|Year : 2015 | Volume
| Issue : 3 | Page : 161-165
Determinants of obsessive compulsive disorder
Sateesh Rangarao Koujalgi1, Adithya A Pandurangi2, Raghavendra B Nayak2, Nanasaheb M Patil1
1 Department of Psychiatry, KLE University's J.N. Medical College, Belagavi, Karnataka, India
2 Department of Psychiatry, Dharwad Institute of Mental Health and Nero Sciences, Karnataka, India
|Date of Web Publication||16-Sep-2015|
Dr. Sateesh Rangarao Koujalgi
Department of Psychiatry, KLE University's J.N. Medical College, Nehru Nagar, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Background: The family has a significant role both in the genesis and prognosis of obsessive-compulsive disorder (OCD). Early identification, treatment and prevention of relapse in patients with OCD have important therapeutic and psychosocial implications. Hence, to study and determine family factors like high expressed emotion (EE) and family dysfunction are essential. These two factors play a significant role in the relapse and course of OCD. Aim: The aim was to study the relationship between family function, EE and OCD. Materials and Methods: The sample included 30 patients who were diagnosed with OCD using International Classification of Diseases-10 Diagnostic Criteria for Research criteria. Yale-Brown obsessive compulsive scale was used to assess the severity of OCD. EE was assessed in cases using Family Emotional Involvement and Criticism Scale and family function was assessed in cases using the family interaction pattern scale (FIPS). Statistical analysis was performed using Statistical Packages for Social Science. Patient and caregivers of the patients were assessed on self-developed socio-demographic proforma. Pearson co-relation co-efficient test was used to study the correlation between OCD, high EE and family dysfunction. Results: The result showed that there are significant correlations between high EE, family dysfunction and OCD. The Pearson correlation co-efficient between OCD and EE shows a significant correlation between the high EE of the caregiver and OCD with P < 0.01. The Pearson correlation co-efficient between OCD and Family Interaction Pattern Scale shows a significant correlation between the family dysfunction of the caregiver and OCD. Conclusion: Impaired family function and high EE in caregivers associated with OCD. Thus clinical interventions may improve the functional abilities of the caregivers.
Keywords: Family dysfunction, high expressed emotion, obsessive compulsive disorder
|How to cite this article:|
Koujalgi SR, Pandurangi AA, Nayak RB, Patil NM. Determinants of obsessive compulsive disorder. J Sci Soc 2015;42:161-5
| Introduction|| |
Obsessive compulsive disorder (OCD) is a chronic psychiatric illness that often causes severe limitations in daily functioning. The lifetime prevalence of OCD is estimated to be 1-3%.  The disorder is characterized by intrusive reiterating thought or action, pervasive doubts and ruminations, accompanied by declaration of distress and interference with life functioning and the presence of insight. This results a distress and social dysfunction in patient and caregivers life. , In spite of pharmacological and psychosocial interventions majority of the patients with OCD continue to experience symptoms. Many OCD patients experience long term course, which affect their daily living in different domains in life.  Family environments like inadequate parenting, frequent family conflicts and disorganized family have been reported as etiological factors in OCD , and impact the course of the illness. Few studies have also reported greater distress and a high rate of psychiatric illness in the caregivers of OCD patients. 
Patients with OCD and caregivers reports significant family dysfunction.  Factors like parenting style, family dysfunction and high expressed emotion (EE) have been explored, especially in relation with schizophrenia.  In OCD, the effects of the relationship between the family dysfunction and high EE is unclear. However, the studies have not looked into the multi-dimensional nature of correlations, the ways in which family dysfunction and high EE and OCD interact with each other. In addition, few studies have had relatively reported cognitive factors, , personality traits , and family factors , influence OCD patient. Thus, there is a need to identify the correlating factors that contribute to OCD. Moreover, there is a little research about the relationship between family dysfunction, high EE and OCD in India. Few studies in the west have reported that family dysfunction and high EE have role in the course of illness. The occurrence of OCD profoundly affects family function. Thus, this study was designed to investigate the multi-dimensional correlation between the determinants and OCD.
| Materials and Methods|| |
The study sample included 30 patients with OCD and 30 key caregivers of the same cohort. Purposive sampling method was used in this study. The samples were collected from psychiatry outpatient department The patients fulfilling International Classification of Diseases-10 Diagnostic Criteria for Research for OCD between the age group of 18-60 years who gave informed consent for study were taken up for the study. Patients were excluded if they were found to have organic mental disorder or other comorbid psychiatric disorder (except for depression). The sociodemographic data of the patients were collected using a semi-structured proforma prepared for this study. Each patient was administered with Yale-Brown obsessive compulsive scale (Y-BOCS)  to assess the severity of OCD. To study the correlation between EE and OCD, Family Emotional Involvement (EI) and Criticism Scale (FEICS)  was used.
