Correlational research on facial and clinical characteristics of adolescents with obsessive-compulsive disorder

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The enrolled study sample comprised 40 adolescents diagnosed with OCD using the Obsessive Compulsive Inventory Child Version (OCI-CV) and 38 healthy controls (HCs). Facial photos, 21 facial diameters, and nine facial angles were collected using image software. In males, lower lip red height was significantly lower in OCD patients than in HCs (P 0.05). In females, the nasolabial angle was smaller in OCD patients than in HCs (P 0.05). The difference in lower lip red height between the OCD group and HC group was positively correlated with mental neutralization symptoms (r = 0.401, P < 0.05). Our findings highlight the relationship between facial and clinical characteristics in OCD patients. Psychiatry adolescent obsessive-compulsive disorder neurodevelopment facial characteristics 1. Introduction Research over the last two decades has identified obsessive–compulsive disorder (OCD) in children and adolescents as one of the most common psychiatric illnesses affecting youth. Epidemiological studies have reported a lifetime prevalence of 1–3% in pediatric populations [ 1 ] and 30–50% of adult patients develop OCD during childhood and adolescence [ 2 ] . OCD in youth is typically a chronic and debilitating disorder [ 3 ] , and the morbid dysfunction caused by OCD commencing in youth may interfere with the trajectory of normal development during critical periods. This may impede the consolidation of processes such as identity and personality formation, social and educational mastery, and future orientation [ 3 ] . Given the high prevalence, morbidity, and functional impairments associated with OCD in children, early detection is crucial. Children with OCD often present with neurodevelopmental disorders such as tic disorder and attention deficit hyperactivity disorder, which are underpinned by a common biological basis. The neurodevelopmental model of OCD, proposed by Rosenberg and Keshavan, theorizes that neurodevelopmental changes in the ventral striatal circuit of the prefrontal lobe are associated with the initial symptoms of OCD [ 4 ] . Growing neuroimaging evidence has highlighted asymmetries and subtle changes in subcortical structures (e.g., thalamus and globus pallidus) in children with OCD, but these changes are absent in adult OCD patients [ 5 ] . A recent genomic study of mental diseases including OCD, autism, attention deficit hyperactivity disorder, and tic disorder demonstrated that pleiotropic risk sites are enriched in genes related to neurogenesis and neurodevelopment, and are expressed in the second trimester peak [ 6 ] . These findings support the neurodevelopmental hypothesis of OCD in children. However, the neurodevelopmental origin and potential causes of OCD have not been elucidated. Minor physical anomalies (MPAs) refer to subtle morphological abnormalities of the craniofacial region and limbs. These abnormalities do not result in obvious cosmetic or functional sequelae. MPAs are markers of abnormal fetal morphogenesis in the early or middle trimester of pregnancy and originate from the ectoderm alongside the fetal brain. As MPAs are affected by genetic and prenatal factors, they may be used as neurodevelopmental indicators [ 7 ] . MPAs include minor deformities and phenotypic variations, and are stable over time. Minor deformities are underpinned by qualitative defects after organogenesis during embryogenesis. Phenotypic genetic variation refers to the quantitative defects that occur after organogenesis and are equivalent to the variation in normal human body measurements. Therefore, screening for MPAs can be achieved via physical measurements [ 8 ] . Previous studies have suggested that the incidence of MPAs is higher in patients with neurodevelopmental disorders such as schizophrenia, autism, and Tourette’s syndrome than health [ 8 , 9 , 10 ] . However, there is currently a paucity of studies on MPAs in children with OCD. Abnormal craniofacial morphology in MPAs is one of the most consistent anatomical phenotypes of neurodevelopmental disorders [ 11 ] .Atypical facial features are observed in many developmental disorders, such as 22q11.2 deletion syndrome and fetal alcohol syndrome [ 12 , 13 ] .Facial morphological abnormalities vary from subtle to severe. During embryonic development, brain and facial tissues both originate from the neuroectoderm and reciprocally affect their development. Genetic or environmental events that interfere with early fetal development will result in morphological abnormalities [ 14 ] . If these deformities are sufficiently prominent, they can be qualitatively identified and classified by inspection, which is currently practiced in clinical genetics and pediatrics [ 15 ] . If abnormal facial morphology is not evident, traditional anthropometric techniques can be used to quantify and grade this morphological disorder. Based on standard anatomical landmarks of individual facial features, facial abnormalities can be measured using manual or conventional two-dimensional photographs [ 16 ] ,and biological significance can be determined based on morphological assessments. Facial deformity is the most easily measured index of brain malformation, which can reflect abnormal brain structure and function via facial abnormalities. Facial morphology is largely determined by genetic factors [ 17 ] .Technological advancements in facial morphological measurements using abnormal facial features to bridge clinical phenotypes and genotypes will enable the identification of genes associated with OCD. Identification of facial abnormalities using face recognition technology [ 18 ] may be facilitate early screening and auxiliary diagnosis of OCD. Based on the neurodevelopmental hypothesis of OCD in children and adolescents, this study selects facial morphological features as the observational indicators of neurodevelopment, and explores the correlation between facial features and clinical symptoms of adolescents with OCD by measuring the dimensions of the subjects’ facial photos. 2. Methods 2.1. Participants Participants were 15- to 17-year-old students studying at two high schools in Ningxia Hui Autonomous Region, China. In total, 2,400 students were approached. We enrolled 40 students diagnosed with OCD group and 38 matched for age and sex health controls. The Child Obsessive Compulsive Scale (OCI-CV) was used to screen for obsessive-compulsive symptoms. A high-risk obsessive-compulsive symptoms group (OCI-CV ≥ 20 points) and non-obsessive-compulsive symptoms group (OCI-CV = 0 points) were screened. Two groups of participants were diagnosed using the MINI interview scale by two attending psychiatrists based on the DSM-5 OCD diagnostic criteria and Yale-Brown Obsessive-Compulsive Scale score ≥ 16 points. To be eligible for participation in the study, participants were required to fulfill the following inclusion criteria: (1) aged 15–17 years old, met the DSM-5 diagnostic criteria for OCD [ 19 ] and had a Yale-Brown Obsessive-Compulsive Scale score ≥ 16 points; (2) first onset and were not treated with serotonin reuptake inhibitors or other psychotropic drugs; (3) obsessive-compulsive symptoms were not secondary to other mental and/or physical diseases; (4) no color vision weakness or blindness; and (5) were right-handed. Participants were excluded from participation if they had: (1) a previous history of depression, panic disorder and/or schizophrenia; (2) severe brain diseases or unstable physical diseases; (3) alcohol or other substance dependence; (4) neurological or hormonal diseases; (4) mental retardation were precluded cooperation in experiments; (5) serious lack of dentition, facial plastic surgery, orthodontic correction, history of surgery, and/or history of trauma; and (6) overweight or wasting. 2.2. Procedures Participants completed all measurements via face-to-face surveys, which were conducted by research staff who received rigorous training prior to fieldwork. The study was approved by the Ethics Committee of the General Hospital of Ningxia Medical University (no.2018 − 131). All participants provided written informed consent after receiving a complete description of the study. Informed consent was obtained from a parent or guardian for participants under 16 years old, after being informed of the study objectives.. 2.3. Measures 2.3.1. Assessment of obsessive-compulsive symptoms 2.3.1.1. The Obsessive-Compulsive Inventory-Child Version (OCI-CV) The OCI-CV was compiled by Foa et al [ 20 ] to measure obsessive-compulsive symptoms in children and adolescents aged 7–17 years. The OCI-CV comprises 21 items and uses a 3-point Likert-type scale ranging from 0 (never) to 2 (always). The score ranges from 0–42 points and includes six dimensions: obsessive-compulsive, hoarding, cleaning, sorting, and mental suspicion/vigilance. The total scores of each dimension were added, with higher scores indicating more severe obsessive-compulsive symptoms. The Chinese version revised by Xing et al [ 21 ] has demonstrated good reliability and validity in adolescents. 2.3.2. The Yale Brown Obsessive Compulsive Scale (YBOCS) The YBOCS was compiled by Goodman et al. [ 22 ] in 1989 to assess the severity of obsessive-compulsive symptoms in patients with OCD. The scale comprises 10 items used to assess the severity of obsessive thinking and behavior. Each item uses a five-level scoring method of 0–4 points. The total score of the scale is 0–40. The scores of the obsessive thinking and compulsive behavior subscales range from 0–20, with higher scores indicating more serious obsessive-compulsive symptoms. Mild, moderate, severe, and extremely severe obsessive-compulsive symptoms are indicated by total scores of 8–15, 16–23, 24–31, and 32–40, respectively. The Chinese version has been demonstrated to have good structural and content validity [ 23 ] and was used to assess the severity of obsessive-compulsive symptoms in OCD patients in this study. 