tracts: the left dorsal cingulum bundle (p=0.005; kE=638), the splenium of the corpus callosum (p=0.007; kE=567), the right corticospinal tract (p=0.008; kE=552), and the left inferior fronto-occipital fasciculus (p=0.043; kE=286) (see Figures 1, 2, 3 and 4 and Table 2). No regions of significantly lower FA in the patients compared to healthy volunteers were identified at this threshold. Post hoc analyses revealed no significant differences in FA between medicated and psychotropic drug-naïve OCD subjects in these four regions. For the areas of higher FA, radial diffusivity was significantly lower in patients than controls in all four white matter regions: the left dorsal cingulum bundle (t=2.98; p=0.005), the splenium (t=3.88; p<0>
Splenium of corpus callosum. (a) Voxels showing significant cluster of higher fractional anisotropy (FA) in the splenium in obsessive-compulsive disorder (OCD) patients compared to controls. (b) Group tractography of the splenium of the corpus callosum with fibers passing through the significant cluster of higher FA.
Cingulum bundle. (a) Voxels showing significant cluster of higher fractional anisotropy (FA) in the left dorsal cingulum bundle in obsessive-compulsive disorder (OCD) patients compared to controls. (b) Group tractography of the left cingulum bundle with fibers passing through the significant cluster of higher FA.

Neuropsychological Functioning
There was a trend for patients to perform worse than controls on the global measure of executive functioning (t (41)=1.97, p=0.055). No significant difference in performance between the patients and controls was demonstrated on the cluster score for response inhibition/cognitive control (t (42)=1.22, p=0.23). Post hoc analyses comparing group performance on each of the individual tests of executive functioning revealed that the patients and controls only differed significantly on categories completed of the WCST (t (42)=1.97, p=0.013). We examined this effect further by comparing performance of the medicated and psychotropic drug-naïve patients separately. Findings revealed that the patients taking SSRIs completed significantly less categories than controls on the WCST (t (31)=2.96, p=0.006). There was, however, no significant difference on this measure between the psychotropic medication-naïve patients and the controls. There was no significant difference between the medication-naïve patients and the control group on any of the measures.
Correlations with Symptom Severity
There were no significant correlations between symptom severity and the four FA measures in patients. Subgroup analyses, however, revealed that FA in the splenium was significantly and positively correlated with total obsessions on the CYBOCS in the subgroup of psychotropic drug-naïve patients (r (7)=0.67, p=0.047), but not in the subgroup of medicated patients (r (12)=−0.07, p=0.841). However, the difference between these two correlations was not statistically significant (z=−1.74; p=0.08; two-tailed).
Correlations with Neuropsychological Measures
Higher FA in the left dorsal cingulum bundle correlated significantly and positively with the global executive functioning score (r (20)=0.43, p=0.047) and the response inhibition/cognitive control cluster score (r (20)=0.67, p=0.001) among patients, but not healthy volunteers (r (19)=−0.03, p=0.90; r (19)=0.06, p=0.79). There was a significant difference in the correlations between FA in the left dorsal cingulum bundle and the response inhibition/cognitive control domain score between the patient and healthy control groups (z=2.29; p=0.02; two-tailed). Higher FA in the left dorsal cingulum bundle was correlated significantly with better performance on the Stroop Color Word Test (r (20)=0.46, p=0.032) and Trail Making Test—Part B (r (20)=0.43, p=0.045) among patients, but not with WCST (r (20)=−0.07, p=0.76) or COWAT (r (20)=0.27, p=0.23) performance. Post hoc analyses indicated that higher FA in the left dorsal cingulum bundle and better response inhibition/cognitive control performance was significant in the psychotropic drug-naïve patients (r (7)=0.76, p=0.018), but not in the medicated patients (r (9)=0.39, p=0.23), although the difference between these correlations was not statistically significant (z=1.08; p=0.28; two-tailed).
Our data provide strong evidence for abnormalities in several white matter tracts in pediatric OCD and suggest that they are present early in the course of illness and before extensive pharmacological intervention. Our results are highly consistent with Zarei and colleagues (2011), who also reported higher FA in several white matter tracts in adolescents with OCD, including the four regions identified in this study. While the study by Zarei and colleagues (2011) found more extensive regions of greater FA in adolescents with OCD than the current study, our data provide evidence for higher FA within select white matter regions earlier in the course of illness (our cohort was, on average, 2.3 years younger) and examines the neuropsychological correlates of these abnormalities. Moreover, investigation of axial and radial diffusivity in post hoc analyses in our study revealed that axial diffusivity was significantly higher and radial diffusivity significantly lower in patients compared to controls. Taken together, our results may be indicative of axonal- and myelin-related pathology, respectively (eg, Song et al, 2002, 2003, 2005) or related to alterations in fiber architecture in patients, and thus may have implications for furthering our understanding regarding white matter deficits in OCD. An important advantage of our study compared to several other DTI studies in OCD includes the use of healthy volunteers individually matched to OCD patients for potentially confounding variables, including age, sex, and intellectual functioning.