The FEICS is a self-reporting scale to measure EE. The FEICS has two subscales:
- Perceived criticism (PC), and
- Intensity of EI.
These two factors are analogous to critical comments and emotional over involvement, the two main factors that are measured through the Camberwell Family Interview.  Cronbach's alpha for both the subscales was 0.74-0.82. Confirmatory factor analysis showed that each item loaded on its proposed factor and not with the other factor. The subscales exhibited correlations and partial correlations with various scales, such as the family adaptability and cohesion evaluation scales,  interpersonal support evaluation list,  and symptom checklist-90. The scale consists of 14 items marked 1-5. The PC subscale score is obtained from the total of even numbered items, and the EI subscale score is obtained from the total of odd numbered items of FEICS.
Caregivers or family members were either parents or spouses living with the patient in the same household and spending maximum time and effort in caring for the patient between the age group if 20-60 years were taken up for the study. To measure the relationship between family function and OCD, each key caregiver of OCD patient was administered Family Interaction Pattern Scale (FIPS) Bhatti et al.  The scale has 106 items under 6 domains, reinforcement, social support, role, communication, cohesion, and leadership. It measures against four-point scale from always to never. The scale device indicates that only caregivers to complete the questionnaires and not a patient. The higher the score shows dysfunction in that sub domains. The scale has the ability to effectively measure family dysfunction in different psychiatric disorder groups, e.g., families of hysterical, alcoholics and depressive disorders and established its inter-rater reliability and test-retest reliability Bhatti et al.  Statistical analysis was performed using Statistical Packages for Social Sciences (SPSS) version 17 software. Pearson correlation co-efficients test was used to assess the correlation between OCD, high EE and family dysfunction, P < 0.01 and P < 0.05 was considered as statistically significant.
| Results|| |
Results from the correlation analyses are shown in [Table 1] and [Table 2].
There was a significant correlation between PC and obsession, compulsion, and total Y-BOCS score at the 0.05 level of significance?
There was a significant correlation between EI and obsession, compulsion and total Y-BOCS score at the 0.01 level of significance.
There was a significant correlation between total score of FEICS score and obsession, compulsion and total Y-BOCS scale the 0.01 level of significance. Patients of OCD experienced significantly higher EE.
There was a significant correlation between reinforcement and obsession, compulsive and total Y-BOCS score at the 0.01 level of significance.
There was a significant correlation between social support and obsession, compulsion, and total Y-BOCS score at the 0.05 level of significance.
There was a significant correlation between role and obsession, compulsion at the 0.05 level of significance. The role and total Y-BOCS score was significance at the 0.01 level of significance.
There was a significant correlation between communication and obsession, compulsion, and total Y-BOCS score at the 0.01 level of significance.
There was a significant correlation between cohesion and obsession at 0.01 level of significance and between cohesion and compulsions at the 0.05 level of significance and between cohesion and total Y-BOCS score at the 0.01 level of significance.
There was a significant correlation between leadership and obsession compulsion and total Y-BOCS score at the 0.01 level of significance.
There was significant correlation between total score of Family Interaction Pattern Scale score and obsession, compulsion and total Y-BOCS score at the 0.01 level of significance.
| Discussion|| |
Correlation between Family Emotional Involvement and Criticism Scale and obsessive compulsive disorder
Sociodemographic features of the study group were published in another article. There was a significant positive correlation between EE and obsessive-compulsive symptomatology at the 0.01 level of significance. This is because the relatives feel that the symptoms may be controlled by the patient. The caregivers feel that the patient would come out of symptoms through criticism, which actually causes the relapse.  The caregivers who hold high EE and criticize symptoms are those, who feel that symptoms are not due to the psychological disorder, but more to the unique patient. Even more caregivers involve themselves with their patient behavior because they feel they are the cause and fault for the illness. This type of emotion may affect very strongly on patient symptoms who may try to improve their life. The caregivers exhibit strong concern toward the patient, but it does not necessarily mean that this helps in the treatment. The over-involvement causes the patient dependent on caregivers, and they feel that they cannot act independently. Hence, expressed emoting practice may worsen OCD. This kind of EE makes the patient to feel helpless and ambivalent because they do have control, as a result this may cause relapse. 