2.4. Facial soft tissue measurement method: two-dimensional photo measurements 2.4.1. Filming locations Two fixed classrooms in the school were selected for measurements. The classrooms were required to be quiet and bright, with suitable temperature and good lighting. The sitting positions and photo locations of participants were fixed. 2.4.2. Posture For orthographic photographs, participants adopted a natural head position, staring ahead with their heads on the Frankfurt plane. For the positive and lateral positions, the sagittal plane of the participant’s head was positioned parallel to the plane of the background screen, and the Frankfurt plane was parallel to the ground. The facial muscles relaxed naturally, and the hair was combed behind the ears to expose the forehead and ears. Tooth occlusion was positioned at the largest occlusion. 2.4.3. Photographic tools and photography methods A Canon EOS700D single-lens reflex digital camera with 18 million pixels was selected. A blue background curtain marked with measurement signs was hung on the classroom wall. Participants were seated in a fixed position. The camera was fixed on a tripod and kept parallel to the ground. The object distance (distance from the lens to the tip of the nose) was 150 cm. The lens center was aligned with the tip of the nose. The shutter speed was 1/60 s. The focal length was 72 mm. The aperture was F3.5. The horizontal and vertical lines of the lens were required to overlap the eye-ear plane and center line of the face, respectively. The shutter was pressed at this time to obtain a facial image. Frontal and lateral photographs were obtained for each participant. 2.4.4. Photo measurement method Anteroposterior and lateral photo data of the two groups were imported into a computer for storage. Digimizer professional medical measurement image software was used to perform fixed-point measurements of the photographs within a period. 2.4.5. Determination of facial soft tissue measurement indexes Using the facial morphometric method established by Farkas [ 16 ] , 21 facial diameters(see Table 1 ), and 9 facial angles were measured(see Table 2 ). Table 1 The facial diameter facial diameter abbreviation Measurement of facial diameter Minimum forehead width (upper face width) ft-ft The straight-line distance between left and right frontal and temporal points Face width (central face width) zy-zy The straight-line distance between the zygomatic points on the left and right sides Interocular width(intercanthal width) en-en The straight-line distance between the inner corners of the left and right eyes Eye cleft width (left and right) en-ex The horizontal distance from the inner canthal point to the perpendicular to the ipsilateral outer canthal point Eye cleft height (left and right) ps-pi The distance between the midpoints of the upper and lower eyelid margins Mandibular angle width (lower face width) go-go The straight-line distance between the left and right mandibular corner points Nasal width al-al The straight-line distance between the left and right nose points Philtrum width ms-ms The distance between midpoints of cristae Philtrum length sn-ls The distance from the lower nose to upper lip Oral fissure width ch-ch The straight-line distance between the left and right corners Lip height ls-li The straight-line distance between the upper lip point and lower lip Distance between the high points of the lip arch cp-cp The distance between the high points of the lip arch Forehead distance tr-n The projection distance from the hairline point to root point of the nose nasal height n-sn The straight-line distance from the base of the nose to point below the nose Nasal length n-prn The distance from the base of the nose to tip of the nose Full lip height sn-sto The straight-line distance from the point of the nose to point of the cleft Upper lip height ls-sto The vertical distance between the midpoint of the upper lip and cleft point Lower lip high sto-li The vertical distance between the midpoint of the lower lip and cleft point Nose high profile n-sn The linear distance from the base of the nose to point below the nose from the side Long nose profile n-prn The distance from the base of the nose to tip of the nose from the side Jaw height sto-gn The distance from the point of the mouth to submental point Table 2 The facial angle Facial angle Abbreviation Measurement of facial diameter Full surface coign ∠g-prn-pg’ The angle between the base of the nose, tip of the nose, and front of the chin reflects the protrusion of the face including the nose Surface coign ∠g-sn-pg’ The angle between the base of the nose, point of the nose, and point of the front of the chin reflects the protrusion of the soft tissue profile Upper lip and chin process angle ∠ula-ns-pos The angle between the protrusion of the upper lip and base of the nose, and between the base of the nose and anterior point of the soft tissue, indicates the protrusion of the upper lip relative to the face Lower lip and chin process angle ∠lla-ns-pos The angle between the protrusion of the upper lip and base of the nose, and between the base of the nose and anterior point of the soft tissue, indicates the protrusion of the upper lip relative to the face Nasofrontal angle ∠g-ns-prn The dorsal line of the nose intersecting the inclined plane from the forehead to the root of the nose reflects the degree of depression of the root of the nose or degree of protrusion of the forehead Angle of nasal process ∠n-prn-sn The included angle of the line connecting the base of the nose-tip point-under-nose point is the angle between the dorsal line of the nose and the line of the columella. Reflect the protrusion of the nose itself Chin Angle of upper and lower lip ∠ula-ns-lla The angle between the protruding point of the upper lip and the base of the nose, and the protruding point of the base of the nose and the protruding point of the lower lip, indicating the relative position of the upper and lower lips Nasolabial angle ∠cm-sn-ula The intersection angle of the line between the columella point and subnasal point, and the line between the subnasal point and upper lip protrusion, reflects the morphological changes and forward and backward positions of the nose and upper lip Chin lip groove angle ∠pos-sl-li The angle between the point of the lower lip, point on the chin, and the front of the chin indicates the degree of lower lip protrusion relative to the chin 2.5. Statistical analyses All analyses were conducted using SPSS software (version 21.0, IBM Corp., Armonk, NY, USA). All reported p-values are two-tailed. The level of statistical significance was set at p < .05. Frequencies/percentages and means/standard deviations describe the distributions of participants according to demographic characteristics. T-test and chi-square test were used to compare two groups. Data were tested for normality, the correlation between facial and clinical features was analyzed by Pearson correlation. 3. Results 3.1. Sample characteristics The study consisted of 78 adolescents (n = 40 in the OCD group and n = 38 in the healthy control (HC) group) aged 15–17 years old (M = 16.25, SD = 0.87). Table 3 presents detailed information on demographics (sex, age, BMI, and years of education) and Y-BOCS score data. The average Y-BOCS score of OCD patients (M = 24.23, SD = 5.45) was higher than that of HCs (M = 1.71, SD = 2.19). Table 3 Comparison of demographic between OCD and HC Variable OCD HC t/x2 P value Male 20(50%) 20(52.6%) 0.054 0.816 Mean age 16.25 ± 0.87 16.24 ± 0.59 0.079 0.938 BMI(kg/m2) 20.39 ± 3.28 20.77 ± 2.36 -0.592 0.555 Years of education 10.80 ± 1.04 10.61 ± 0.86 0.904 0.369 Y-BOCS score 24.23 ± 5.45 1.71 ± 2.19 23.716 0.000** Note: ***:P < 0.001 3.2. Comparison of facial radial lines between OCD and HC Lower lip height in OCD patients was significantly lower than that in HCs (Table 4 ). No significant differences were observed in the other 20 facial diameters (all P > 0.05). Table 4 Comparison of Lower lip height (± s) n Lower lip height t P value -2.415 0.018* OCD 40 7.68 ± 1.69 HC 38 8.56 ± 1.52 Male -2.427 0.020* OCD 20 7.86 ± 1.83 HC 20 9.12 ± 1.44 Female -0.890 0.379 OCD 20 7.51 ± 1.56 HC 18 7.94 ± 1.39 Note: *:P < 0.05 3.3. Comparison of facial angle between OCD and HC groups The nasolabial angle in female and male OCD patients was significantly lower than that in the control group (Table 5 ). No significant differences were observed in other facial angles (all P > 0.05). Table 5 Comparison of Nasolabial angle (± s) n Nasolabial angle t P value -1.363 0.177 OCD 40 93.69 ± 9.20 Control 38 97.06 ± 12.51 Male 0.367 0.716 OCD 20 94.82 ± 10.06 Control 20 93.50 ± 10.59 Female -2.618 0.013* OCD 20 92.56 ± 8.35 Control 18 101.03 ± 11.48 Note: *:P < 0.05 3.4. Relationship between facial and clinical features in OCD and HC groups Lower lip height in the OCD group was positively correlated with the mental neutralization dimension (r = 0.401, P < 0.05). No correlation was observed with other symptom dimensions (Table 6 ). Lower lip height in male OCD patients was not correlated with the OCI-CV. Nasolabial angle in female OCD patients was not correlated with the OCI-CV. Table 6 Correlation between lower lip red height and clinical features in OCD and control group (± s) OCI-CV r value P value Total score for OCD symptoms 0.252 0.116 Obsessional thoughts -0.009 0.957 Hoarding 0.055 0.736 Washing 0.057 0.729 Sort -0.263 0.101 Mental neutralization 0.401 0.010* Suspicion/examination 0.042 0.797 Note: *:P < 0.05 4. Discussion Childhood OCD is a neurodevelopmental subtype of OCD which shares a biological basis with neurodevelopmental disorders such as schizophrenia, autism, and tic disorder [ 24 , 25 ] . Growing neuroimaging and neuropsychological evidence indicates that OCD in children is a neurodevelopmental disorder