Family functioning in patients with obsessive compulsive disorder: A case - control study
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.157064
Background: Psychological disorders can have a direct impact on family functioning. Family dysfunction is an indirect factor leading to the relapse of psychological disorders. Literature on family dysfunction in anxiety disorder is limited. Role of family and its functioning in obsessive-compulsive disorder (OCD) may help in better understanding of the role of social factors in OCD. Aim: The aim was to compare family functions in patients with OCD and compare with controls. Materials and Methods: The sample included 30 cases and 30 age and sex-matched controls. The patients were diagnosed as having OCD using ICD-10 DCR criteria. Yale-Brown Obsessive Compulsive Scale was used to assess the severity of OCD among patients. General Health Questionnaire was used as screening instruments for psychiatric disorder among the control population. Family function was assessed in cases and control using the Family Interaction Patterns Schedule (FIPS). Statistical analysis was performed using SPSS software. Results: Obsessive compulsive disorder patients in comparison controls had significantly increased total FIPS score (P = 0.001). Conclusion: Families with OCD are more significantly impaired in multiple domains of family dynamics than families without member suffering from OCD. It is, therefore, essential that family-based structure effective assessment be sought in the psychosocial management of OCD. Keywords: Anxiety disorder, family function, obsessive compulsive disorder
Obsessive compulsive disorder (OCD) is a common kind of anxiety disorder with different clinical manifestations, course and outcome. The lifetime prevalence of OCD is 1-3% Lennertz et al. [1] Psychosocial studies on OCD have found an increased risk of family dysfunction with family members experiencing the blame, social stigma and guilt Shafran et al., [2] Tynes et al. [3] Family dynamics like pathological ways of parenting, frequent family hassles and poor family outlines have been contributing factors in the etiology of OCD and may have impact on the clinical course of the illness Alonso et al., [4] Piacentini et al. [5] Few clinical studies have found pathological stress and a higher incidence of psychological disorders in the families of OCD Ramos-Cerqueira et al. [6] Few studies have provided compelling evidence that families are also pathologically involved with OCD patient Hibbs et al. [7] Shafran et al. [2] found that around 67% of spouses, 17% of parents and 16% of children, sibling or others are involved themselves into patient OCD symptoms. Families of patients with OCD are often noted to be having few boundaries, poor limit setting and quite often, they avoid conflict in order to maintain peace in the family. This in turn increases the stress on the family as well as on the patient. A study by Van Noppen et al. [8] found that OCD may worsen family functioning. There is little knowledge with respect to:
To address these issues current study was designed to compare the family functioning in patients with OCD and normal control.
The study sample included key caregivers of 30 patients with OCD and 30 age and sex-matched normal individual in control group between the age of 18-60 years who gave informed consent were taken up for the study. Purposive sampling method was used in this study. The samples were collected from psychiatry outpatient department. The patients had to fulfil the criteria for OCD as per the ICD-10 DCR criteria. The control group was assessed for psychiatric disorders using General Health Questionnaire and individual with any psychiatric disorder were excluded. A semi-structured proforma was prepared for this study, which included registration number, age, sex, education, marital status, domicile, mother tongue, type of family, occupation and family income. Each patient was assessed for severity of OCD with Yale-Brown Obsessive Compulsive Scale. Goodman et al. [9] To measure the quality of family functioning each key caregiver of OCD patient was administered Family Interaction Pattern Scale (FIPS) Bhatti et al. [10] and the same was administered to normal control key caregivers cohort. The scale has 106 items under 6 domains, reinforcement, social support, role, communication, cohesion and leadership. It measures against 4-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. [10] The FIPS has six subscales. Leadership A family takes a decision through consensus for the growth of the family system. Communication It is a process through which the family system communicates their feelings, emotions and personal views. Roles Socio-culturally approved tasks to be performed by family system, according to their age and sex. Reinforcement Process adopted by the family system to enable the members to design desirable behavior. Cohesiveness Process adopted by the family system for mutual trust and interpersonal reciprocal relationship. Social support Social support system is a process to generate and maintains an internal and external social milieu for existence and growth of the family system. These six subscales exhibit family dynamics. Statistical analysis was carried out using SPSS version 13 software. T-test was used to assess the difference between two groups and P < 0.05 was considered as statistically significant.
