• clinical phenotypes
• obsessive-compulsive disorder
• romantic love
• yale-brown obsessive-compulsive scale

Obsessive-compulsive disorder (OCD) is a heterogeneous psychiatric condition that is defined by two main features: obsessions, i.e. intrusive thoughts, images or urges that are experienced as involuntary, unwanted and distressing, and compulsions, that are repetitive and ritualistic behaviors or mental acts that the individual feels compelled to perform in response to an obsession. Furthermore, OCD may lead to a high impairment in social and work fields, thus decreasing the quality of life. In spite of a progressive nosological autonomy of this disorder, OCD is still clouded by the unknown. Its etiopatogenesis is likely multifactorial and determined by the intertwining of specific genetic, biological and environmental factors. Nevertheless, this model seems to be too simplistic, as it may not reflect the heterogeneity of the clinical picture of OCD. Moreover, in spite of significant improvements of its treatment strategies, the response rates are still unsatisfactory while strengthening the notion that several pieces of the puzzle are missing. According to some scholars, phenotype research might play an important role in better understanding its etiology and improving therapeutic intervention. More recently, some observational studies paved the way to the hypothesis that romantic love (RL) may influence the phenotypic expression of OCD, either by acting as a modulator or as a precipitant factor, albeit the question of whether love-influenced OCD effectively represents a specific phenotype of this disorder is still unclear.
The present study was conceived with the aim of investigating the impact of RL on the clinical expression of OCD. The main objective was to investigate how the clinical expression of OCD changes depending on whether its onset was secondary to the start of RL or following a romantic break-up, and whether two distinct phenotypes of OCD could emerge, possibly characterized by the prevalence of specific obsessions and compulsions. We will therefore refer to the expressions love-precipitated OCD (LP-OCD) in subjects who reported the onset of OCD at the beginning of a romantic relationship, and break-up OCD (BU-OCD) in subjects who instead reported its onset after the end of the relationship. We also investigated the correlation between the two hypothesized clinical phenotypes of OCD and the several clinical and socio-demographic variables, i.e. age of onset, onset, course, gender, marital status, work, and psychiatric comorbidities. In particular, we hypothesized that, due to the different features of the precipitant factor in the two groups, the rates of comorbidities, especially in the spectrum of mood and anxiety disorders, might be different in the two groups, with a prevalence of the former in BU-OCD and the latter in LP-OCD.
This research included a sample of 212 OCD patients attending outpatient units at the University Psychiatric Clinic of Pisa, Italy, and the Federal University of Rio de Janeiro, Brazil. Specific inclusion and exclusion criteria were applied, psychiatric and personal history were collected as part of their clinical records. The assessment instruments herein used were: the Structured Clinical Interview for DSM-5 Disorders (SCID-5) for a complete diagnostic evaluation; the Yale OCD Natural History Questionnaire to evaluate whether romantic relationships were a precipitating factor for OCD (either falling in love or breaking-up); and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) for a comprehensive assessment of OCD symptoms dimensions and severity. The subjects were divided into two groups (LP-OCD and BU-OCD) according to the romantic factor causing the onset of OCD.
Our findings partially supported our hypothesis. In spite of higher rates of mood and anxiety disorders, namely major depressive disorder, generalized anxiety disorder and social anxiety disorder, in both groups, there were no significant differences between LP-OCD and BU-OCD individuals. Such findings suggest that psychiatric comorbidities in RL-influenced OCD do not differ from the most reported comorbidities in this disorder, and that the onset of OCD after falling in love or breaking-up do not lead to higher rates of anxiety disorders in the former case and of mood disorders in the latter. The average age of OCD onset was significantly different in the two groups (16.57 ± 7.36 in the LP-OCD and 12.95 ± 6.82 in the BU-OCD, p-value =0.002). We hypothesized that the increased susceptibility to the effects of a break-up may be the mirror of a vulnerability of the brain's maturational stages in young individuals who are at risk of OCD. In both groups, the most common onset and course of OCD were, respectively, acute and chronic, with no significant differences amongst the two groups. We also found a trend towards three types of obsessions and compulsions namely aggression, sexual/religious and symmetry, in the BU-OCD group, possibly reflecting some normal features of a romantic relationship that might lead specific OCD dimensions whereas its onset occurs prematurely. Finally, we found similar results for the obsessions, compulsions and total Y-BOCS scores amongst the two groups, that were also indicative of severe clinical pictures. Such findings were against our original hypothesis, meaning that an onset of OCD during the falling in love phase or following a break-up does not influence the overall severity of this disorder.
In spite of some limitations, our findings overall suggest that different stages of RL may influence some features of OCD, namely the age of onset and specific dimensions, whilst not contributing to the overall severity of the clinical picture. These findings, together with current literature on this specific topic, should encourage further research to better clarify the impact of RL on OCD. They also define some of the features of these individuals and how the most natural experience of humankind, that is love, may pave the way for the onset and the features of OCD, similarly to other mental disorders, whereas the evidence is currently more sound.