Emmelkamp et al.  stated that the problem will occur if caregivers view OCD symptoms as a disease over which patient has control. It appears that the caregivers high EE and the patient's relapse is causally interrelated. This could be because of the failure of the family system to take care of the patient and lack of knowledge about mental illness and coping skills, which predispose or precipitate in patient's dysfunction and causes relapse. Moreover, since the high EE is considered as an undesirable phenomenon, then this means the families are labeled as bad families. Most of these caregivers might feel the high degree of frustration and anger at home environment while handling the patient's symptoms. It has been proven in an acute anxiety provoking situation person may behave stereotypically. Such a typical unusual coping style in the natural home environment may correlate with OC symptoms. Moreover, our clinical observation states that caregiver express their irritation more directly on the patient. Emmelkamp et al.  reported that OCD patient relapse due to high EE. The anger and criticism of caregivers have shown less benefit in psychosocial interventions.  Yet another study was done by Renshaw et al.  reported that caregivers who demonstrated a high level of EE where received less benefit from behavior therapy. Moreover, high EE is directly associated with poor course of illness and outcome. ,,
Correlation between Family Interaction Pattern Scale and obsessive compulsive disorder
The present study found a positive correlation between OCD and family dysfunction in the domains of reinforcement, social support, role, communication, cohesion and leadership at 0.01 level of significance. The dimensions of family function, social support, role, communication, cohesion, reinforcement and leadership become dysfunctional in the presence of obsessive-compulsive symptomatology. OCD can have an adverse effect on the family function. May families become dysfunctional with the presence of an OCD patient and the involvement of the family in the symptoms. The possible reason could be the functional impairment in patients with OCD and long term adjustment with them OCD patient might influence the family function. Calvocoressi et al.  reported that one-third of caregivers reassured the patient 3 or more times per week, and the same ratio involved in compulsion related behavior or took over daily living activities that were the patients' responsibility. When patients do not assume responsibility, the other family members might take responsibility, consequences of which the caregivers may experience family dysfunction. Many caregivers modify family function to accommodate the patient. This is especially to manage the patients' distress. Moreover, caregivers reported 60-90% distress and family dysfunction.  The presence of OCD patient in the family may disturb household work. The family members are over-burdened and may become harsh in conversation or may avoid talking with each other without any apparent reason. Shafran et al.  studied the reactions of 98 family members in which 67% spouse or partners, 17% parents, 16% children, sibling or others, who were volunteers and scored high on OCD symptoms. 60% of these family members assisted in patients rituals like checking and giving reassurance. Only 10% of respondents did not feel any interference by the patient. 20% of the respondents reported greater interference. Families of OCD patients tend to have difficulties in accommodating few boundaries, poor limit setting and avoidance of conflict and problem. Cooper  reported 75% of caregivers experienced disruption in their lives because of the OCD patient, including loss of personal relationship, loss of leisure time and financial problem. They also develop rejecting attitudes towards the patient and family dysfunction or family stress may arise while trying to accommodate them. It was noticed that there is a direct causal relationship between OCD and family dysfunction.
The other reason may be that the caregivers may not communicate their responsibility clearly. This causes disengaged and resentment in communication. The caregivers may try to control obsessive-compulsive symptoms and correct the patients' behavior. This creates more confusion and distress in the family milieu. Such caregivers may use emotion-focused coping mode than problem solving focused mode earlier researches have explored the family functioning in OCD and reported that OCD induces stress on the patient and caregivers, along with guilt, blame, and social stigma. , A study on western sample  demonstrated that greater family dysfunction and modification of routine correlated with more severe OCD symptoms. Thus, more focus should be given to address these issues while conducting family intervention. Thus, it is important to include psychoeducation to family members in all psychiatric care centers, which may help to prevent relapse.
Another possible intervention is making home visits and providing social support. Family self-help groups in the community help the caregivers and the patients to discuss about the illness and may reduce relapses rates. It also indirectly enhances social support among the caregivers.
The present study showed that, there is a positive correlation between the family dysfunction, high EE and OCD. However, our study has certain limitations. The sample size was relatively small, and it was a hospital based short-term cross-sectional descriptive study. The study could have been community-based. The caregivers economic conditions, the personality of the respondents were not studied, which may influence the results. The other limitation may be the caregivers were not specified like all parents, spouses or relatives. It is necessary because different sorts of key caregivers define and maintain different kind of family dynamics. However, the study results enable mental healthcare professionals to have a better understanding about family functioning in OCD. None the less more studies on larger sample size may gain a stronghold.
Despite the relatively small sample size of the study, the study has important implication for management. Having an OCD patient the caregivers have a deleterious effect on family functioning. Like several other psychiatric illnesses, apart from the individual suffering from mental illness OCD leads to family problems. Thus, family-based interventions can reduce the distress of the caregivers, and may promote quality of life.
| Conclusion|| |
This study has tried to explore the relationship between the family function, EEs and OCD. The study results demonstrate a positive correlation between family dysfunction, high EE and OCD. Thus, psychosocial management programs must be aimed at alleviating family dysfunction and to bring healthy EE among the caregivers.
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[Table 1], [Table 2]