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Mental health literacy and obsessive–compulsive personality disorder
Psychiatry Research 215 (2014) 223–228
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Mental health literacy and obsessive–compulsive personality disorder Iakovina Koutoufa a, Adrian Furnham a,b,n a b
Research Department of Clinical, Educational and Health Psychology, University College London, 26 Bedford Way, London WC1H 0AP, UK Norwegian Business School, Nydalsveien, Oslo, Norway
art ic l e i nf o
a b s t r a c t
Article history: Received 7 May 2013 Received in revised form 18 October 2013 Accepted 21 October 2013 Available online 6 November 2013
An opportunistic sample of 342 participants completed a vignette identification task that required them to name the possible psychological problem of an individual described in vignettes describing people with depression, schizophrenia, OCD and OCPD. Participants rated the degree to which they believed the individual experienced distress, they felt sympathetic towards the described individual, and the degree to which they believed the individual was well-adjusted in the community. There were very low recognition rates of OCPD, with participants more likely to identify depression, schizophrenia and OCD. Analysis of distress, sympathy and adjustment ratings also revealed significant differences between the disorders. The findings highlight the necessity of greater mental health awareness and the importance of psycho-education in order to increase successful treatment seeking of OCPD patients. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Mental health literacy OCD OCPD
1. Introduction Mental Health Literacy (MHL) is defined as ‘the knowledge and beliefs about mental disorders which aid their recognition, management or prevention’ (Jorm et al., 1997). Jorm's (2000) review highlighted that a great majority of members of the public could not recognise mental disorders or pathological distress. For example, Jorm et al. (1997) found that 39% of the participants were able to label depression, but only 27% of them correctly identified schizophrenia. More recent studies have reported higher recognition rates on depression and schizophrenia: namely 97% for depression and 61% for schizophrenia but only 39% for anti-social personality disorder (Furnham et al., 2009). However, this increase in mental health literacy may not reflect an increase in awareness, but may be the result of methodological differences in the assessment and measurement of mental health literacy in different samples (Furnham and Dadabhoy, 2012). Yet recent longitudinal research has provided evidence of real positive changes over time in MHL (Reavley and Jorm, in press). Various demographic variables have also been found to have an effect on mental health literacy. Fischer and Goldney (2003) found that younger and more educated people have more informed beliefs about mental illnesses. Gender has also been found to have a significant effect on identification of disorders (Furnham et al., in press). Riedel-Heller et al. (2005) found that females were more likely to suggest psychotherapy as a treatment for depression and schizophrenia than psychotropic drugs. Culture may also have an n Corresponding author at: Research Department of Clinical, Educational and Health Psychology, University College London, 26 Bedford Way, London WC1H 0AP, UK. Tel.: þ44 2076795395. E-mail address: [email protected] (A. Furnham).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.10.027
impact on the explanatory models and attitudes towards mental health literacy (Kleinman, 1988) and can determine motivations and treatment decisions (Rogler and Cortes, 1993). Jorm et al. (1997) also suggested that contact with a mental patient affects the lay beliefs in the sense that they become better informed about the cause and manifestation of mental illnesses. Lauber et al. (2003) also found that previous contact with a mental patient increased recognition of depression. Schomerus et al. (2013) investigated the consequence of what they called continuum beliefs (as opposed to categorical beliefs) about people with various mental illnesses. They found, as predicted, that continuum beliefs were associated with less stigmatising attitudes, particularly with regard to schizophrenia and alcohol dependence suggesting the importance of educating people about the continuous nature of most psychopathological phenomena. Furnham and Winceslaus (2012) found the majority of their participants failed to recognise the personality disorders. The disorder that yielded the highest recognition rate was paranoid personality disorder, identified by only 36% of participants. Similarly, Furnham et al. (2011) found that a large proportion of their participants perceived a psychological problem as present, but very few of them were able to ‘correctly’ label the personality disorders. One of their hypotheses was that Obsessive–Compulsive Personality Disorder (OCPD) would be identified more due to its extensive projection in the media compared to other disorders. Although it yielded one of the highest scores in correct labelling, OCPD was recognised as a psychological problem by less than half of their participants. A highly salient paper for this research area is a study by Coles et al. (2013) on the public's knowledge of OCD. In all 575 American adults took part in a telephone interview study and they found 90% reported that they symptoms were a cause of concern and
