Family accommodation in obsessive–compulsive disorder: Relation to symptom dimensions, clinical and family characteristics

Psychiatry Research 179 (2010) 204–211

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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Family accommodation in obsessive–compulsive disorder: Relation to symptom dimensions, clinical and family characteristics Umberto Albert a,⁎, Filippo Bogetto a, Giuseppe Maina a, Paola Saracco a, Cinthia Brunatto a, David Mataix-Cols b a b

Mood and Anxiety Disorders Unit, Department of Neurosciences, University of Turin, Italy King's College London, Institute of Psychiatry, London, UK

a r t i c l e

i n f o

Article history: Received 31 October 2008 Received in revised form 11 May 2009 Accepted 15 June 2009 Keywords: Obsessive–compulsive disorder Family members Accommodation Predictors Symptom dimensions

a b s t r a c t Family accommodation is the term used to indicate the process whereby family members of patients with obsessive–compulsive disorder (OCD) assist or participate in the patients' rituals. Family accommodation is a relatively under-researched phenomenon in OCD but an important one because it may be predictive of poor treatment outcome. This study systematically examined several socio-demographic and clinical variables that are associated with family accommodation in a well-characterized sample of adult patients and their healthy family members. Experienced clinicians administered the Family Accommodation Scale (FAS) to 141 psychopathology-free family members cohabiting with 97 patients with OCD. The items of the FAS were first subjected to principal component analysis (PCA) and the resulting domains of family accommodation (Participation, Modification, and Distress and Consequences) introduced as dependent variables in a series of multiple regression models assessing the relationship between family accommodation domains and a wide range of clinical variables, including Axis I and II psychopathology and symptom dimensions derived from the Yale–Brown Obsessive–Compulsive Scale (YBOCS) Symptom Checklist. The results showed that family accommodation was common, with the provision of reassurance, participation in rituals and assisting the patient in avoidance being the most frequent practices (occurring on a daily basis in 47%, 35%, and 43% of family members, respectively). The PCA of the YBOCS Symptom Checklist yielded four symptom dimensions, which were identical to those previously identified in the international literature. Multiple linear regression analyses showed that a higher score on the contamination/washing symptom dimension and a positive family history for an anxiety disorder other than OCD (referring to a family member other than the participant in this study) predicted greater scores on several domains of family accommodation. Our study confirms that family accommodation is frequent and distressing in psychopathology-free family members cohabiting with adult OCD patients. Family accommodation is particularly frequent and distressing when the patient has prominent contamination/washing symptoms and/or when another family member has a history of an anxiety disorder. Such families may be more likely to benefit from family-based interventions but this remains to be tested in controlled trials. © 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Families of patients with obsessive–compulsive disorder (OCD) are often more involved in the patients' symptoms than families of other psychiatric patients because obsessions and compulsions often take place at home (Cooper, 1996; Renshaw et al., 2005) and this results in a greater impairment in quality of life (Maina et al., 2006; StenglerWenzke et al., 2006; Albert et al., 2007). Accommodation is the term used to indicate the process whereby family members assist or

⁎ Corresponding author. Mood and Anxiety Disorders Unit, Department of Neurosciences, University of Turin, Via Cherasco 11 – 10126 Torino, Italy. Tel.: +39 011 6335425; fax: +39 011 673473. E-mail address: [email protected] (U. Albert). 0165-1781/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2009.06.008

participate in the patient's rituals. It includes behaviors such as feeling obliged to assist a relative with OCD when he/she is performing a ritual or respecting the rigid rules that OCD imposes on the patient (Cooper, 1996). Because family accommodation has been found to be associated with a poorer treatment outcome both in adults (Chambless and Steketee, 1999; Ferrão et al., 2006) and in children or adolescents (Storch et al., 2008) with OCD, reducing family accommodation could represent an important clinical target in itself. It is possible that interventions aimed at reducing family accommodation may result in a significant improvement of obsessive–compulsive symptoms. Such interventions have been proposed as part of broader cognitivebehavioral treatments (Franklin et al., 1998; Piacentini, 1999; Waters et al., 2001; Barrett et al., 2004a,b; Martin and Thienemann, 2005;