distinct to OCD in adults [ 26 ] . Facial morphology shares the strongest embryonic relationship with the brain and is the most consistent anatomical phenotype of neurodevelopmental disorders [ 11 ] . Neurodevelopmental risk markers generally change before the appearance of clinical symptoms and play a prominent role in early clinical detection, auxiliary diagnosis, and prognosis. Reports on neurodevelopmental risk markers such as neurological soft signs and cortical folding in OCD exist [ 27 , 28 ] , but data on facial morphology as a neurodevelopmental risk marker for OCD are lacking. In this study, we compared the facial morphology of adolescent OCD patients with that of HCs. We observed that the lower lip redness of OCD patients was significantly lower than that of HCs, suggestive of thinner lower lips in OCD patients. The lower lip redness of male OCD patients was significantly lower than that of male HCs, indicating that the lower lips of male OCD patients were thinner. The nasolabial angle of female OCD patients was significantly smaller than that of female HCs. Lip angle reflects morphological changes of the nose and upper lip. An upturned nose tip or protruding upper lip will lead to a smaller angle. The facial morphology differences of the aforementioned OCD patients were concentrated in the nose and lips. Facial brain development occurs in the early and second trimester of pregnancy. Facial brain morphogenesis is a major midline process. The abnormal facial morphology of OCD patients centered in the nose and lips, which are located along the facial midline. During embryonic development, the mid-face is filled with cranial neural crest cells, which modulate forebrain development [ 14 ] . The nose and lips develop from the frontal nasal process of the embryonic primordia. According to the embryonic model, specific brain regions and areas of craniofacial abnormalities are linked. Therefore, abnormal frontal nasal derivatives in OCD may be related to the front and back of embryonic brain regions. The frontal and posterior diencephalon correspond to the frontal and thalamic regions, respectively [ 16 ] . This is consistent with structural abnormalities of the putamen/globus pallidus, thalamus, prefrontal cortex, and caudate nucleus in children with OCD [ 29 ] . Patients with mental disorders such as schizophrenia and bipolar disorder may have abnormal facial morphology [ 14 ] , typically concentrated in the frontonasal area [ 30 ] . Collectively, these results suggest a potential shared biological basis of schizophrenia and OCD. We observed that the nasolabial angle of female OCD patients was smaller than that of HCs. The nasolabial angle reflects morphological changes of the nose and upper lip, indicating that the nose tip was upturned or upper lip was protruding, suggesting that female OCD patients had a higher degree of facial protrusion. During the development of the facial and brain, the face grows forward faster than the brain; this difference in growth may underpin the decrease in forebrain growth and protrusion of the anterior midface [ 31 ] . Based on the correspondence between embryonic facial and brain development, it is speculated that frontal cortical development in female OCD patients was diminished. This result is consistent with the neurobiological basis of abnormal frontal cortical development in children with OCD [ 26 ] . However, this result was not observed in male OCD patients, possibly due to the small sample size and limited measurement accuracy of the two-dimensional photographic facial measurement method. Future studies should expand the sample size and employ three-dimensional face laser-scanning technology to clarify these issues. The heritability of facial morphological features can reach 75%; with minimal interference from environmental factors, these traits remain stable and are regulated by corresponding genes. Abnormal facial morphology can reflect abnormal brain morphology and is easier to measure than brain structure. Facial morphological variation can be used for in-body functional research [ 32 ] . Genetic studies of the face have reported that the DCHS2 gene is associated with nasolabial angle and nose protrusion; lip morphology is related to genes ACAD9, HOXDcluster, FREM1, and RAB7A [ 33 ] . Based on this, it is speculated that the above-mentioned genes may be related to OCD candidate genes, which will be further verified in future studies。 In this study, correlational analysis between facial and clinical features of adolescents with OCD or HCs revealed that the lower lip redness of facial features was positively correlated with mental neutrality. This suggests that OCD patients with different symptom dimensions may have different facial features. Due to the high heritability of facial morphology and corresponding genetic underpinnings, it is speculated that the dimension of mental neutralization symptoms may be more hereditary and may be modulated by the relevant genes. Completion of the facial genetic maps, advancements in three-dimensional facial imaging quantitative analysis, and application of facial recognition technology in disease diagnosis [ 18 ] , pathogenic genes underpinning OCD may be identified based on facial morphological variation in the future. This study adopted the method of measuring participants’ facial features in frontal and lateral two-dimensional photographs. This method only permitted two-dimensional, but not three-dimensional, structural features of the face to be obtained. This may have overlooked minor variations in facial features. Future research should employ facial 3D laser scanning photographic technology or artificial intelligence face recognition technology to collect facial images and use computer deep-learning technology to analyze facial feature images to obtain more facial variation information. Further, the use of facial features as neurodevelopmental indicators did not verify the relationship between facial and brain morphology. In the future, this approach can be combined with brain magnetic resonance imaging to improve the extrapolation of results. In addition, we identified facial feature-related variation in adolescents with OCD and used human facial genetic maps to speculate on susceptibility genes that were associated with OCD, but causative mechanisms could not be verified. Animal models or in vivo studies should be performed in the future to clarify the relationship between related genes and OCD. The cross-sectional design limited our ability to infer temporal and potential causal effects between facial characteristics and OCD in adolescents. The sample size of this study was small, the results obtained may not be generalizable. Future research should use larger sample sizes with longitudinal or cross-lag designs to provide insight into causal mechanisms. 5. Summary In conclusion, this study identified a correlation between facial features and OCD. Male OCD patients had a thinner lower lip and female OCD patients had smaller nasolabial angles. The facial features of adolescents with OCD were positively correlated with lower lip redness and mental neutrality. Abbreviations OCI-CV: Child Obsessive Compulsive Scale MPAs: Minor physical anomalies OCD: obsessive-compulsive disorder HC: healthy control YBOCS: The Yale Brown Obsessive Compulsive Scale Declarations Ethics approval and consent to participate The protocol for this study was approved by the Ethics Committee of the General Hospital of Ningxia Medical University. All participants provided written informed consent after receiving a complete description of the study. Informed consent was obtained from a parent or guardian for participants under 16 years old. Consent for publication Not applicable. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests All authors declared no conflict of interest. Funding This study was funded by by the key research and development projects of Ningxia (grant number: 2019BFG02006).. The funding source did not play any role in study design; in the collection, analysis, and interpretation of data; in the writing of the paper; and in the decision to submit the article for publication. Authors' Contributions YRW: writing – original draft, writing – review and editing; SHC: case diagnosis and inclusion, data curation and software, writing – original draft; XMM: writing – review and editing; JYL: data curation; RXZ: writing – review and editing; JQF: funding acquisition, project administration, supervision. All authors contributed to and have approved the final manuscript. 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[25]Ekinci O, Erkan EA(2020)Neurological Soft Signs and Clinical Features of Tic-Related Obsessive-Compulsive Disorder Indicate a Unique Subtype. J Nerv Ment Dis208:21-27. [26]Abramovitch A, Mittelman A, Henin A(2012)Neuroimaging and neuropsychological findings in pediatric obsessive–compulsive disorder: a review and developmental considerations. Neuropsychiatry2:313-329. [27]Jaafari N,Fernandez De La CL,Grau M,Knowles E,Radua J,Wooderson S,Segalas C,Alonso P,Phillips M L,Menchon JM,Mataix-Cols D(2013)Neurological soft signs in obsessive-compulsive disorder: two empirical studies and meta-analysis. Psychol Med43:1069-1079. [28]Rus OG,Reess TJ,Wagner G,Zaudig M,Zimmer C,Koch K(2017)Hypogyrification in obsessive-compulsive disorder. Psychological Medicine47:1053-1061. [29]Chaim H, Dick JV, Else DH,.Chaim HA, Dick JV, De HaanAC,Frits B(2009)Paediatric obsessive – compulsive disorder, a neurodevelopmental disorder Evidence from neuroimaging. Neuroscience and Biobehavioral Reviews33:818-830. [30]Hennessy RJ, Baldwin PA, Browne DJ,Kinsella A,Waddington JL(2010)Frontonasal dysmorphology in bipolar disorder by 3D laser surface imaging and geometric morphometrics: Comparisons with schizophrenia. Schizophrenia Research122:63-71. [31]Hennessy RJ, Kinsella A, Waddington JL(2002)3D laser surface scanning and geometric morphometric analysis of craniofacial shape as an index of cerebro-craniofacial morphogenesis: initial application to sexual dimorphism. Biological Psychiatry51:507-514. [32]Xiong Z,Dankova G,Howe LJ,Lee MK(2019)Novel genetic loci affecting facial shape variation in humans. Elife8. [33]Richmond S, Howe LJ, Lewis S,Stergiakouli E,Zhurov A(2018)Facial Genetics: A Brief Overview. Front Genet9:462. Cite Share Download PDF Status: Published Journal Publication published 01 Dec, 2021 Read the published version in BMC Psychiatry → Version 1 posted Reviewer # 3 agreed at journal 08 May, 2021 Reviewer # 2 agreed at journal 08 May, 2021 Review # 1 received at journal 08 Apr, 2021 Reviewer # 1 agreed at journal 30 Mar, 2021 Reviewers invited by journal 27 Mar, 2021 Editor assigned by journal 22 Mar, 2021 Submission checks completed at journal 22 Mar, 2021 Editor invited by journal 22 Mar, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-362348","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":18472960,"identity":"868d2844-c66e-47b4-a27a-e3decd2ad6e7","order_by":0,"name":"Yanrong Wang","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yanrong","middleName":"","lastName":"Wang","suffix":""},{"id":18472961,"identity":"b788b62b-dba3-4f8a-a3a4-d3058da03859","order_by":1,"name":"Shaohua Chang","email":"","orcid":"","institution":"Ning An Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shaohua","middleName":"","lastName":"Chang","suffix":""},{"id":18472962,"identity":"c1e93944-27a3-4693-ba82-ecccec9548e6","order_by":2,"name":"Xiaomin Ma","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaomin","middleName":"","lastName":"Ma","suffix":""},{"id":18472963,"identity":"668e4f16-dcee-4857-a779-417e50d86377","order_by":3,"name":"Jiying Li","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jiying","middleName":"","lastName":"Li","suffix":""},{"id":18472964,"identity":"539d1e8c-857a-41d5-8790-767d71f23b79","order_by":4,"name":"Ruixia Zhang","email":"","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ruixia","middleName":"","lastName":"Zhang","suffix":""},{"id":18472965,"identity":"9cf4c8ca-2af9-45a4-9b77-3183b5044423","order_by":5,"name":"jianqun fang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIie3RsQrCMBCA4QuBuqR2zegjHBTqEvBBXDJlEzp2KBgR6tjZt8gjRA46BXyFPoKjg4N1c0tGwfzDTfmGywHkcj/Yynrgr04dR85pTiLC+2UEw66XwmAiWUY5EHN3sZFphJEDGQyvSQBCr/ZxAlML2KmiodLPMJmDjZEdhO1TByMaWmtkluJEQEC4DSTrs0CZTNhpIESeTqaWQzBa0vLJOmUXIclx6JSuRqL50as4Aem/Dqijzz9VNu3muVwu98e9AfjXPxFCRzVjAAAAAElFTkSuQmCC","orcid":"","institution":"Ningxia Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"jianqun","middleName":"","lastName":"fang","suffix":""}],"badges":[],"createdAt":"2021-03-25 17:45:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-362348/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-362348/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-021-03612-5","type":"published","date":"2021-12-01T14:03:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":16369204,"identity":"db35decb-d020-4ad0-9a4a-e6aa58733cc6","added_by":"auto","created_at":"2021-12-11 14:03:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":465555,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-362348/v1/7ab6f5cc-8200-43be-8af7-076ea2698cb8.pdf"}],"financialInterests":"","formattedTitle":"Correlational research on facial and clinical characteristics of adolescents with obsessive-compulsive disorder","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eResearch over the last two decades has identified obsessive\u0026ndash;compulsive disorder (OCD) in children and adolescents as one of the most common psychiatric illnesses affecting youth. Epidemiological studies have reported a lifetime prevalence of 1\u0026ndash;3% in pediatric populations \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003eand 30\u0026ndash;50% of adult patients develop OCD during childhood and adolescence\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. OCD in youth is typically a chronic and debilitating disorder\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e, and the morbid dysfunction caused by OCD commencing in youth may interfere with the trajectory of normal development during critical periods. This may impede the consolidation of processes such as identity and personality formation, social and educational mastery, and future orientation\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Given the high prevalence, morbidity, and functional impairments associated with OCD in children, early detection is crucial.\u003c/p\u003e\n\u003cp\u003eChildren with OCD often present with neurodevelopmental disorders such as tic disorder and attention deficit hyperactivity disorder, which are underpinned by a common biological basis. The neurodevelopmental model of OCD, proposed by Rosenberg and Keshavan, theorizes that neurodevelopmental changes in the ventral striatal circuit of the prefrontal lobe are associated with the initial symptoms of OCD\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Growing neuroimaging evidence has highlighted asymmetries and subtle changes in subcortical structures (e.g., thalamus and globus pallidus) in children with OCD, but these changes are absent in adult OCD patients\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. A recent genomic study of mental diseases including OCD, autism, attention deficit hyperactivity disorder, and tic disorder demonstrated that pleiotropic risk sites are enriched in genes related to neurogenesis and neurodevelopment, and are expressed in the second trimester peak\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. These findings support the neurodevelopmental hypothesis of OCD in children. However, the neurodevelopmental origin and potential causes of OCD have not been elucidated.\u003c/p\u003e\n\u003cp\u003eMinor physical anomalies (MPAs) refer to subtle morphological abnormalities of the craniofacial region and limbs. These abnormalities do not result in obvious cosmetic or functional sequelae. MPAs are markers of abnormal fetal morphogenesis in the early or middle trimester of pregnancy and originate from the ectoderm alongside the fetal brain. As MPAs are affected by genetic and prenatal factors, they may be used as neurodevelopmental indicators\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. MPAs include minor deformities and phenotypic variations, and are stable over time. Minor deformities are underpinned by qualitative defects after organogenesis during embryogenesis. Phenotypic genetic variation refers to the quantitative defects that occur after organogenesis and are equivalent to the variation in normal human body measurements. Therefore, screening for MPAs can be achieved via physical measurements\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Previous studies have suggested that the incidence of MPAs is higher in patients with neurodevelopmental disorders such as schizophrenia, autism, and Tourette\u0026rsquo;s syndrome than health\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. However, there is currently a paucity of studies on MPAs in children with OCD.\u003c/p\u003e\n\u003cp\u003eAbnormal craniofacial morphology in MPAs is one of the most consistent anatomical phenotypes of neurodevelopmental disorders\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.Atypical facial features are observed in many developmental disorders, such as 22q11.2 deletion syndrome and fetal alcohol syndrome\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.Facial morphological abnormalities vary from subtle to severe. During embryonic development, brain and facial tissues both originate from the neuroectoderm and reciprocally affect their development. Genetic or environmental events that interfere with early fetal development will result in morphological abnormalities\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. If these deformities are sufficiently prominent, they can be qualitatively identified and classified by inspection, which is currently practiced in clinical genetics and pediatrics\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. If abnormal facial morphology is not evident, traditional anthropometric techniques can be used to quantify and grade this morphological disorder. Based on standard anatomical landmarks of individual facial features, facial abnormalities can be measured using manual or conventional two-dimensional photographs\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e,and biological significance can be determined based on morphological assessments. Facial deformity is the most easily measured index of brain malformation, which can reflect abnormal brain structure and function via facial abnormalities. Facial morphology is largely determined by genetic factors\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.Technological advancements in facial morphological measurements using abnormal facial features to bridge clinical phenotypes and genotypes will enable the identification of genes associated with OCD. Identification of facial abnormalities using face recognition technology\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e may be facilitate early screening and auxiliary diagnosis of OCD. Based on the neurodevelopmental hypothesis of OCD in children and adolescents, this study selects facial morphological features as the observational indicators of neurodevelopment, and explores the correlation between facial features and clinical symptoms of adolescents with OCD by measuring the dimensions of the subjects\u0026rsquo; facial photos.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.1. Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were 15- to 17-year-old students studying at two high schools in Ningxia Hui Autonomous Region, China. In total, 2,400 students were approached. We enrolled 40 students diagnosed with OCD group and 38 matched for age and sex health controls. The Child Obsessive Compulsive Scale (OCI-CV) was used to screen for obsessive-compulsive symptoms. A high-risk obsessive-compulsive symptoms group (OCI-CV\u0026thinsp;\u0026ge;\u0026thinsp;20 points) and non-obsessive-compulsive symptoms group (OCI-CV\u0026thinsp;=\u0026thinsp;0 points) were screened. Two groups of participants were diagnosed using the MINI interview scale by two attending psychiatrists based on the DSM-5 OCD diagnostic criteria and Yale-Brown Obsessive-Compulsive Scale score\u0026thinsp;\u0026ge;\u0026thinsp;16 points.\u003c/p\u003e\n\u003cp\u003eTo be eligible for participation in the study, participants were required to fulfill the following inclusion criteria: (1) aged 15\u0026ndash;17 years old, met the DSM-5 diagnostic criteria for OCD\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003eand had a Yale-Brown Obsessive-Compulsive Scale score\u0026thinsp;\u0026ge;\u0026thinsp;16 points; (2) first onset and were not treated with serotonin reuptake inhibitors or other psychotropic drugs; (3) obsessive-compulsive symptoms were not secondary to other mental and/or physical diseases; (4) no color vision weakness or blindness; and (5) were right-handed. Participants were excluded from participation if they had: (1) a previous history of depression, panic disorder and/or schizophrenia; (2) severe brain diseases or unstable physical diseases; (3) alcohol or other substance dependence; (4) neurological or hormonal diseases; (4) mental retardation were precluded cooperation in experiments; (5) serious lack of dentition, facial plastic surgery, orthodontic correction, history of surgery, and/or history of trauma; and (6) overweight or wasting.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants completed all measurements via face-to-face surveys, which were conducted by research staff who received rigorous training prior to fieldwork.\u003c/p\u003e\n\u003cdiv class=\"Ethics-ToolTip\"\u003eThe study was approved by the Ethics Committee of the General Hospital of Ningxia Medical University (no.2018\u0026thinsp;\u0026minus;\u0026thinsp;131).\u003c/div\u003e\n\u003cdiv class=\"Ethics-ToolTip\"\u003eAll participants provided written informed consent after receiving a complete description of the study.\u003c/div\u003e\n\u003cdiv class=\"Ethics-ToolTip\"\u003eInformed consent was obtained from a parent or guardian for participants under 16 years old, after being informed of the study objectives..\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.3. Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.1. Assessment of obsessive-compulsive symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec7\" class=\"Section4\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.1.1. The Obsessive-Compulsive Inventory-Child Version (OCI-CV)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe OCI-CV was compiled by Foa et al\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003eto measure obsessive-compulsive symptoms in children and adolescents aged 7\u0026ndash;17 years. The OCI-CV comprises 21 items and uses a 3-point Likert-type scale ranging from 0 (never) to 2 (always). The score ranges from 0\u0026ndash;42 points and includes six dimensions: obsessive-compulsive, hoarding, cleaning, sorting, and mental suspicion/vigilance. The total scores of each dimension were added, with higher scores indicating more severe obsessive-compulsive symptoms. The Chinese version revised by Xing et al\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003ehas demonstrated good reliability and validity in adolescents.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.2. The Yale Brown Obsessive Compulsive Scale (YBOCS)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe YBOCS was compiled by Goodman et al. \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003ein 1989 to assess the severity of obsessive-compulsive symptoms in patients with OCD. The scale comprises 10 items used to assess the severity of obsessive thinking and behavior. Each item uses a five-level scoring method of 0\u0026ndash;4 points. The total score of the scale is 0\u0026ndash;40. The scores of the obsessive thinking and compulsive behavior subscales range from 0\u0026ndash;20, with higher scores indicating more serious obsessive-compulsive symptoms. Mild, moderate, severe, and extremely severe obsessive-compulsive symptoms are indicated by total scores of 8\u0026ndash;15, 16\u0026ndash;23, 24\u0026ndash;31, and 32\u0026ndash;40, respectively. The Chinese version has been demonstrated to have good structural and content validity\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e and was used to assess the severity of obsessive-compulsive symptoms in OCD patients in this study.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Facial soft tissue measurement method: two-dimensional photo measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.4.1. Filming locations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo fixed classrooms in the school were selected for measurements. The classrooms were required to be quiet and bright, with suitable temperature and good lighting. The sitting positions and photo locations of participants were fixed.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.4.2. Posture\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor orthographic photographs, participants adopted a natural head position, staring ahead with their heads on the Frankfurt plane. For the positive and lateral positions, the sagittal plane of the participant\u0026rsquo;s head was positioned parallel to the plane of the background screen, and the Frankfurt plane was parallel to the ground. The facial muscles relaxed naturally, and the hair was combed behind the ears to expose the forehead and ears. Tooth occlusion was positioned at the largest occlusion.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.4.3. Photographic tools and photography methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA Canon EOS700D single-lens reflex digital camera with 18\u0026nbsp;million pixels was selected. A blue background curtain marked with measurement signs was hung on the classroom wall. Participants were seated in a fixed position. The camera was fixed on a tripod and kept parallel to the ground. The object distance (distance from the lens to the tip of the nose) was 150 cm. The lens center was aligned with the tip of the nose. The shutter speed was 1/60 s. The focal length was 72 mm. The aperture was F3.5. The horizontal and vertical lines of the lens were required to overlap the eye-ear plane and center line of the face, respectively. The shutter was pressed at this time to obtain a facial image. Frontal and lateral photographs were obtained for each participant.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.4.4. Photo measurement method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnteroposterior and lateral photo data of the two groups were imported into a computer for storage. Digimizer professional medical measurement image software was used to perform fixed-point measurements of the photographs within a period.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.4.5. Determination of facial soft tissue measurement indexes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing the facial morphometric method established by Farkas\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, 21 facial diameters(see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e), and 9 facial angles were measured(see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe facial diameter\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003efacial diameter\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eabbreviation\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMeasurement of facial diameter\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMinimum forehead width (upper face width)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eft-ft\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe straight-line distance between left and right frontal and temporal points\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFace width (central face width)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ezy-zy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe straight-line distance between the zygomatic points on the left and right sides\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInterocular width(intercanthal width)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003een-en\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe straight-line distance between the inner corners of the left and right eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEye cleft width (left and right)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003een-ex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe horizontal distance from the inner canthal point to the perpendicular to the ipsilateral outer canthal point\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEye cleft height (left and right)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eps-pi\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe distance between the midpoints of the upper and lower eyelid margins\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMandibular angle width (lower face width)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ego-go\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe straight-line distance between the left and right mandibular corner points\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNasal width\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eal-al\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe straight-line distance between the left and right nose points\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhiltrum width\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ems-ms\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe distance between midpoints of cristae\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhiltrum length\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esn-ls\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe distance from the lower nose to upper lip\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOral fissure width\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ech-ch\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe straight-line distance between the left and right corners\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLip height\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003els-li\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe straight-line distance between the upper lip point and lower lip\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDistance between the high points of the lip arch\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ecp-cp\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe distance between the high points of the lip arch\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eForehead distance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003etr-n\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe projection distance from the hairline point to root point of the nose\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003enasal height\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en-sn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe straight-line distance from the base of the nose to point below the nose\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNasal length\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en-prn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe distance from the base of the nose to tip of the nose\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFull lip height\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esn-sto\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe straight-line distance from the point of the nose to point of the cleft\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUpper lip height\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003els-sto\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe vertical distance between the midpoint of the upper lip and cleft point\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLower lip high\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esto-li\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe vertical distance between the midpoint of the lower lip and cleft point\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNose high profile\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en-sn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe linear distance from the base of the nose to point below the nose from the side\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLong nose profile\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003en-prn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe distance from the base of the nose to tip of the nose from the side\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJaw height\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esto-gn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe distance from the point of the mouth to submental point\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe facial angle\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFacial angle\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAbbreviation\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMeasurement of facial diameter\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFull surface coign\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ang;g-prn-pg\u0026rsquo;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe angle between the base of the nose, tip of the nose, and front of the chin reflects the protrusion of the face including the nose\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSurface coign\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ang;g-sn-pg\u0026rsquo;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe angle between the base of the nose, point of the nose, and point of the front of the chin reflects the protrusion of the soft tissue profile\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUpper lip and chin process angle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ang;ula-ns-pos\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe angle between the protrusion of the upper lip and base of the nose, and between the base of the nose and anterior point of the soft tissue, indicates the protrusion of the upper lip relative to the face\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLower lip and chin process angle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ang;lla-ns-pos\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe angle between the protrusion of the upper lip and base of the nose, and between the base of the nose and anterior point of the soft tissue, indicates the protrusion of the upper lip relative to the face\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNasofrontal angle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ang;g-ns-prn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe dorsal line of the nose intersecting the inclined plane from the forehead to the root of the nose reflects the degree of depression of the root of the nose or degree of protrusion of the forehead\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAngle of nasal process\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ang;n-prn-sn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe included angle of the line connecting the base of the nose-tip point-under-nose point is the angle between the dorsal line of the nose and the line of the columella. Reflect the protrusion of the nose itself\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChin Angle of upper and lower lip\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ang;ula-ns-lla\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe angle between the protruding point of the upper lip and the base of the nose, and the protruding point of the base of the nose and the protruding point of the lower lip, indicating the relative position of the upper and lower lips\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNasolabial angle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ang;cm-sn-ula\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe intersection angle of the line between the columella point and subnasal point, and the line between the subnasal point and upper lip protrusion, reflects the morphological changes and forward and backward positions of the nose and upper lip\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChin lip groove angle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ang;pos-sl-li\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe angle between the point of the lower lip, point on the chin, and the front of the chin indicates the degree of lower lip protrusion relative to the chin\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n\u003ch2\u003e\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e2.5. Statistical analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted using SPSS software (version 21.0, IBM Corp., Armonk, NY, USA). All reported p-values are two-tailed. The level of statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;.05. Frequencies/percentages and means/standard deviations describe the distributions of participants according to demographic characteristics. T-test and chi-square test were used to compare two groups. Data were tested for normality, the correlation between facial and clinical features was analyzed by Pearson correlation.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n\u003cp\u003e\u003cstrong\u003e3.1. Sample characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study consisted of 78 adolescents (n\u0026thinsp;=\u0026thinsp;40 in the OCD group and n\u0026thinsp;=\u0026thinsp;38 in the healthy control (HC) group) aged 15\u0026ndash;17 years old (M\u0026thinsp;=\u0026thinsp;16.25, SD\u0026thinsp;=\u0026thinsp;0.87). Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e presents detailed information on demographics (sex, age, BMI, and years of education) and Y-BOCS score data. The average Y-BOCS score of OCD patients (M\u0026thinsp;=\u0026thinsp;24.23, SD\u0026thinsp;=\u0026thinsp;5.45) was higher than that of HCs (M\u0026thinsp;=\u0026thinsp;1.71, SD\u0026thinsp;=\u0026thinsp;2.19).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of demographic between OCD and HC\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOCD\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eHC\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003et/x2\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20(50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20(52.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.054\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.816\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean age\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.079\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.938\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBMI(kg/m2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20.39\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.592\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.555\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYears of education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.904\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.369\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eY-BOCS score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.23\u0026thinsp;\u0026plusmn;\u0026thinsp;5.45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23.716\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.000**\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003eNote: ***:P\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Comparison of facial radial lines between OCD and HC\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLower lip height in OCD patients was significantly lower than that in HCs (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). No significant differences were observed in the other 20 facial diameters (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of Lower lip height (\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLower lip height\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003et\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-2.415\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.018*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOCD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e7.