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that the person described should seek professional help. They noted that only a third of the respondents labelled the disorder correctly as OCD, Better educated, higher social class and younger people were better at correctly labelling the symptoms. Interestingly the respondents were more hopeful of the success of psychotherapy than medication as a cure. This study concerned the recognition of OCPD which is a Cluster C personality disorder, according to the DSM classification system. It is, according to DSM-V (American Psychiatric Association, 2013) one of the most common of the personality disorders with an estimated prevalence from 2.1 to 7.9% of the population, diagnosed twice as often in males compared to females. There has been a heated debate regarding OCPD's relation to obsessive–compulsive disorder (OCD), with the two extreme standpoints claiming either that OCPD is completely unrelated to OCD or that OCPD is a prerequisite for the development of OCD. However, most individuals with OCD do not have a pattern of behaviour that fulfils the criteria for OCPD (Mancebo et al., 2005). Additionally, it is argued that OCPD is an egosyntonic disorder, implying that the symptoms are in congruency with the individual's goals and desires, whereas OCD is egodystonic, which means that symptoms cause distress and anxiety to the individual who recognises the abnormal nature of the symptoms (Taylor et al., 2011). Few studies have looked specifically at the mental health literacy of OCD and OCPD particularly how they compared with one another and the more commonly researched schizophrenia. It is suggested by MHL researchers that recognition of mental illness has benefits because people with particular conditions are more sympathetically dealt with and offer more and better (more professional) help. This seems to be the case where there are evidence-based treatments but the same may not be the case for OCPD. Indeed there seems to be very little evidence for the availability, feasibility or proven efficacy of any treatment for OCPD (de Reus and Emmelkamp, 2010) which would make the task near impossible for a person eager to help themselves and/or others who they suspected had the condition. However given the fact that many people with personality disorder fail to recognise their symptoms it often behoves others like family members who, with better MHL, may offer help and advice. This study aims to investigate the ability of lay people to identify OCPD as a psychological illness and to evaluate the individual's adjustment in the community. The first hypothesis (H1) was that OCPD will be significantly less recognised than depression, schizophrenia and OCD (Furnham et al., 2011). The second hypothesis (H2) was that lay ratings of distress and sympathy will be lower and adjustment ratings of the individual will be higher for OCPD individuals than other disorders (Furnham et al., 2011). The third hypothesis (H3) is that higher sympathy and adjustment but lower distress scores will predict increased obsessive symptoms due to the egosyntonic nature of OCPD and the theory that obsessive thoughts are in a continuum in the population and it is frequency and intensity that defines clinical pathology of obsessions and compulsions (Berry and Laskey, 2012). The fourth hypothesis (H4) is that gender (H4a), personal experience of mental illness (H4b), study of psychology (H4c) and contact with a mental patient (H4d) would predict mental health literacy of OCPD and ratings of distress, sympathy and adjustment.
2. Method
11.7% (N¼40) held a postgraduate degree, 2.6% (N¼ 9) held other higher qualifications, 2.4% (N¼8) held GCSEs/American 10th grade, 2.9% (N¼ 10) had graduated a foundation course and 3.8% (N¼ 13) held no academic qualifications. Regarding their occupational status, many of the respondents were students (75.4%, N¼ 258), but there were also some participants in professional occupations (9.6%, N¼ 33), intermediate occupations (10.5%, N¼ 36), skilled occupations (1.8%, N¼6), semi-skilled occupations (0.9%, N¼ 3), unskilled occupations (0.3%, N¼1), or other types of occupations (i.e. Armed Forces) (1.5%, N¼ 5). The minority of participants had not studied Psychology (26.0%) or Psychiatry (7.5%). Additionally, most of the participants had not been diagnosed with a mental disorder (95.0%, N¼ 325). The most common disorders among participants who had been diagnosed with a mental disorder (5.0%, N¼ 17) were depression (41.2%, N¼ 7) and anxiety disorders including OCD (35.3%, N¼ 6). More than half of the respondents (53.2%, N¼182) had known someone who has been diagnosed with a mental disorder. The majority had known someone who has been diagnosed with depression (48.4%, N¼ 88).