U. Albert et al. / Psychiatry Research 179 (2010) 204–211

Freeman et al., 2007) or as the focus of psychoeducational programs, the efficacy of which is currently under study (Cuijpers, 1999; Renshaw et al., 2005; Albert et al., 2006; Maina et al., 2006). Different methods have been employed to assess accommodating behaviors in relatives of OCD patients. For example, Shafran et al. (1995) administered a self-administered questionnaire to 88 family members of individuals with obsessive–compulsive symptoms and found that 60% of the family members were involved to some extent in rituals performed by the patient. Another group developed a clinicianadministered instrument, the Family Accommodation Scale (FAS) which assesses the nature and frequency of accommodating behaviors of family members of persons with OCD (Calvocoressi et al., 1995; Calvocoressi et al., 1999). The FAS is a reliable and valid instrument and the most widely used to assess family accommodation in OCD (Calvocoressi et al., 1999). Because family accommodation is currently conceptualized as a unitary construct, researchers often calculate the total score of the FAS (e.g., Storch et al., 2007; Stewart et al., 2008). However, family accommodation may be a multifactorial phenomenon and different variables may be associated with different domains of family accommodation. Indeed, family members of OCD patients might be involved in the patients' symptoms in a variety of ways. For example, they can provide reassurance, directly participate in the rituals, or assist the patient in performing the rituals, and they often modify their personal routine (work schedule, leisure activities, and family relations) to fit around the patients' symptoms (e.g., not inviting people at home due to the patient's contamination fears). Furthermore, family members may be afraid of the patient displaying anger and abusive behavior if they do not accommodate. The latter may be a substantial source of distress for the families. While some researchers have grouped items of the FAS to form different domains of accommodation (Peris et al., 2008), to our knowledge, no studies have empirically explored the factor structure of this scale. To date, only six studies have examined the degree of family accommodation in OCD using the FAS, two in children (Storch et al., 2007; Peris et al., 2008) and four in adult samples (Calvocoressi et al., 1995, 1999; Ramos-Cerqueira et al., 2008; Stewart et al., 2008). All of these studies reported high family accommodation but only one (Ramos-Cerqueira et al., 2008) excluded family members with psychiatric disorders. The latter is important because there is some evidence to suggest that psychopathology in the relatives correlates with the degree of family accommodation (Peris et al., 2008). It is therefore important that family accommodation studies exclude psychopathology in the family members in order to examine the true impact of OCD on otherwise healthy families. We predict high levels of accommodation in psychopathology-free family members. Furthermore, only four of the available studies specifically examined the clinical correlates of family accommodation (Storch et al., 2007; Peris et al., 2008; Stewart et al., 2008; Ramos-Cerqueira et al., 2008). This is potentially important because it can help clinicians to identify families that may require additional familybased interventions. The two pediatric studies (Storch et al., 2007; Peris et al., 2008) found that parental psychopathology (as measured with the Global Severity Index on the Brief Symptom Inventory), parental OCD (YBOCS ≥ 16) and child OCD severity (CYBOCS) were associated with higher parental involvement in rituals (FAS Total Involvement score). Ramos-Cerqueira et al. (2008) found that family accommodation and emotional burden were associated with one another and with the severity of patient obsessive–compulsive symptoms. In an adult OCD study (Stewart et al., 2008), the only predictors of higher family accommodation were severity of the patient's OCD (YBOCS score) and a higher score on the contamination/ cleaning symptom dimension. Regarding the latter finding, the authors suggested that the families of patients with such symptoms may require additional therapeutic input to help them gradually reduce their involvement in the patients' rituals. These interesting

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findings require replication in large samples of patients and their relatives. The aim of the present exploratory study was therefore three-fold: 1) to assess the extent of family accommodation in a large sample of healthy family members of adults with OCD, 2) to examine the factor structure of the FAS, and 3) to examine the independent contribution of a wide range of variables, including Axis I and II comorbidity and symptom dimension scores, to various domains of family accommodation. 2. Methods 2.1. Participants 2.1.1. OCD patients We enrolled all consecutive patients (n = 97) with a principal diagnosis of OCD and with a YBOCS total score ≥16, who were referred to the Mood and Anxiety Disorders Unit of the University of Turin, Italy between 2004 and 2007. This is a tertiary referral center located within the University Hospital, and is specialized in the treatment of patients with OCD. The research protocol was reviewed and approved by the local Ethical Committee. All patients gave their informed consent prior to enrollment in the study. 2.1.2. Family members For each patient, we selected one or more family members on the basis of the following criteria: a) above 18 years of age; b) living with the patient for at least 2 years; c) absence of any history of mental disorder; d) not being involved in the care of any other family member suffering from severe physical or mental illness; and e) informed consent to participate. The family members were interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) Axis I Disorders, Non Patient version (SCID-NP) (First et al., 2001) in order to exclude the presence of any current or lifetime mental disorders. Of the potentially suitable family members, 21 (12.9%) met criteria for one or more psychiatric disorders and were therefore excluded from the study. This yielded a final sample of 141 healthy family members. 2.2. Measures 2.2.1. OCD patients A systematic face-to-face interview that consisted of structured and semistructured components was used to collect data from patients. Diagnostic evaluation and Axis I comorbidities were recorded by means of the Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID-I; First et al., 1996). Personality disorders were ascertained with the Structured Clinical Interview for DSM-IV Axis II Disorders (SCIDII; First et al., 1997). All socio-demographic and illness characteristics were obtained through the administration of a semistructured interview, developed and used in previous studies (Bogetto et al., 1999; Albert et al., 2002; Albert et al., 2004; Maina et al., 2004), with a format that covered the following areas: (a) Socio-demographic data: age, sex, marital status (single, married, divorced, widowed), and years of education. (b) Onset of OCD: illness onset was dated within a 1-month period as the first occurrence of obsessive and compulsive symptoms, and when at least one of them caused marked distress, was time consuming (more than 1 h a day) or interfered with the person's normal daily functioning (normal routine, occupational and social activities). (c) Obsessive–compulsive symptoms: OCD symptoms were measured with the YBOCS (Goodman et al., 1989a,b); first, we elicited the presence of specific types of current and past obsessions and compulsions using the Symptom Checklist, and then we rated the severity of OCD symptoms with the Severity Scale. In addition, the following rating scales were included in the assessment of OCD patients: Hamilton Rating Scale for Anxiety (HAM-A) (Hamilton, 1959) and 17-item Hamilton Rating Scale for Depression (HAM-D) (Hamilton, 1960). For both rating scales, the total score is derived from summation of the items. The interview and all the ratings were completed by psychiatrists with at least 4 years of experience in anxiety and mood disorders. High reliability and diagnostic concordance have been documented in previous reports (Albert et al., 2004; Maina et al., 2005). 2.2.2. Family members Family accommodation was measured using the FAS (Calvocoressi et al., 1995), a 13-item clinician-rated measure that assesses the degree to which family members of subjects with OCD have accommodated patient rituals over the preceding month. It measures both the behavioral involvement of family members in OCD (e.g., participation in rituals and modification of daily routines due to OCD) and the level of family distress and disruption associated with this involvement. The sum of all 13 items yields a total FAS score, with higher scores indicating greater family participation,