Our findings are consistent with the hypothesis that myelination may be occurring prematurely in children and adolescents with OCD (Zarei et al, 2011). These data thus support the hypothesis that OCD may be a neurodevelopmental disorder (Huyser et al, 2009; Rosenberg and Keshavan, 1998) with potentially differing patterns of pruning and myelination occurring throughout development and raises the intriguing possibility that these abnormalities could serve as biomarkers in the disorder. While there is a critical need for longitudinal studies to confirm these initial findings, several cross-sectional studies support the possibility for a developmentally mediated dysplasia in OCD, although findings have not always been consistent regarding the direction of associations. For example, Rosenberg and colleagues (1997a) found that psychotropic medication-naïve children with OCD lacked age-associated increases in corpus callosum size observed in healthy children. In contrast, Carmona and colleagues (2007) reported a positive relationship between age and left caudate gray matter volume in children with OCD, but not in healthy children.
There is increasing evidence implicating the anterior cingulate in children and adults with OCD, including findings of two recent meta-analyses: one that found less gray matter in the bilateral anterior cingulate (Radua and Mataix-Cols, 2009) and another that found less gray matter in the left anterior cingulate (Rotge et al, 2009). Moreover, functional neuroimaging studies have consistently reported greater brain activity in the anterior cingulate in adult patients with OCD during symptom provocation (Adler et al, 2000; Breiter et al, 1996; Rauch et al, 1994), during executive functioning tasks in both pediatric (Huyser et al, 2010) and adult samples (van den Heuvel et al, 2005), and in adults while at rest (Swedo et al, 1989). In addition, recent studies indicate altered functional connectivity of the anterior cingulate in pediatric OCD patients (eg, Fitzgerald et al, 2010). Prior DTI studies in adults have reported lower FA within the cingulate region (Cannistraro et al, 2007; Garibotto et al, 2010; Szeszko et al, 2005), thus highlighting potentially critical sampling differences in child vs adult patient populations (or possibly methodological differences) that may be strongly relevant to the interpretation of neurobiological models of OCD. Moreover, inconsistencies may be partially due to differences in medication and treatment histories of patients, given prior findings that reported higher FA in adults with OCD may be reduced through treatment with SSRIs (Yoo et al, 2007). Our findings thus extend this prior DTI work in adult OCD by implicating the white matter comprising the left cingulum in pediatric patients and providing a potential mechanism through which aberrant connectivity could relate to gray matter structural alterations.
The finding of higher FA in the corpus callosum among patients converges with empirical findings from structural (Fontenelle et al, 2011; Mac Master et al, 1999; Park et al, 2011; Rosenberg et al, 1997a) and diffusion tensor (Bora et al, 2011; Fontenelle et al, 2011; Nakamae et al, 2011; Saito et al, 2008) neuroimaging studies implicating abnormalities in this region in OCD. In particular, several studies noted abnormalities specifically in the splenium among patients. For example, Park and colleagues (2011) reported greater area and thickness in the caudal portion of the splenium in adults with OCD compared to healthy volunteers and Rosenberg and colleagues (1997a) reported greater splenium size in psychotropic drug-naïve pediatric patients with OCD that correlated with symptom severity. It is noteworthy that both human and animal studies indicate that the splenium interconnects the corpus callosum with posterior parietal and occipital cortices (de Lacoste et al, 1985; Jarbo et al, 2011; Pandya et al, 1971; Putnam et al, 2010), thus implicating abnormalities in posterior brain regions that could play a role in a wide range of OCD phenomenology involving visual processing, including increased attention towards irrelevant details (Koch et al, 2012).
Our findings also indicate higher FA in OCD patients in a posterior region of the left inferior fronto-occipital fasciculus. The inferior fronto-occipital fasciculus is one of the major efferent and afferent projections to the frontal lobes. It runs from the lateral portion of the frontal lobe to the posterior parietal and occipital cortex, transversing the external and extreme capsules of the basal ganglia along the way and is the only direct connection between the occipital and frontal lobes (Garibotto et al, 2010; Wakana et al, 2004). As Garibotto and colleagues (2010) point out the involvement of the parietal and occipital cortex in OCD, although less well established, could play a role in OCD clinical phenomenology, including distressful, intrusive imagery (Garibotto et al, 2010) and excessive visual attention to OCD-related themes.