2.2. Measures Vignettes. The questionnaire consisted of five vignettes, describing one case of depression, one case of OCPD, one case of schizophrenia and two cases of OCD to check for reliability given that this is an issue in this research area (Sai and Furnham, 2013). The data for the two OCD cases were combined to attempt to ensure greater reliability in the analysis. The vignette describing a depressive patient was adapted from Jorm et al. (2006) and the vignette describing the schizophrenia case was adapted from Link et al. (1999). The OCPD vignette was adapted from Furnham and Winceslaus (2012). The first OCD (OCD1) vignette was adapted from Pirutinsky et al. (2009) and the second OCD (OCD2) vignette was adapted from a training programme developed by Coyle (2002). All of the vignettes were typical cases in order to demonstrate the criteria of each disorder in an easily comprehensible manner. The vignettes' length ranged from 71 to 205 (words). Half the participants completed the male version and the other half the female version of each vignette (see Appendix). In both versions the vignettes were presented in the order of depression, OCPD, schizophrenia, OCD1 and OCD2. After each vignette participants were asked to answer an open-ended question ‘What, if anything, would you say is X's main problem?’ There was a qualitative content analysis on the participant's responses for maximal response identification. Participants' responses to this question were also categorised as either ‘correct’ or ‘incorrect’ in order to determine how many participants correctly identified each vignette. For the depression vignette, correct answers were considered to be ‘depression’ and ‘depressed’. For the schizophrenia vignette, ‘paranoid schizophrenia’, ‘schizophrenia’ and ‘schizophrenic’ were deemed correct. For the OCPD vignette, ‘obsessive–compulsive personality disorder’ and ‘OCPD’ were deemed correct. Finally, for the OCD vignette, ‘compulsive disorder’, ‘OCD’, ‘obsessive’ and ‘obsessive–compulsive behaviour’ was deemed correct. There were essentially two ways to get either a correct or incorrect score: if the answer used the above labels or suggested the person understood the condition the answer was considered correct; if there was no response, or an incorrect label or description was used the response was considered incorrect. After each vignette there were five questions based on a Likert scale ranging from 1 (Not at all) to 7 (Extremely). These questions' scope was to evaluate the degree to which participants felt sympathetic towards the described patient and whether they found the patient's condition distressing. Additionally, they evaluated the degree to which they thought the patient was happy, successful at their work or school, and satisfied with their personal relationships.
2.3. Procedure The study was approved by the appropriate college ethics committee. The questionnaire was distributed either in its online form (mass emails) or in person using an opportunistic sampling method, in an effort to obtain a representative sample. Non-student participants were recruited by the second author at various non-academic conferences he attended. Approximately half completed the study on-line and half by paper copy. Analysis showed fewer than chance significant differences in either the demographics or responses of the two groups. All participants signed a consent form prior to their participation and they were all informed of the anonymous and confidential nature of the questionnaire. No remuneration was offered. Participants were informed that the questionnaire was regarding their beliefs and attitudes towards the mentally ill. Those who completed the paper copy were debriefed and thanked for their participation.
2.1. Participants
3. Results A total of 342 participants took part in this study, of whom 129 were male (37.7%) and 213 were female (62.3%). The age range of participants was between 18 and 65 years (M¼23.31, S.D.¼ 12.03). The majority of participants were White (69.0%, N¼ 236), with the remainder being Asian (21.3%, N¼ 73), mixed (4.7%, N¼ 16), Black AfricanCaribbean (1.2%, N¼ 4), Hispanic (0.6%, N¼ 2), or other (3.2%, N¼11). The majority held a high-school diploma (43.0%, N¼ 147), 33.6% (N¼ 115) held an undergraduate degree,
3.1. Vignette identification analysis Gender of patient described in the vignette was counterbalanced successfully as there were no significant differences in the
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two types of questionnaire (F (1, 340)¼ 0.10, p¼ 0.75). Depression was identified by 79.0% of the participants, schizophrenia by 59.0%, OCD by 63.0% of the participants and OCPD by only 2.0%. Thus if OCD and OCPD were combined and considered equivalently ‘correct’ it meant just under two thirds of the population were able to detect/label the disorder correctly. Depression was significantly more identified than OCPD (x2 (1, N ¼342) ¼261.00, p o0.001). Schizophrenia was also significantly more identified than OCPD (x2 (1, N ¼342)¼ 188.24, p o0.001). Results from the two OCD cases were similar and not statistically different. Finally, OCD was also significantly identified more than OCPD (x2 (1, N ¼342) ¼202.12, p o0.001).
3.2. Vignette labelling analysis A content analysis was further conducted in order to identify the most common lay labels of OCPD. Table 1 shows the rankings of answers provided by participants in the open-ended question ‘What do you think is X's main problem?’ The label ‘perfectionism/ perfectionist’ was most common in participants’ responses. Interestingly, 14.9% of participants identified OCPD as OCD. Ratings of Distress, Sympathy and Adjustment. The results showed that the differences in the means of the ratings for patient distress were significant between the different disorders (F (2.8, 937.8)¼ 134.28, po0.001). Post hoc pairwise comparisons of the distress means of each disorder, with Bonferroni adjustments was conducted in order to identify where the significant differences lay. Depression (M¼ 5.98) differed significantly from OCPD (M¼4.92) (t (341)¼12.60, po0.001), schizophrenia (M¼6.30) (t (341)¼4.85, po0.001) and OCD (M¼ 5.50) (t (341)¼6.88, po0.001). Schizophrenia also yielded significantly higher distress scores than OCPD (t (341)¼17.14, po0.001) and OCD (t (341)¼12.92, po0.001). OCD differed significantly from OCPD (t (341)¼ 7.73, po0.001). Overall, OCPD ratings yielded the lowest distress ratings. Sympathy ratings towards vignette characters were also compared among mental disorders using a one-way repeated measure ANOVA. The results showed that the differences between ratings of sympathy towards the different cases of mental disorders were significant (F (2.8, 950.5) ¼186.76, po 0.001). Additional post hoc pairwise comparisons with Bonferroni adjustments indicated that depression (M¼ 5.32) had significantly higher sympathy ratings than OCPD (M¼3.67) (t (341) ¼ 17. 76, p o0.001), but lower than schizophrenia (M¼5.51) (t (341) ¼2.37, p ¼0.019) and OCD (M¼4.79) (t (341)¼6.76, po0.001). Schizophrenia differed significantly from OCPD (t (341)¼18.80, po0.001) and OCD (t (341)¼ 9.67, po0.001). OCD also yielded significantly higher sympathy scores than OCPD (t (341)¼ 13.31, po0.001). Overall, participants felt lowest sympathy for OCPD patients.
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Adjustment ratings of each person described in the vignettes were also compared between the different disorders. Adjustment scores were computed by adding up the participants’ ratings on the patient’s happiness, quality of relationships and success at work (Fig. 1). The rationale for this computation was that the ratings were highly significantly correlated (r 40.50) within and between vignettes. The results indicated that the differences between lay adjustment ratings for each disorder were significant (F (3, 1023)¼ 456.47, p o0.001). Further post hoc pairwise comparisons with Bonferroni adjustments indicated that depression (M ¼5.82) had significantly lower adjustment ratings than OCPD (M¼ 10.47) (t (341) ¼28.31, p o0.001) and OCD (M ¼9.83) (t (341) ¼24.39, p o0.001). Schizophrenia (M ¼5.89) differed significantly from OCD (t (341) ¼23.25, p o0.001) and OCPD (t (341) ¼ 26.79, p o0.001). OCD showed significantly lower adjustment ratings than OCPD (t (341) ¼ 3.85, p o0.001). However, depression and schizophrenia patients did not differ significantly in their adjustment ratings (t (341) ¼ 0.417, p ¼0.667). 3.3. Demographic variables One-way independent samples ANOVAs were conducted for each control variable with OCPD identification and ratings of distress, sympathy and adjustment as dependent variables. In terms of gender, females’ mean rating of distress for the OCPD vignette was 5.08 whereas the males’ mean rating was 4.67. This difference was significant (F (1, 340) ¼7.06, p ¼0.008). Additionally, females yielded a lower average score of sympathy ratings (M ¼3.67) compared to males (M¼4.43) and this difference was also significant (F (1, 340) ¼4.75, p¼ 0.030). Finally, there was also a significant difference between genders in adjustment ratings (F (1, 340) ¼12.35, p o0.001) with females (M ¼10.10) scoring lower in the adjustment scale of the OCPD vignette than males (M ¼11.08). Participants who have studied psychology and mental illnesses yielded significantly higher scores on distress (M¼ 5.22) than participants who have not studied psychology (M¼ 4.81) (F (1, 340)¼5.82, p¼0.016). Similarly, participants who had studied psychology scored significantly higher in sympathy (M¼4.30) than the ones who had not (M¼3.45) (F (1, 340)¼20.92, po0.001). Finally, those who knew someone with a mental illness yielded significantly higher scores on sympathy towards OCPD patients (M ¼3.83) than the ones who did not (M¼ 3.49) (F (1, 340) ¼3.92,
Table1 Ranking of lay beliefs of obsessive–compulsive personality disorder. Label category Perfectionism/perfectionist ‘Workaholic’/addicted to work/works too hard/too focused on work Obsessive compulsive disorder Other/non-specific (i.e. selfish, indecisive) Anxiety disorder/stress/unable to relax ‘Control freak’/need to control/controlling Obsessions/compulsions Obsessive compulsive personality disorder Retentive personality/type A personality/neurotic Nothing/do not know Mania/autism Total