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U. Albert et al. / Psychiatry Research 179 (2010) 204–211

Table 1 Socio-demographic and clinical characteristics of subjects included.

Patients (N = 97) Age: mean ± S.D. Educational level: mean ± S.D. Married: n (%) Gender: n (%) Male Female Age at onset: mean ± S.D. OCD OC symptoms Type of onset: n (%) Abrupt Insidious YBOCS: mean ± S.D. Total score Obsession subscore Compulsion subscore HAM-D: mean ± S.D. HAM-A: mean ± S.D. Current Axis I comorbidity: n (%) At least one disorder At least one anxiety disorder At least one mood disorder Lifetime Axis I comorbidity: n (%) At least one disorder At least one anxiety disorder At least one mood disorder Axis II comorbidity: n (%) Positive family history: n (%) OCD Other anxiety disorders Mood disorders Family members (n = 141) Age, mean ± S.D. Gender: n (%) Male Female Kinship: n (%) Parents Spouses Offspring Siblings

Mean/N

S.D./%

35.6 11.9 46

12.3 3.2 47.4

49 48

50.5 49.5

22.9 16.9

10.4 9.2

32 65

33.0 67.0

25.5 12.9 12.6 9.8 12.0

5.6 3.1 3.2 5.6 7.1

were eigenvalues N 1 and interpretability of the factors. The internal consistency of the derived factors and total scale was then examined (Cronbach's alpha). To derive symptom dimension scores, we performed PCAs on seven of the eight obsession categories and six of the seven compulsion categories using the method used in previous studies (Baer, 1994; Leckman et al., 1997; Mataix-Cols et al., 2005). To achieve sufficient power, this PCA was performed on a larger sample of 329 OCD patients, which included the 97 participants in the current study. As it is common practice in this field, the miscellaneous obsessions and compulsions categories were excluded from the analysis because they contain a wide range or heterogeneous and relatively infrequent symptoms. Symptoms present at time of assessment, in the past or both (lifetime symptoms) were coded as 1, and symptoms that were never present were coded as 0. The number of lifetime symptoms endorsed under each symptom category was summed to form a score for each of the 13 major symptom categories. Initial factors were extracted using PCA, followed by an orthogonal (Varimax) rotation. Criteria for retaining the factors were eigenvalues N 1 and interpretability of the factors. We next examined the association between the various domains of family accommodation and socio-demographic and clinical variables hypothesized to predict higher accommodation in relatives of OCD patients using bivariate correlation analyses and independent samples t-tests. Non-parametric tests were used instead when the assumptions of normality and/or homogeneity of variances were not met. Given the dearth of research into the clinical variables associated with family accommodation in OCD, we considered our study to be exploratory and decided not to adjust our significance thresholds for multiple testing. Finally, the variables found to be significant at the conventional alpha level of 0.05 in the above analyses were then entered as regressors into separate stepwise multiple linear regression models with the various accommodation domains as the dependent variables (P to enter = 0.05; P to leave = 0.10). Participants with more than three missing variables were excluded from the analyses; for the remaining missing data, the sample size was allowed to fluctuate in order to maximize the power for each analysis.