Despite findings of white matter abnormalities in OCD, their functional correlates have not been well-investigated either in pediatric or adults cohorts. We found that higher FA in the left dorsal cingulum bundle in patients was correlated with better performance on two measures of response inhibition/cognitive control, the Stroop Color Word Test, and Trails B of the TMT. Importantly, this portion of the cingulum bundle is believed to play a critical role in cognitive functions, including response selection and cognitively demanding information-processing tasks. Specifically, the corresponding portion of the anterior cingulate is known to be activated by cognitively demanding tasks that involve stimulus–response selection despite competing streams of information (Bush et al, 2000), such as the Stroop Color Word Test and Trails B of the TMT. The finding that higher FA in this region was correlated with better performance among patients, in the absence of group differences in neuropsychological functioning on these tasks, is consistent with the hypothesis that these abnormalities may serve a compensatory mechanism, thus allowing patients to perform commensurate with healthy individuals in the face of competing and conflicting information. The finding that greater dorsal left dorsal cingulum bundle FA was associated with greater response inhibition and cognitive control may seem inconsistent with the finding that greater splenium FA was associated with greater OCD symptoms, but it is important to acknowledge that these findings were observed in different tracts that may have differing effects on OCD phenomenology.
The overall findings of this study implicate a pattern of higher FA in OCD in childhood and adolescence. Although we did not identify significant differences in FA between medicated and psychotropic drug-naïve patients, it is conceivable that FA differences are more robust in children and thus less affected by the relatively short treatment histories of children, and/or that higher FA in pediatric OCD is related to premature myelination and is not consistent across the lifespan. Investigation of subgroup analyses regarding medication effects revealed that there was a positive relationship between FA in the splenium and symptom severity in the subgroup of patients who were psychotropic drug-naïve, but not in the subgroup of patients who were being treated with SSRIs. In addition, we found that the effect of greater dorsal left dorsal cingulum bundle FA being associated with greater response inhibition and cognitive control was driven by the psychotropic drug-naïve patient group, and was less robust in medicated patients. It is, however, important to exercise caution in interpreting these results given the reduced statistical power of the small sample sizes and the fact that the correlations in medicated patients and psychotropic drug-naïve patients were not significantly different from each other. The pattern of results in this study suggests the possibility that medication may be subtly altering the course of white matter development in ways that affect the relationship between white matter and its clinical correlates. It is worth noting, however, that Zarei and colleagues reported that symptom severity correlated positively with greater FA in white matter tracts in various regions across their entire sample of adolescents with OCD, only a portion of whom were medication naïve. Longitudinal studies are necessary to determine how developmental aberrations in white matter in OCD may change with age and/or treatment history.
There were several limitations to this study that should be acknowledged. Our sample included both medicated and psychotropic drug-naïve patients and subgroup analyses limit our power to draw firm conclusions regarding the potential effects of medications. The age range of our sample was broad, including both prepubescent children and adolescents and the effects of hormonal measures on white matter indices could not be investigated. We also note that higher FA could conceivably result from partial voluming in surrounding structures. Moreover, it should also be acknowledged that we did not employ cardiac gating, which could have potentially affected our findings particularly with regard to the corpus callosum, that smoothing could diminish accuracy regarding the localization of findings, and that our FA results could be affected by the use of linear registration algorithms (Smith et al, 2006).
In sum, we report a pattern of higher FA within white matter tracts of pediatric OCD patients suggesting that white matter abnormalities play a role in OCD pathogenesis early in the course of the disorder. Moreover, our findings suggest that higher FA in the cingulum bundle may be serving a compensatory mechanism, allowing pediatric patients to inhibit certain pre-potent responses and perform commensurate with healthy individuals in the face of competing and conflicting information.

Abramovitch A, Dar R, Schweiger A, Hermesh H (2011). Neuropsychological impairments and their association with obsessive-compulsive symptom severity in obsessive-compulsive disorder. Arch Clin Neuropsychol 26: 364–376.
Adler CM, McDonough-Ryan P, Sax KW, Holland SK, Arndt S, Strakowski SM (2000). fMRI of neuronal activation with symptom provocation in unmedicated patients with obsessive compulsive disorder. J Psychiatr Res 34: 317–324.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn. American Psychiatric Association: Washington, DC.
Bannon S, Gonsalvez CJ, Croft RJ, Boyce PM (2002). Response inhibition deficits in obsessive-compulsive disorder. Psychiatry Res 110: 165–174.
Beers SR, Rosenberg DR, Dick EL, Williams T, O’Hearn KM, Birmaher B et al (1999). Neuropsychological study of frontal lobe function in psychotropic-naive children with obsessive-compulsive disorder. Am J Psychiatry 156: 777–779.
Bora E, Harrison BJ, Fornito A, Cocchi L, Pujol J, Fontenelle LF et al (2011). White matter microstructure in patients with obsessive-compulsive disorder. J Psychiatry Neurosci 36: 42–46.
Breiter HC, Rauch SL, Kwong KK, Baker JR, Weisskoff RM, Kennedy DN et al (1996). Functional magnetic resonance imaging of symptom provocation in obsessive-compulsive disorder. Arch Gen Psychiatry 53: 595–606.

No hay comentarios: