BRIEF REPORT Obsessive-Compulsive Symptoms Among Patients with Sydenham Chorea Fernando R. Asbahr, Marjorie A. Garvey, Lisa A. Snider, Dirce M. Zanetta, Helio Elkis, and Susan E. Swedo Background: Among patients with tic disorders, a distinctive clinical profile of obsessive-compulsive symptomatology has been described. The present investigation was designed to document the phenomenology of obsessive-compulsive symptoms (OCS) among patients with Sydenham chorea (SC), the neurologic variant of rheumatic fever. We hypothesized that OCS occurring in association with SC would be similar to those among patients with tic disorders. Methods: The authors studied the presence of OCS in 73 patients with SC by using the Yale-Brown Obsessive-Compulsive Scale at the Pediatric Clinics of the University of São Paulo Medical Center in São Paulo, Brazil (n = 45) and at the National Institute of Mental Health in Bethesda, Maryland (n = 28). Results: The most frequent symptoms observed among subjects with comorbid SC and OCS were aggressive, contamination, and somatic obsessions and checking, cleaning, and repeating compulsions. A principal component factor analysis yielded a five-factor solution (accounting for 64.5% of the total variance), with contamination and symmetry obsessions and cleaning compulsions loading highly. Conclusions: The symptoms observed among the SC patients were different from those reported by patients with tic disorders but were similar to those previously noted among samples of pediatric patients with primary obsessive-compulsive disorder. Key Words: Sydenham chorea, rheumatic fever, obsessive-com- pulsive symptoms, obsessive-compulsive disorder, tic disorders, factor analysis O bsessive-compulsive disorder (OCD) is a neurobiological disorder with heterogeneous symptomatology. Although the symptoms of OCD are diverse, they fall into several general categories that are consistent across culturally and geo- graphically diverse populations (Honjo et al 1989; Thomsen and Mikkelsen 1991). Patients today present with symptoms similar to those first described by Janet in 1903 (Janet 1903). The similarity of the symptoms over time and across different cultures implies a neurobiological basis for OCD, and a growing body of evi- dence suggests that obsessive-compulsive symptoms (OCS) re- sult from dysfunction of the orbito–frontal–striatothalamocortical circuitry. Neuroimaging studies have demonstrated structural and functional abnormalities of the caudate nucleus (Giedd et al 1996, 2000; Insel 1992; Luxenberg et al 1988; Rauch 2000). Obsessive-compulsive disorder symptoms can also occur in disorders of the basal ganglia that are associated with abnormal movements. For example, OCD has been observed in patients with Sydenham chorea (SC), a neurologic variant of rheumatic fever (Swedo et al 1989a). In prospective studies of SC, up to 70% of patients acutely develop obsessions and compulsions associ- ated with the choreic movements (Asbahr et al 1998; Swedo 1993). Recently, Swedo et al (1993, 1994) have suggested that SC might be a medical model for OCD, although, for this to be the case, the OCD symptoms in patients with SC should be similar to those found in patients who do not have SC. To date, no one has examined the OCD symptom profile in patients with SC. It is possible that OCD associated with movement disorders is distinct from the basic disorder (OCD without movement disorders). This has been suggested by studies of tic-related OCD symptoms. There is a particularly close association between tic disorders, including Tourette’s syndrome, and OCD. Findings from studies of OCS among patients with tic disorders suggest that these patients have a unique symptom profile. Unlike symptoms in patients who have OCD with no abnormal movements, the predominant symptoms in tic-related OCD are aggressive or violent thoughts and images, symmetry concerns, and compul- sive rituals involving blinking, touching, tapping, or rubbing (George et al 1993; Holzer et al 1994; Leckman et al 1994, 1995). The results of a recent study by Leckman et al (2003) suggested that familial factors contributed to the symptom dimension phenotypes among these patients and their first-degree relatives. The distinctive symptom profile, in combination with unique reports in gender ratio, age at onset, family history, and diverging responses to treatment, suggests that tic-related OCD might be a separate phenotype of the disorder. The purpose of the present investigation was to describe the OCS experienced by patients with SC and to compare them with those seen in children with tic disorder. A comparison of these disorders is important because it might provide insights into whether SC is a medical model of OCD. We thus hypothesized that the obsessive-compulsive symptomatology observed in the SC group would be similar to that previously reported for patients with tic disorders. Methods and Materials Subjects One hundred fourteen patients with SC were assessed at the Pediatric Clinics of the University of São Paulo Medical Center (USP) in São Paulo, Brazil, or at the National Institute of Mental Health (NIMH) in Bethesda, Maryland during the study period (USP, n = 62, 54.4% of the total sample; NIMH, n = 52, 45.6% of the total sample). Seventy-three (64%) of the 114 SC patients were eligible for the study. Subjects were selected according to the development of OCS among all patients with SC. For the screening of patients, the following instruments were used: the From the Department of Psychiatry (FRA, HE), Laboratory of Medical Investiga- tion (LIM-23) (FRA), University of São Paulo Medical School; Department of Epidemiology and Public Health (DMZ), School of Medicine of São Jose do Rio Preto, São Jose do Rio Preto, São Paulo, Brazil; Medical Neurology Branch (MAG), National Institute of Neurological Disorders and Stroke; and the Pediatrics and Developmental Neuropsychiatry Branch (LAS, SES), National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland. Address reprint requests to Fernando R. Asbahr, M.D., Ph.D., Departamento de Psiquiatria da FMUSP, Rua Dr. Ovídio Pires de Campos, 785, Caixa Postal 8091, CEP: 05403-010, São Paulo, Brazil; E-mail: frasbahr@usp.br. Received February 27, 2004; revised October 04, 2004; revised January 5, 2005; accepted January 21, 2005. BIOL PSYCHIATRY 2005;57:1073–1076 0006-3223/05/$30.00 doi:10.1016/j.biopsych.2005.01.037 © 2005 Society of Biological Psychiatry