57 16 45

58.8 16.5 46.4

72 27 57 47

74.2 27.8 58.8 48.5

24 18 30

24.7 18.6 30.9

3.1. Sample characteristics

50.6

13.2

61 80

43.3 56.7

The socio-demographic and clinical characteristics of the 97 patients included in the study are provided in Table 1. These are comparable to other clinical samples of referred OCD patients. Table 1 also shows the socio-demographic characteristics of the 141 family

80 48 5 8

56.7 34.0 3.5 5.7

3. Results

Table 2 Principal component analysis of the 13 items of the Family Accommodation Scale (N = 141). Factor loading FAS items

greater modification of functioning, greater personal distress and greater perceived consequences of not participating in the patients' symptoms. The FAS has demonstrated good reliability (internal consistency: α = 0.76–0.80) and validity (Calvocoressi et al., 1995). Health-related quality of life in the family members was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) (Stewart et al., 1988; Ware and Sherbourne, 1992; Ware et al., 1993). The SF-36 contains eight scales for assessing limitations in physical activities (including bathing or dressing) because of health problems (physical functioning), limitations in usual role activities (work or other daily activities) because of physical health problems (role limitations due to physical health), bodily pain, general health perceptions (general health), energy and fatigue (vitality), limitations in social activities because of physical or emotional problems (social functioning), limitations in usual role activities (work or other daily activities) because of emotional problems (role limitations due to emotional problems), and general mental health (psychological distress and well-being) (mental health). Scores are given on a range from 0 (worst possible health) to 100 (best health) for each scale. These eight scales have been observed to define distinct physical and mental health clusters in factor analytic studies of both general and patient populations in the United States. The physical and mental health components accounted for more than 80% of the reliable variance in SF-36 scale scores and are expressed as t scores (mean ± S.D. = 50 ± 10). The SF-36 has been validated for its use in Italy and Italian norms are available for it (Apolone et al., 1997).

2.3. Data analysis As accommodation is a multidimensional construct, a principal component analysis (PCA), followed by an orthogonal (Varimax) rotation, was performed on the 13 items of the FAS in order to derive the dimensional structure of the scale and confirm the subscales used in previous studies (Peris et al., 2008). Criteria for retaining the factors

Factor 1

Factor 2

Modification Distress and Consequences Item 1 — Frequency of patient 0.08 reassurance Item 2 — Frequency of providing items 0.32 for patient's compulsive behaviors Item 3 — Frequency of participating − 0.01 in patient's compulsive behaviors Item 4 — Frequency of assisting the 0.13 patient in avoidance Item 5 — Modifying personal routine 0.59 due to patient's symptoms Item 6 — Modifying family routine due 0.56 to patient's symptoms Item 7 — Assuming responsibilities that 0.74 are normally the patient's responsibility Item 8 — Modifying work schedule due 0.67 to patient's symptoms Item 9 — Modifying leisure activities due 0.76 to patient's symptoms Item 10 — Does helping the patient lead 0.27 to distress? Item 11 — Has patient become distressed 0.15 when you did not accommodate? Item 12 — Has patient become angry/ 0.15 abusive when did not accommodate? Item 13 — Has ritual time increased when 0.07 you did not participate? % explained variance 19.04

Factor 3 Participation

0.10

0.73

0.07

0.40

0.21

0.73

0.13

0.78

0.08

0.39

0.43

0.26

0.11

0.19

0.11

− 0.14

0.27

0.10

0.65

0.04

0.73

0.29

0.85

− 0.01

0.64

0.35

18.77

17.94

U. Albert et al. / Psychiatry Research 179 (2010) 204–211 Table 3 Principal component analysis of the 13 major symptom categories of the Yale–Brown Obsessive–Compulsive Scale Symptom Checklist (YBOCS-SC) in 329 patients with OCD. Factor loading YBOCS-SC symptom category

Factor 1

Factor 2

Factor 3

Factor 4

Symmetry/ Repeating, Ordering, Counting, Checking

Aggressive, Religious, Sexual, Somatic

Contamination/ Cleaning

Hoarding

Symmetry obsessions Repeating rituals Ordering compulsions Counting compulsions Checking compulsions Aggressive obsessions Religious obsessions Sexual obsessions Somatic obsessions Contamination obsessions Cleaning compulsions Hoarding obsessions Hoarding compulsions % explained variance

0.77 0.67 0.63 0.55 0.41 0.08 0.04 − 0.09 0.22 − 0.05 0.13 0.13 0.06 15.46

− 0.17 0.24 − 0.23 0.30 0.38 0.74 0.67 0.59 0.39 0.11 − 0.02 0.07 0.12 14.61

0.14 − 0.13 0.26 − 0.08 0.15 0.03 0.05 − 0.09 0.29 0.92 0.86 0.03 0.05 14.07

0.11 − 0.03 0.14 0.11 − 0.11 0.01 0.09 0.24 − 0.13 0.04 0.06 0.90 0.90 13.60

members included: 43% of them were male, 56% were parents, 34% spouses, and only a minority were offspring (3.5%) or siblings (5.7%). 3.2. Factor structure and reliability of the FAS The PCA performed on the sample of 141 relatives yielded a threefactor solution which accounted for 55.74% of the total variance in the FAS data (Table 2). The first factor, which accounted for 19% of the variance, included items 5–9 (Modification subscale). The second factor, which explained 19% of the variance, included items 10–13 (Distress and Consequences subscale). The third factor included items 1–4 and explained 18% of the variance (Participation subscale). Internal consistency coefficients (Cronbach's α) were as follows: Participation, α = 0.67; Modification, α = 0.76; Distress & Consequences, α= 0.75; 13-item total score, α = 0.83. 3.3. Factor structure of the YBOCS Symptom Checklist The PCA performed on a wider sample of 329 patients (51.4% men, mean age 34.7 ± 11.6, mean YBOCS total score 24.9 ± 6.4) yielded a