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e8.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-2.427\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.020*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOCD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e7.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e9.12\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.890\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.379\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOCD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e7.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e7.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003eNote: *:P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3. Comparison of facial angle between OCD and HC groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe nasolabial angle in female and male OCD patients was significantly lower than that in the control group (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). No significant differences were observed in other facial angles (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of Nasolabial angle (\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNasolabial angle\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003et\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-1.363\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.177\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOCD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e93.69\u0026thinsp;\u0026plusmn;\u0026thinsp;9.20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e97.06\u0026thinsp;\u0026plusmn;\u0026thinsp;12.51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.367\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.716\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOCD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e94.82\u0026thinsp;\u0026plusmn;\u0026thinsp;10.06\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e93.50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-2.618\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.013*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOCD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e92.56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e101.03\u0026thinsp;\u0026plusmn;\u0026thinsp;11.48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003eNote: *:P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4. Relationship between facial and clinical features in OCD and HC groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLower lip height in the OCD group was positively correlated with the mental neutralization dimension (r\u0026thinsp;=\u0026thinsp;0.401, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No correlation was observed with other symptom dimensions (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e). Lower lip height in male OCD patients was not correlated with the OCI-CV. Nasolabial angle in female OCD patients was not correlated with the OCI-CV.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab6\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCorrelation between lower lip red height and clinical features in OCD and control group (\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOCI-CV\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003er value\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal score for OCD symptoms\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.252\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.116\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eObsessional thoughts\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.009\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.957\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHoarding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.055\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.736\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWashing\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.057\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.729\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSort\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e-0.263\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.101\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMental neutralization\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.401\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.010*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSuspicion/examination\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.042\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.797\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003eNote: *:P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eChildhood OCD is a neurodevelopmental subtype of OCD which shares a biological basis with neurodevelopmental disorders such as schizophrenia, autism, and tic disorder\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Growing neuroimaging and neuropsychological evidence indicates that OCD in children is a neurodevelopmental disorder distinct to OCD in adults\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Facial morphology shares the strongest embryonic relationship with the brain and is the most consistent anatomical phenotype of neurodevelopmental disorders\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Neurodevelopmental risk markers generally change before the appearance of clinical symptoms and play a prominent role in early clinical detection, auxiliary diagnosis, and prognosis. Reports on neurodevelopmental risk markers such as neurological soft signs and cortical folding in OCD exist\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e, but data on facial morphology as a neurodevelopmental risk marker for OCD are lacking.\u003c/p\u003e\n\u003cp\u003eIn this study, we compared the facial morphology of adolescent OCD patients with that of HCs. We observed that the lower lip redness of OCD patients was significantly lower than that of HCs, suggestive of thinner lower lips in OCD patients. The lower lip redness of male OCD patients was significantly lower than that of male HCs, indicating that the lower lips of male OCD patients were thinner. The nasolabial angle of female OCD patients was significantly smaller than that of female HCs. Lip angle reflects morphological changes of the nose and upper lip. An upturned nose tip or protruding upper lip will lead to a smaller angle. The facial morphology differences of the aforementioned OCD patients were concentrated in the nose and lips. Facial brain development occurs in the early and second trimester of pregnancy. Facial brain morphogenesis is a major midline process. The abnormal facial morphology of OCD patients centered in the nose and lips, which are located along the facial midline. During embryonic development, the mid-face is filled with cranial neural crest cells, which modulate forebrain development\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. The nose and lips develop from the frontal nasal process of the embryonic primordia. According to the embryonic model, specific brain regions and areas of craniofacial abnormalities are linked. Therefore, abnormal frontal nasal derivatives in OCD may be related to the front and back of embryonic brain regions.\u003c/p\u003e\n\u003cp\u003eThe frontal and posterior diencephalon correspond to the frontal and thalamic regions, respectively\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. This is consistent with structural abnormalities of the putamen/globus pallidus, thalamus, prefrontal cortex, and caudate nucleus in children with OCD\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. Patients with mental disorders such as schizophrenia and bipolar disorder may have abnormal facial morphology\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, typically concentrated in the frontonasal area\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Collectively, these results suggest a potential shared biological basis of schizophrenia and OCD.\u003c/p\u003e\n\u003cp\u003eWe observed that the nasolabial angle of female OCD patients was smaller than that of HCs. The nasolabial angle reflects morphological changes of the nose and upper lip, indicating that the nose tip was upturned or upper lip was protruding, suggesting that female OCD patients had a higher degree of facial protrusion. During the development of the facial and brain, the face grows forward faster than the brain; this difference in growth may underpin the decrease in forebrain growth and protrusion of the anterior midface\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. Based on the correspondence between embryonic facial and brain development, it is speculated that frontal cortical development in female OCD patients was diminished. This result is consistent with the neurobiological basis of abnormal frontal cortical development in children with OCD\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. However, this result was not observed in male OCD patients, possibly due to the small sample size and limited measurement accuracy of the two-dimensional photographic facial measurement method. Future studies should expand the sample size and employ three-dimensional face laser-scanning technology to clarify these issues.