Participants (%) 20.5 15.8 14.9 14.5 12.6 11.1 3.8 2.0 1.8 1.5 1.5 100.0
Fig. 1. Mean lay ratings of adjustment for depression, OCPD, schizophrenia and OCD.
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p ¼0.048). They also scored the OCPD case with significantly lower adjustment score (M ¼9.97) than the participants who did not have contact with someone with a mental disorder (M¼ 11.02). A multiple regression was computed to test the fourth hypothesis but was not significant. Personal experience of a mental disorder did not predict ratings of distress, sympathy or adjustment. None of the demographic variables predicted OCPD identification, but this could be due to the highly skewed responses and the very low percentage of correct responses.
4. Discussion This study addressed the mental health literacy of lay people in terms of the obsessive–compulsive personality disorder. It is evident from the results that this relatively well-educated sample had very little understanding of OCPD and the majority of them were unable to identify it as a mental illness. The first hypothesis that OCPD would be less recognised than depression, schizophrenia and OCD (Furnham et al., 2011) was supported. The analysis of the vignette identification task revealed that depression yielded the highest identification score, fitting in line with previous research (Jorm et al., 1997; Furnham et al., 2009). This could be explained by the fact that the other disorders are much more common in everyday language and mass media (Furnham and Buck, 2003). Additionally, the vignette labelling analysis showed that participants most commonly labelled OCPD patients as ‘perfectionists’. Perfectionism is the primary and most consistent factor associated with OCPD (de Reus and Emmelkamp, 2010). This could imply that participants may have an understanding of the symptomatology of OCPD but may not know the psychological term for it (Link et al., 1999). This could also be argued due to the fact that approximately 15% of the participants labelled OCPD as OCD, showing an understanding of the obsessive nature of OCPD. This could possibly correspond to the academic view of obsessive compulsive spectrum disorders, implying that OCPD and OCD are both part of a continuum (Pollak, 1979). Consistent with the second hypothesis, ratings of distress and sympathy were lower for OCPD than any other disorder. Additionally, adjustment ratings were significantly higher for OCPD than the other disorders. Furnham et al. (2011) suggested that the more likely a participant was to identify a psychological problem in a vignette, the less likely they were to rate the described individual as well adjusted. Additionally, low recognition of OCPD as a mental illness could explain the low ratings of distress and sympathy. The fact that OCPD is an egosyntonic disorder may account for the higher perceived adjustment ratings (Cullen et al., 2008), though requires further exploration. It has also been argued that OCPD may enhance life functioning and employment success in certain circumstances (Ullrich et al., 2007). Therefore, participants may not perceive OCPD as a mental disorder but more as a trait (i.e. perfectionism) that does not have a severe impact on their adjustment and does not cause a significant amount of distress. It was predicted that higher sympathy and adjustment ratings but lower distress ratings will predict increased obsessive thoughts due to the egosyntonic nature of OCPD. Results indicated that only adjustment significantly contributed to the explanation of the variability in sub-clinical obsessive thoughts. Clearly people have relatively little understanding of OCPD. Results indicated that females rated higher distress and sympathy but lower adjustment in OCPD individuals. These results are consistent with previous literature. Females tend to show higher social empathy, which may affect their perceptions of emotion (Furnham et al., 2009, 2011; Furnham and Manning, 1997). Also participants who had contact with an individual with a mental disorder rated significantly higher sympathy and lower adjustment for OCPD