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four-factor solution which accounted for 58% of the total variance in the YBOCS-SC data (Table 3). Symmetry obsessions plus repeating, ordering/arranging, counting, and checking compulsions loaded highly on the first factor, accounting for 15% of the variance. The second factor included aggressive, religious, sexual, and somatic obsessions, explaining 15% of the variance. Contamination obsessions and cleaning compulsions loaded highly on the third factor, accounting for 14% of the variance. The fourth factor included hoarding obsessions and compulsions, explaining another 14% of the variance. Reanalysis using an oblique rotation method (Promax) yielded the same four-factor solution. 3.4. Family accommodation The frequency of family accommodating behaviors is reported in Table 4. Forty-seven percent of the family members provided reassurance to their affected relative every day, 43% assisted the patient in avoiding things that might make him/her more anxious every day and 35% directly participated in rituals on a daily basis. These practices were associated with a significant distress, with 65% reporting at least moderate levels of distress. 3.5. Bivariate associations between family accommodation and characteristics of the OCD patients Regarding socio-demographic variables, age, gender, and marital status of the patient were not associated with family accommodation. Relatives of more educated patients reported a greater degree of modification of their personal and family routines, work schedule, and leisure activities. Concerning clinical variables, type of onset was related to the FAS 13-item total score: family members of patients with an abrupt onset showed greater accommodation scores than those of subjects with an insidious onset (FAS 13-item total score: 25.37 ± 10.13 vs. 21.76 ± 9.12; Mann–Whitney U test: U = 1677.5, Z = − 2.234, P = 0.026). Higher scores on the YBOCS (total, obsessions, and compulsions subscores) were associated with higher scores on several of the accommodation descriptors (specifically, higher total scores were associated with higher scores on the FAS Modification, Distress and Consequences and Total scores; higher obsession scores with the FAS Modification and Total scores; higher compulsion scores with the FAS Distress and Consequences scores). Age at onset of symptoms or disorder, course of the disorder, HAM-A and HAM-D scores were not associated with family accommodation. Scores on the contamination/

Table 4 Responses to the Family Accommodation Scale (FAS) of the 141 family members. FAS item

Mean (S.D.)

Range

13-item total score Participation Frequency of patient reassurance Frequency of providing items for patient's compulsive behaviors Frequency of participating in patient's compulsive behaviors Frequency of assisting the patient in avoidance Modification Modifying personal routine due to patient's symptoms Modifying family routine due to patient's symptoms Assuming responsibilities that are normally the patient's responsibility Modifying work schedule due to patient's symptoms Modifying leisure activities due to patient's symptoms

22.94 (9.58) 8.68 (4.04) 2.91 (1.31) 0.86 (1.35) 2.21 (1.64) 2.71 (1.38) 7.53 (4.44) 1.59 (1.51) 1.91 (1.28) 1.61 (1.20) 0.80 (0.97) 1.62 (1.20)

1–48 0–16 0–4 0–4 0–4 0–4 0–20 0–4 0–4 0–4 0–4 0–4

Mean (S.D.) Distress and Consequences Does helping the patient lead to distress? Has patient become distressed when you did not accommodate? Has patient become angry/abusive when you did not accommodate? Has ritual time increased when you did not participate?

6.72 (3.59) 2.04 (1.11) 1.85 (1.13) 1.35 (1.26) 1.48 (1.23)

Never, %

1–3×/month %

1–2×/week, %

3–6/week, %

Daily, %

8.5 61.7 25.5 10.6

8.5 15.6 13.5 9.2

14.2 9.2 11.3 21.3

21.3 2.1 14.2 16.3

47.5 11.3 35.5 42.6

31.9 14.9 19.9 48.2 20.6

26.2 26.2 31.9 31.2 29.1

12.8 27.0 22.7 14.9 24.1

9.2 17.0 18.4 3.5 19.9

19.9 14.9 7.1 2.1 6.4

Range

Not at all, %

Mild, %

Moderate, %

Severe, %

Extreme, %

0–16 0–4 0–4 0–4 0–4

7.8 10.6 30.5 25.5

27.0 31.2 34.0 30.5

27.7 29.8 12.8 21.3

28.4 19.1 15.6 15.6

9.2 9.2 7.1 7.1

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U. Albert et al. / Psychiatry Research 179 (2010) 204–211

Table 5 Correlations among family accommodation and continuous variables: only statistical significant results are shown (Spearman's rho and P-value).