Sociodemographic details and descriptive profile of OCD cohort were published in other article (Indian Journal of Psychological Medicine 2014; 36 pp 138-41). The details of the family functioning among groups are described in [Table 1]. Family functioning was assessed in both the groups using FIPS. The mean score of reinforcement in patient with OCD was 24.63 ± 4.84 and in the control group was 16.90 ± 1.18 with P = 0.001. The mean score of social support in patient with OCD was 26.36 ± 6.85 and control cohort had 16.56 ± 1.30 with P < 0.001. The mean score of role in patient with OCD was 63.73 ± 13.07 and control cohort had 41.83 ± 2.27 with P = 0.001. The mean score of communication in patient with OCD was 65.50 ± 12.13 and control group had 45.33 ± 1.86 with P < 0.001. The mean scores of cohesion in patient with OCD 39.00 ± 7.95 and control group had 22.50 ± 1.33 with P < 0.001. The mean score of leadership in patient with OCD was 43.43 ± 8.07 and control cohort had 29.33 ± 1.09 with P < 0.001. The overall mean FIPS scores were 263.43 ± 43.06 and 172.60 ± 5.69 for OCD cohort and control cohort respectively with P < 0.001.
This was a case - control study to find out the level of family functioning among OCD patient in comparison to normal controls. Our results show that the families of patients with OCD group experience considerable family dysfunction in the areas of reinforcement, social support, role, communication, cohesion and leadership. The FIPS was used to assess family functioning in both cohorts. Mean scores of reinforcement, social support, role, communication, cohesion, leadership and total FIPS were significantly more inpatient with OCD (P = 0.001 for all seven areas). Study indicates family dynamics seems to have significant family pathology. One possible reason for the differences in the area of reinforcement could be parents of OCD group may induce more discipline measures and subsequently produces excessive positive reinforcement for a behavior by assuming that they may have better control over symptoms. A study by Steketee and Pruyn, [11] provides compelling evidence that 30-40% of parents of OCD patients would be having subclinical obsessive and compulsive symptoms and obsessive-compulsive personality traits. These traits and symptoms may reinforce the patient's symptoms in OCD. Due to waxing and waning course of the illness, OCD group may restrict themselves with respect to manipulation of internal and external social milieu. Even formal and informal relationship may be hampered which may cause poor social support. An epidemiological study done by a Cassel, [12] indicated that the social support has a significant effect on health and wellbeing of the OCD patients. Social support is perceived at three levels, primary, secondary, and tertiary. The primary social support covers mainly family, key caregivers; secondary social support includes friends, neighbors and relatives, and third domain covers voluntary and government agencies or religious organizations. Jikun and Xudong [13] conducted a similar study involving caregivers of patients with OCD and control families. The findings suggested that OCD had substantial impairment in perceived social support. The prime thing that evolved from this research was that the unhealthy range of family and dysfunctional family exist in the patient with OCD, and it has a definite impact on the caregivers and can be extensive. Ramos-Cerqueira et al. in 2002 6] did a study that specifically looked at the association between social support and psychological disorder in the families of patients with OCD. Their study found that poor social support was higher among relatives of OCD. They concluded that there were significant relationships between psychological disorder among caregivers and poor social support. Further studies are needed in this area to find out which aspect of social support lacks in OCD group that will be helpful in the psychosocial management of such patients. It is apparent from the present study that the role performance problem may exist in OCD group that may be in the form of either performing appropriate role or role allocation. This could be because the presence of obsessive and compulsive symptoms leads to distress, tension and worry in the family. Moreover, the family members of OCD patient are frequently involved in patient's obsessive and compulsive behavior. Thus, it is plausible that caregivers may experience feelings of anger and frustration, family role conflicts and disrupt social life. On the other hand, families may completely resist or oppose for performing patient's compulsive behavior. Hence, this has a definite impact on role performance, warmth and probably leads to disorganization within the family. The findings of our study are in lines with the findings of earlier studies by Van Noppen et al. [14] and Mehta [15] where they found that poor role performance predicted worse outcome and impact on family role. Looking at our sample, we found that the communication pattern in OCD families significantly differed from normal controls. The possible reasons could be repetitive behavior which may arrest assisting memory, inability in decision making, and altering environmental cues are associated with cognitive dysfunction. Indeed, due to these reasons OCD families may not be accessible to open communication. They may also lack nonverbal communication, which results in psychological reactions like feeling of loss, sadness and anxiety which suggests critical or restricted communication. The findings of this study are similar to the findings by Van Noppen et al. [8] where they asserted communication dysfunction in families with OCD patients. The study demonstrated that cohesion was diffused in OCD group. The symptoms may be severe and disrupt the degree of intimacy in relationships. Thus, the patient may be held responsible for the family pathology. Another possible explanation may be that despite the OCD psychopathology, some families are enmeshed in vain behavior of patients. This shows unhealthy cohesion. Many families may become affectionless and may reject the patient. The findings of our study are in lines with the findings of previous studies by Riggs et al. [16] and Van Noppen et al. [17] The last principal area of leadership was differed in both study groups. The reason for this finding could be that the OCD symptoms may diffuse the structure of decision-making process. As the disease progresses, parents decline the self-reliance, self-control and decision capacity of the patient. These suggest conflict decision among family members. Obsessive compulsive disorder may have a profound effect on the family and impair family functioning in several areas of family dynamics. Families of patients with OCD reports significant impairment in family dynamics and distress in family relationship. This is seen both in adults and children with OCD, which accounts 60-90% of family distress. [18] Yet another study by Geffken et al. [19] reported that the positive hope of the family on OCD treatment may help in active problem solving process and strengthen family social support, but negative coping strategies may induce denial and disengagement coping mechanism which results family dysfunction. A study by Amir et al. [20] reported that it is essential for the family to understand accommodating behavior of patients with OCD. If it is misunderstood, the family may develop a sense of guilt frustration and disappointment. A study by Derisley et al. [21] demonstrated family dysfunction in caregivers of OCD patients in Chinese population. The study demonstrated that the OCD group had significantly higher impairment in family functioning than the control group. The family members of OCD group experienced family dysfunction in the dimensions of reinforcement, social support, role, communication, cohesion and leadership with regard to caring of OCD person. They experienced severe psychological stress with regard to caring of the ill person, which may precipitate family dysfunction. They also experienced considerable guilt about not enough having been done for the ill and the feeling that they were the cause or contributed for the patient illness suggesting that the presence of OCD patient in the family increased the risk of family dysfunction. The mean global FIPS score in OCD group was significantly higher compared to normal cohort. It may be hypothesized that poor coping skills and lack of knowledge about illness leads family dysfunction. So, educating the family about illness, providing problem-solving skills and restoring social support will help the family to cope-up more effectively. Thus, family dynamics may restore in a healthy way that futile the prognosis. The study showed that family assessment of each OCD patient in all the phases is necessary. However, the study has certain limitations. This is a study on small sample size and is a short-term cross-sectional descriptive study where the quality of family functioning in OCD patient was assessed. Other caveats are caregivers were not specified like all of them parents, spouses or relatives. It is necessary because different sorts of key caregivers define and maintain a different kind of the family dynamic. However yield results similar to studies in the past. More studies on larger sample size may gain a stronghold.
The present study has showed that patient with OCD experienced considerable degree of family dysfunction. This has important implication for management of patient with OCD. For mental health professionals dealing with OCD, an awareness of the nature of the problem faced by the patient and family will help them in dealing more effectively with the patient and his family.
[Table 1]
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