individuals (Lauber et al., 2003). Regression results showed however that none of the demographic variables predicted OCPD identification, but it is speculated that it is due to the highly skewed responses in vignette identification. This study has several implications of mental health literacy of OCPD. The fact that the vast majority of participants failed to recognise the disorder implies that lay people have very little understanding of the nature of OCPD as a mental illness. This could have detrimental implications on the treatment seeking behaviour of patients. Cullen et al. (2008) found that increased symptomatology of OCPD is correlated with lower treatment seeking primarily due to the egosyntonic nature of OCPD. Farrer et al. (2008) suggested that help-seeking can be improved with better recognition of mental disorders and increased understanding of causes and treatments. Lauber et al. (2001) suggested that help-seeking behaviour of mental patients is greatly affected by the recommendations of their social network. This implies that if their social network, family and peers, are adequately informed of the nature of OCPD, they encourage the person to seek treatment (Furnham et al., 2011). The nature of OCPD also causes difficulty in the therapeutic alliance. Very often patients believe they have no reason for being treated. However, an improved OCPD literacy could allow the patient to recognise the pathological nature of their condition and build an effective and co-operative relationship with the therapist (Cummings et al., 2011). Recognition of OCPD has also a great influence on the attitude and behaviour towards OCPD patients and it is, thus, crucial in the context of anti-stigma campaigns and measures against discrimination towards the mentally ill (Lauber et al., 2003). Interestingly, it has been found that stereotypes of dangerousness are on the increase and that the stigma of mental patients remains a detrimental feature of the lives of people with such conditions (Markowitz, 1998). Link et al. (1999) also found that social distance towards a mentally ill person is not caused solely because of their undesirable traits but also because they induce fear. Therefore, better mental health literacy will aim to inform the public of the true behavioural manifestations of OCPD and reduce stigmatisation. Mental health literacy for OCPD could be improved by mass media campaigns, school-based programmes or educational interventions within families. Other ways of enhancing mental health literacy of OCPD could potentially include the promotion of Mental Health First Aid Training aiming to inform the public of the nature of mental disorders (Kitchener and Jorm, 2002). There are however several limitations to this study. First of all, the sample cannot be considered representative, as participants tended to be young and well educated, which may affect the knowledge of psychiatric literacy. Further, their choice to participate could lead to inherent biases such that it yields an over optimistic view of MHL. Further there may well be significant culture differences in MHL with regard to this topic such that OCPD is rated a more serious and distressing problem in some cultures rather than others. Personality disorders have been highly debated in the western psychiatry and their classification and diagnosis have changed throughout the years. Next, it could also be argued that the vignette methodology presents limitations in terms of the extent to which the vignettes describe salient behaviours of each disorder (Williams et al, 2012). It is important to equate the severity of the disorder when comparing vignettes which must have a direct affect on the ratings of distress and adjustments. This suggests the importance of pilot work to ensure severity equivalence. Also an improvement could be the presentation of supplementary material to the vignettes, for example, a video tape recording of patients. Also in this study we did not have another personality disorder to examine whether there is a difference in ratings of AXIS I and AXIS II disorders. In this study we only had AXIS I disorders for comparison thus
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we could not know whether there was a difference in the MHL with respect to the different axes. Riedel-Heller et al. (2005) pointed out that in real-life people are forced to act and make informed decisions in terms of psychological treatments. Therefore, it may be important to focus on the decision-making process of individuals in terms of their action plan when a member of their social network is diagnosed with a mental disorder in real-life circumstances. Regardless of their beliefs, decision-making takes into account a number of other factors (i.e. cost of therapy, temperament of the patient) before choosing the right treatment option. Future research could potentially investigate the motives behind the beliefs of participants. It would also be interesting to investigate potential causal relationships between social and psychological circumstances and mental health literacy. It is also possible that by describing the study as ‘beliefs about and attitudes towards the mentally ill’ the results are biased in that participant’s were primed to think the individuals in the vignettes had some sort of mental illness. A different label may have overcome this problem. Finally the study did not look at help-seeking beliefs: namely what participants described in each vignettes might or should do to get help for their problems. This may yield a particularly useful insight into the perceived aetiology and prognosis for OCPD.