3.6. Bivariate associations between family accommodation and characteristics of the family members

Family members (n = 141)

Age, gender, and kinship of family members were not associated with family accommodation. However, as seen in Table 5, family accommodation scores (except for Participation) were inversely correlated with the two summary components of the SF-36. That is, the greater the score on the FAS, the poorer the perceived quality of life of the family member is.

Education (patient) YBOCS total score YBOCS obsessions YBOCS compulsions Factor 3 score (contamination/cleaning) SF-36 Physical Summary Component SF-36 Mental Summary Component

FAS Modification 0.182 (0.031) 0.200 (0.017) 0.253 (0.002)

FAS Distress and Consequences

FAS 13-item total score

–

– 0.181 (0.032)

0.177 (0.036) 0.209 (0.013)

–

–

–

0.201 (0.017)

0.188 (0.026) 0.211 (0.012)

− 0.169 (0.045)

− 0.217 (0.010)

− 0.204 (0.015)

− 0.423 (b0.001)

− 0.415 (b0.001)

− 0.401 (b0.001)

0.183 (0.030)

No correlations were found with the FAS Participation score.

washing (factor 3), but not the other symptom dimensions, were positively correlated with scores on the FAS Modification and Distress and Consequences subscales and with the 13-item total score (Table 5). The association between current or lifetime Axis I comorbid disorders and family accommodation is shown in Table 6. Moreover, we examined the association between a current or lifetime anxiety disorder (other than OCD) and mood disorder; we found that only a current mood disorder correlated with family accommodation (see Table 6). The presence of Axis II comorbidity was not associated with increased family accommodation. Finally, we found positive correlations between a positive family history for anxiety disorders other than OCD (at least one family member, other than the one being assessed with the FAS, has a current or lifetime anxiety disorder) and all the FAS domains: FAS Participation, 10.33 ± 3.45 vs. 8.29 ± 4.09 Mann–Whitney U test, P = 0.022; FAS Modification, 10.67 ± 2.86 vs. 6.79 ± 4.44 Mann–Whitney U test, P b 0.001; FAS Distress and Consequences, 8.93 ± 4.01 vs. 6.20 ± 3.29 Mann–Whitney U test, P = 0.002; FAS 13-item total score, 29.93 ± 7.21 vs. 21.28 ± 9.34 Mann–Whitney U test, P b 0.001. Neither a positive family history for OCD nor for mood disorders correlated with accommodation scores.

3.7. Multiple regression models We next performed a series of stepwise multiple linear regression analyses with each of the FAS subscales as dependent variables and the variables found to be significantly correlated with accommodation in the bivariate analyses as independent variables. Thus, the following independent variables were entered in the models. For the FAS Modification subscale: patients' years of education, YBOCS total score and obsessions subscore, YBOCS factor 3 (contamination obsessions/cleaning compulsions) scores, current and lifetime Axis I comorbidity, current mood disorder comorbidity, and family history of another anxiety disorder; for the FAS Distress and Consequences subscale: YBOCS total score, compulsions subscore, YBOCS factor 3 (contamination obsessions/cleaning compulsions) scores, current Axis I comorbidity, and family history of another anxiety disorder; for the FAS Participation subscale: family history of another anxiety disorder; and for FAS 13-item total score: type of onset, YBOCS total score, obsessions subscore, YBOCS factor 3 (contamination obsessions/cleaning compulsions) scores, current Axis I comorbidity, current mood disorder comorbidity, and family history of another anxiety disorder. The four final models are shown in Table 7. A positive family history for an anxiety disorder other than OCD (referring to a family member other than the participant to the study) was associated with greater scores on all the accommodation domains. Similarly, the presence of contamination/washing symptoms was independently associated with higher scores on the FAS Modification and Distress and Consequences subscales and with the 13-item total score. Lifetime comorbidity was

Table 6 Effect of comorbid disorders on family accommodation scores (only significant differences are shown). Current Axis I disorders

Lifetime Axis I disorders

Current mood disorders

Accommodation scores mean ± S.D.

Yes (N = 79)

No (N = 62)

Mann–Whitney U test (P)

Yes (N = 100)

No (N = 41)

Mann–Whitney U test (P)

Yes (N = 63)

No (N = 78)

Mann–Whitney U test (P)

FAS Modification FAS Distress and Consequences FAS 13-item total score

8.56 ± 4.27 7.24 ± 3.65 24.90 ± 9.33

6.23 ± 4.35 6.06 ± 3.44 20.44 ± 9.38

1724.0 (0.003) 1933.0 (0.031) 1799.0 (0.007)

8.29 ± 4.37 – –

5.68 ± 4.11 – –

1367.0 (0.002) – –

8.67 ± 3.93 – 25.11 ± 8.20

6.62 ± 4.64 – 21.18 ± 10.28

1803.0 (0.007) – 1916.5 (0.025)

No correlations were found with the FAS Participation score.