\u003c/p\u003e\n\u003cp\u003eThe heritability of facial morphological features can reach 75%; with minimal interference from environmental factors, these traits remain stable and are regulated by corresponding genes. Abnormal facial morphology can reflect abnormal brain morphology and is easier to measure than brain structure. Facial morphological variation can be used for in-body functional research\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. Genetic studies of the face have reported that the \u003cem\u003eDCHS2\u003c/em\u003e gene is associated with nasolabial angle and nose protrusion; lip morphology is related to genes ACAD9, HOXDcluster, FREM1, and RAB7A\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. Based on this, it is speculated that the above-mentioned genes may be related to OCD candidate genes, which will be further verified in future studies。\u003c/p\u003e\n\u003cp\u003eIn this study, correlational analysis between facial and clinical features of adolescents with OCD or HCs revealed that the lower lip redness of facial features was positively correlated with mental neutrality. This suggests that OCD patients with different symptom dimensions may have different facial features. Due to the high heritability of facial morphology and corresponding genetic underpinnings, it is speculated that the dimension of mental neutralization symptoms may be more hereditary and may be modulated by the relevant genes. Completion of the facial genetic maps, advancements in three-dimensional facial imaging quantitative analysis, and application of facial recognition technology in disease diagnosis\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, pathogenic genes underpinning OCD may be identified based on facial morphological variation in the future.\u003c/p\u003e\n\u003cp\u003eThis study adopted the method of measuring participants\u0026rsquo; facial features in frontal and lateral two-dimensional photographs. This method only permitted two-dimensional, but not three-dimensional, structural features of the face to be obtained. This may have overlooked minor variations in facial features. Future research should employ facial 3D laser scanning photographic technology or artificial intelligence face recognition technology to collect facial images and use computer deep-learning technology to analyze facial feature images to obtain more facial variation information. Further, the use of facial features as neurodevelopmental indicators did not verify the relationship between facial and brain morphology. In the future, this approach can be combined with brain magnetic resonance imaging to improve the extrapolation of results. In addition, we identified facial feature-related variation in adolescents with OCD and used human facial genetic maps to speculate on susceptibility genes that were associated with OCD, but causative mechanisms could not be verified. Animal models or \u003cem\u003ein vivo\u003c/em\u003e studies should be performed in the future to clarify the relationship between related genes and OCD. The cross-sectional design limited our ability to infer temporal and potential causal effects between facial characteristics and OCD in adolescents. The sample size of this study was small, the results obtained may not be generalizable. Future research should use larger sample sizes with longitudinal or cross-lag designs to provide insight into causal mechanisms.\u003c/p\u003e"},{"header":"5. Summary","content":" \u003cp\u003eIn conclusion, this study identified a correlation between facial features and OCD. Male OCD patients had a thinner lower lip and female OCD patients had smaller nasolabial angles. The facial features of adolescents with OCD were positively correlated with lower lip redness and mental neutrality.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eOCI-CV: Child Obsessive Compulsive Scale \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMPAs: Minor physical anomalies\u003c/p\u003e\n\u003cp\u003eOCD: obsessive-compulsive disorder\u003c/p\u003e\n\u003cp\u003eHC: healthy control\u003c/p\u003e\n\u003cp\u003eYBOCS: The Yale Brown Obsessive Compulsive Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol for this study was approved by the Ethics Committee of the General Hospital of Ningxia Medical University. All participants provided written informed consent after receiving a complete description of the study. Informed consent was obtained from a parent or guardian for participants under 16 years old.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declared no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by by the key research and development projects of Ningxia (grant number: 2019BFG02006).. The funding source did not play any role in study design; in the collection, analysis, and interpretation of data; in the writing of the paper; and in the decision to submit the article for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' Contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYRW: writing \u0026ndash; original draft, writing \u0026ndash; review and editing; SHC: case diagnosis and inclusion, data curation and software, writing \u0026ndash; original draft; XMM: writing \u0026ndash; review and editing; JYL: data curation; RXZ: writing \u0026ndash; review and editing; JQF: funding acquisition, project administration, supervision. All authors contributed to and have approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank all the people who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e[1]Flament MF, Whitaker A, Rapoport JL（1988）Obsessive Compulsive Disorder in Adolescence: An Epidemiological Study. Journal of the American Academy of Child \u0026amp; Adolescent Psychiatry27:764-771.\u003c/p\u003e\n\u003cp\u003e[2]Ruscio AM, Stein DJ, Chiu WT,Ruscio Kessler RC(2010)The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry15:53-63.\u003c/p\u003e\n\u003cp\u003e[3]BergCZ,RapoportJL,WhitakerA,\u003cu\u003eDavies\u0026nbsp;M,\u003c/u\u003e\u0026nbsp;\u0026nbsp;\u003cu\u003eLeonard\u0026nbsp;H,\u003c/u\u003e\u0026nbsp;\u0026nbsp;\u003cu\u003eSwedo\u0026nbsp;SE,\u003c/u\u003e\u0026nbsp;\u0026nbsp;\u003cu\u003eBraiman\u0026nbsp;S,\u003c/u\u003e\u0026nbsp;\u0026nbsp;\u003cu\u003eLenane\u0026nbsp;M(1989)\u003c/u\u003e. Childhood obsessive compulsive disorder: a two-year prospective follow-up of a community sample. J Am Acad Child Adolesc Psychiatry28:528-533.\u003c/p\u003e\n\u003cp\u003e[4]Rosenberg DR, Keshavan MS（1998）Toward a Neurodevelopmental Model of Obsessive\u0026ndash;Compulsive Disorder. 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Front Genet9:462.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"adolescent, obsessive-compulsive disorder, neurodevelopment, facial characteristics","lastPublishedDoi":"10.21203/rs.3.rs-362348/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-362348/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe examined the relationship between facial morphological features and clinical characteristics of adolescents with obsessive-compulsive disorder (OCD). The enrolled study sample comprised 40 adolescents diagnosed with OCD using the Obsessive Compulsive Inventory Child Version (OCI-CV) and 38 healthy controls (HCs). Facial photos, 21 facial diameters, and nine facial angles were collected using image software. In males, lower lip red height was significantly lower in OCD patients than in HCs (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); no significant differences were observed in other facial indicators (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In females, the nasolabial angle was smaller in OCD patients than in HCs (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); no significant differences were observed in other facial indicators (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The difference in lower lip red height between the OCD group and HC group was positively correlated with mental neutralization symptoms (r\u0026thinsp;=\u0026thinsp;0.401, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Our findings highlight the relationship between facial and clinical characteristics in OCD patients.\u003c/p\u003e","manuscriptTitle":"Correlational research on facial and clinical characteristics of adolescents with obsessive-compulsive disorder","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-03-26 21:32:59","doi":"10.21203/rs.3.rs-362348/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2021-05-09T01:00:00+00:00","index":3,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-05-09T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-04-09T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable pending editorial decision\n"},{"type":"reviewerAgreed","content":"","date":"2021-03-31T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-03-28T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-03-23T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-03-22T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-03-22T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aee7d973-5c24-4bb4-af67-478e2c2a12c7","owner":[],"postedDate":"March 26th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":3250065,"name":"Psychiatry"}],"tags":[],"updatedAt":"2021-12-11T14:03:28+00:00","versionOfRecord":{"articleIdentity":"rs-362348","link":"https://doi.org/10.1186/s12888-021-03612-5","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2021-12-01 14:03:28","publishedOnDateReadable":"December 1st, 2021"},"versionCreatedAt":"2021-03-26 21:32:59","video":"","vorDoi":"10.1186/s12888-021-03612-5","vorDoiUrl":"https://doi.org/10.1186/s12888-021-03612-5","workflowStages":[]},"version":"v1","identity":"rs-362348","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-362348","identity":"rs-362348","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}