Appendix 1. The five vignettes 1. Jane has been feeling down recently, she finds it difficult to get out of bed in the morning and has been having difficulty sleeping. She cannot find the energy or motivation to do anything, including going to work or seeing her friends. Even walking around the house feels like an effort. She has lost her appetite and subsequently lost weight. She frequently thinks about death, and sometimes considers committing suicide. (DEPRESSION) 2. Laura is a married 45-year old lawyer. She was the youngest full partner in the firm’s history and is known as the hardest driving member of the firm. She is too proud to turn down a new case and too much of a perfectionist to be satisfied with the work done by her assistants. Displeased by their writing style and sentence structure she finds herself constantly correcting their briefs and therefore is unable to keep up with her schedule. When assignments get backed up, she cannot decide which to address first, starts making schedules for herself and her staff, but then is unable to meet them and starts working 15 h a day. Laura never seemed to be able to relax. Even on vacations, she develops elaborate activity schedules for every family member and gets angry and impatient if they refuse to follow her plans. Her husband is fed up with their marriage and can no longer tolerate the emotional coldness, rigid demands and long working hours. (OCPD) 3. Up until a year ago, life was pretty okay for Jack. But then, things started to change. He thought that people around him were making disapproving comments and talking behind his back. Jack was convinced that people were spying on him and that they could hear what he was thinking. Jack lost his drive to participate in his usual work and family activities and retreated to his home, eventually spending most of his day in his room. Jack was hearing voices even though no one else was around. These voices told him what to do and what to think. He has been living this way for six months. (SCHIZOPHRENIA) 4. Ben is 19 years old and lives at home while learning at a college town. Ben has difficulty with his front door. Whenever leaving his house, he thinks that he has not locked the door and he
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feels compelled to return to his door over and over again to check that it is locked. He also feels unable to leave his home unless he looks over his front windows five times, to check that they are not broken. Consequently, it can take Ben an extra hour to leave his house and get to college, and yet, when he leaves, he is still concerned that his door is not locked. Recently, Ben saw a sign in the street warning about open manhole covers during construction. Since then, he has become preoccupied with ensuring that all the manhole covers in the street are closed, that they are lying flat and level with the road, and that there are no gaps between the covers and the holes. Ben checks manhole covers whenever he goes to college and he finds himself worrying about them throughout his way to college. These worries increasingly consume his daily life and those around him have become concerned. (OCD) 5. James is a 15-year old African American male who lives with his mother in a lower middle class neighbourhood bordering a major metropolitan area. James's mother has a history of generalised anxiety disorder (GAD). In fact, when she is particularly anxious and tense, his mother occasionally verbally berates James and then apologizes when she is feeling somewhat calmer. James has no known medical problems. James has a great deal of difficulty concentrating on and completing any of his school work. He wants to do well and his mother supports his educational success. However, he is constantly distracted by powerful and strange thoughts, such as counting how many times he blinks and how many steps it takes to get to the hallway. The possibility that germs could be on door handles or windows also forces him to avoid touching them unless he first uses a cloth (which he carries with him always) to clean them off. In fact, if he misplaces or forgets to bring a clean cloth with him, he feels a great deal of anxiety, feels paralyzed, and may get physically ill. James realizes that his behaviour does not make sense, and it frustrates him a lot that he cannot overcome these powerful thoughts. (OCD)