Table 7 Stepwise multiple linear regressions predicting family accommodation in OCD. Family members (n = 141)

FAS Participationa e

Constant FH for anxiety disorder Factor 3 score (contamination/cleaning) Lifetime comorbidity YBOCS compulsions

FAS Modificationb

FAS Distress and Consequencesc e

FAS 13-item total scored

β

t

P

β

t

P

β

t

P

βe

t

P

– 0.200 –

22.270 2.403 –

b0.001 0.018 –

– 0.302 0.177

8.870 3.797 2.261

b0.001 b0.001 0.025

– 0.275 0.170

3.105 3.450 2.142

0.002 0.001 0.034

– 0.356 0.222

25.585 4.592 2.870

b0.001 b0.001 0.005

– –

– –

– –

0.170 –

2.106 –

0.037 –

– 0.169

– 2.117

– 0.036

– –

– –

– –

FH = family history. a R2 = 0.040; adjusted R2 = 0.033; F = 5.774; P = 0.018. b R2 = 0.187; adjusted R2 = 0.169; F = 10.395; P b 0.001. c R2 = 0.151; adjusted R2 = 0.133; F = 8.080; P b 0.001. d R2 = 0.178; adjusted R2 = 0.166; F = 14.790; P b 0.001. e Standardized coefficients.

e

U. Albert et al. / Psychiatry Research 179 (2010) 204–211

independently associated with greater FAS Modification scores and YBOCS compulsion scores was independently associated with FAS Distress & Consequences scores. 4. Discussion The aim of the present exploratory study was to identify the frequency and type of family accommodation among healthy family members of adults with OCD, and to examine the independent contribution of a wide range of variables, including Axis I and II comorbidity and symptom dimension scores, to various domains of accommodation in a large sample of psychopathology-free relatives of well-characterized patients. As expected, accommodating behaviors were found to be highly prevalent among family members of our patients, with the provision of reassurance, participation in rituals and assisting the patient in avoidance being the most frequent practices (occurring on a daily basis in 47%, 35%, and 43% of family members, respectively). These results are in line with previous studies in adults (Calvocoressi et al., 1995; Calvocoressi et al., 1999; Renshaw et al., 2005; Ramos-Cerqueira et al., 2008; Stewart et al., 2008) and children with OCD (Allsop and Verduyn, 1990; Storch et al., 2007; Peris et al., 2008). It is important to notice that our patients were referred to a tertiary teaching hospital and therefore may represent a moderately severe subgroup of OCD patients (mean YBOCS of 25) with high rates of comorbid Axis I and II disorders. In fact, 57% had at least another current Axis I disorder (72 % lifetime), and 47% had at least one Axis II disorder. It is therefore possible that our results of a high frequency of accommodating behaviors among family members cohabiting with OCD patients may not generalize to other less severe samples from non-tertiary clinics or the community. As the vast majority of interventions including family members are targeted to relatives of children and adolescents with OCD (Franklin et al., 1998; Barrett et al., 2004a,b; Martin and Thienemann, 2005; Renshaw et al., 2005; Freeman et al., 2007), our results are of clinical importance and highlight that the relatives of adult patients may also benefit from being included in the treatment plan. Accommodating behaviors caused family members distress, with 92.3% of them reporting at least a mild distress. Moreover, we found an association between accommodation (higher total score and subscale scores) and a poorer quality of life (physical and mental summary components of the SF-36) in relatives. This association confirms results of previous authors who found that family distress and burden, poorer family functioning, and high levels of parental anxiety and depression are proportional to the extent of accommodation (Calvocoressi et al., 1995; Calvocoressi et al., 1999; Amir et al., 2000; Ramos-Cerqueira et al., 2008). The present study also confirms in an independent sample our previous results that the FAS score is one of the independent predictors of poorer quality of life (physical domain) among relatives (Physical Summary Component) (Albert et al., 2007). To our knowledge, this is the first study to examine the factor structure of the 13-item FAS. A PCA yielded a three-factor structure corresponding to a Participation scale, a Modification scale and a Distress and Consequences scale. This suggests that family accommodation is a multidimensional construct, and that different aspects of family accommodation may be related to different clinical and family characteristics. For example, our results suggest that impairment in quality of life of the relatives is related to a higher degree of modification of personal, family routine and leisure activities strictly related to obsessive–compulsive symptoms, as well as to higher distress and worse consequences, rather than to the direct participation in rituals. Our bivariate correlation analyses confirmed that accommodation of family members is not dependent on their age or gender or to whether the relative was the spouse, a parent or a sibling of the patient (Calvocoressi et al., 1999). We deliberately excluded those relatives who

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had OCD or another Axis I disorder because psychopathology in the parents correlates with the degree of family accommodation (Peris et al., 2008). Our results suggest that accommodating behaviors are highly prevalent even in psychopathology-free relatives of OCD patients, suggesting that family accommodation is frequent in many families, which may be otherwise completely healthy. Turning to the characteristics of the patients, the severity of OCD (YBOCS total score) was associated with both modification of personal/family routine and higher distress/worse consequences of not accommodating. We also found that obsessions (YBOCS obsession score) are associated with a greater modification of functioning, while compulsions (YBOCS compulsion score) with greater distress and worse consequences. When we examined the independent contribution of each factor to the FAS scores with the stepwise regression analysis, we found that only the severity of compulsions was predictive of a higher degree of distress and angry/abusive behaviors of the patients when not accommodated (or at least to the degree of anxiety/distress in the patients as perceived and rated by their family members). The relationship between accommodation and severity of OCD has been found in several previous reports (Calvocoressi et al., 1995, 1999; Storch et al., 2007; Peris et al., 2008; Ramos-Cerqueira et al., 2008; Stewart et al., 2008; Van Noppen and Steketee, 2009). Whether family accommodation is a precursor or a consequence of OCD severity remains to be fully understood and future prospective studies are warranted in order to further elucidate the direction of causality. Both hypotheses may be correct: it is plausible that the more severe the OCD, the greater the family accommodation because family members are empathically trying to reduce the level of anxiety/ distress experienced by their loved ones. Conversely, accommodation is thought to interfere with cognitive-behavior therapy in that it reduces the chances of patients exposing themselves to anxietyprovoking situations. Indeed, preliminary results suggest that the increased family accommodation is associated with reduced response to cognitive-behavior therapy and/or pharmacotherapy (Amir et al., 2000; Ferrão et al., 2006; Storch et al., 2008; Van Noppen and Steketee, 2009). Our multiple regression analyses revealed that two variables were most strongly associated with the various domains of family accommodation: high scores on the contamination/washing symptom dimension and the presence of a positive family history for an anxiety disorder other than OCD. The relatives of patients with prominent contamination/washing symptoms had higher family accommodation scores, a finding that replicates a previous study by Stewart et al. (2008). This association remained significant even after controlling for the potential contribution of other factors, such as overall illness severity and the presence and severity of other types of OCD symptoms. Specifically, the relatives of patients with contamination/ washing symptoms reported substantial changes in their daily activities (work schedule, leisure activities, family relations, etc.) to fit around the patients' symptoms (e.g., not inviting people at home due to the patient's contamination fears). Furthermore, high scores on the contamination/washing dimension were also associated with elevated scores on the Distress and Consequences scale of the FAS, suggesting that these symptoms are associated with high levels of distress and potentially anger/abusive behaviors in the patients if the family members do not accommodate. These findings, together with our recent report of reduced physical quality of life in patients with contamination/washing symptoms (Albert et al., 2010), further support the idea that OCD is not a unitary disorder and “one size does not fit all” (Mataix-Cols et al., 2005). Clinicians should be aware of the high probability of family accommodation in patients with contamination/washing symptoms and researchers should test the possibility that family-based cognitive-behavioral interventions may be particularly beneficial for these families. The other predictor of greater accommodation, which remained significant in the multiple linear regression analysis and correlated with

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all the dimensions of accommodation, was a positive family history for another anxiety disorder (that is, the patient has another family member other than the one evaluated with the FAS who has a current or lifetime anxiety disorder). A limitation of the present study is that we assessed mental disorders in the family through the information given by the patients; despite this limitation, this result suggests that if a healthy relative has been exposed to having another family member with an anxiety disorder he/she would probably be more prone to accommodate behaviors of the patient, and we speculate that this is because he/she has been “sensitized” and is more intolerant to the anxiety that the patient would manifest when not accommodated. This result requires replication using structured diagnostic interviews but, if confirmed, it would implicate that psychoeducational interventions aimed at helping relatives to improve their ability to cope with the sufferer's anxiety may be beneficial. Another possible explanation is that families with several members affected with an anxiety disorder (including OCD) may be more prone to perceive the patient to be in control of his/her symptoms or behaviors, leading to more hostility and criticism as well as increased family accommodation, as suggested by Van Noppen and Steketee (2009). The main strengths of our study were the enrollment of a large sample of psychopathology-free relatives of patients who were well characterized in terms of clinical presentation of the disorder, the novel factor analysis of the FAS items resulting in three meaningful subscales, the examination of empirically derived symptom dimensions of OCD and the use of a series of regression analyses which allowed us to identify independent predictors of family accommodation. The main limitations of our study were the cross-sectional nature of the study and the lack of structured interviews to assess psychiatric disorders in other family members not included in the study (thus relying on patient report). Ideally, future studies should also examine whether different domains of family accommodation are predictive of treatment outcome in OCD. In conclusion, our study confirms that family accommodation is frequent and distressing in psychopathology-free family members cohabiting with adult OCD patients. Family accommodation is particularly frequent and distressing when the patient has prominent contamination/washing symptoms and/or when another family member has a history of an anxiety disorder. Such families may be more likely to benefit from family-based interventions but this remains to be tested in controlled trials.

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