References American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. American Psychiatric Association, Washington DC. (DSM-5). Berry, L.M., Laskey, B., 2012. A review of obsessive intrusive thoughts in the general population. Journal of Obsessive-Compulsive and Related Disorders 1, 125–132. Coles, M.E., Heimberg, R.G., Weiss, B.D., 2013. The public's knowledge and beliefs about obsessive compulsive disorder. Depression and Anxiety 30, 778–785. Coyle, S., 2002. Anxiety and related disorders in children and adolescents: a training outline, the Pennsylvania child welfare training program. University of Pittsburgh, Pittsburgh, PA. Cullen, G., Samuels, J.F., Pinto, A., Fyer, A.J., McCracken, J.T., Rauch, S.L., Murphy, D.L., Greenberg, B.D., Knowles, J.A., Piacentini, J., Bienvenu, O.J., Grados, M.A., Riddle, M.A., Rasmussen, S.A., Pauls, D.L., Willour, V.L., Shugart, Y.Y., Liang, K.Y., HoehnSaric, R., Nesdadt, G., 2008. Demographic and clinical characteristics associated with treatment status in family members with obsessive-compulsive disorder. Depression and Anxiety 25, 218–224. Cummings, J.A., Hayes, A.M., Newman, C.F., Beck, A.T., 2011. Navigating therapeutic alliance ruptures in cognitive therapy for avoidant and obsessive-compulsive personality disorders and comorbid axis I disorders. International Journal of Cognitive Therapy 4, 397–414. de Reus, R.J.M., Emmelkamp, P.M.G., 2010. Obsessive-compulsive personality disorder: a review of current empirical findings. Personality and Mental Health 6, 1–21. Farrer, L., Leach, L., Griffiths, K.M., Christensen, H., Jorm, A.F., 2008. Age differences in mental health literacy. BMC Public Health 8, 125. Fischer, L.J., Goldney, R.D., 2003. Differences in community mental health literacy in older and younger Australians. International Journal of Geriatric Psychiatry 18, 33–40. Furnham, A., Abajian, N., McClelland, A., 2011. Psychiatric literacy and personality disorders. Psychiatry Research 189, 110–114. Furnham, A., Buck, C., 2003. A comparison of lay-beliefs about autism and obsessive-compulsive disorder. International Journal of Social Psychiatry 49, 287–307.
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I. Koutoufa, A. Furnham / Psychiatry Research 215 (2014) 223–228
Furnham, A., Dadabhoy, H., 2012. Beliefs about causes, behavioural manifestations and treatment of borderline personality disorder in a community sample. Psychiatry Research 197, 307–313. Furnham, A., Daoud, Y., Swami, V., 2009. “How to spot a psychopath”. Lay theories of psychopathy. Social Psychiatry and Psychiatric Epidemiology 44, 464–472. Furnham, A., Manning, R., 1997. Young people's theories of anorexia nervosa and obesity. Counseling Psychology Quarterly 10, 389–415. Furnham, A., Winceslaus, J., 2012. Psychiatric literacy and the personality disorders. Psychopathology 45, 29–41. Furnham, A., Annis, J., Cleridou, K., Gender differences in the mental health literacy of young people. International Journal of Adolescent Medicine and Health, http://dx.doi.org/10.1177/0004867413495317, in press. Jorm, A.F., 2000. Mental health literacy: public knowledge and beliefs about mental disorders. British Journal of Psychiatry 177, 396–401. Jorm, A., Christensen, H., Griffiths, K.M., 2006. The public's ability to recognize mental disorders and their beliefs about treatment: changes in Australia over 8 years. Australian and New Zealand Journal of Psychiatry 40, 36–41. Jorm, A., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B., Politt, P., 1997. Mental health literacy: a survey of the public's ability to recognize mental disorder and their beliefs about the effectiveness of treatment. The Medical Journal of Australia 166, 182–186. Kitchener, B.A., Jorm, A.F., 2002. Mental health first aid training for the public: evaluation of effects on knowledge, attitudes and helping behaviour. BMC Psychiatry 2, 10. Kleinman, A., 1988. Rethinking Psychiatry: from Cultural Category to Personal Experience. Free Press, New York. Lauber, C., Nordt, C., Falcato, L., Rossler, W., 2001. Lay recommendations on how to treat mental disorder. Social Psychiatry and Psychiatric Epidemiology 36, 553–556. Lauber, C.V., Nordt, C., Falcato, L., Rossler, W., 2003. Do people recognize mental illness? Factors influencing mental health literacy. European Archives of Psychiatry and Clinical Neuroscience 253, 248–251. Link, B.G., Phelan, J.C., Bresnaham, M., Stueve, A., Pescosolido, B.A., 1999. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89, 1328–1333.
Mancebo, M.C., Eisen, J.L., Grant, J.E., Rasmussen, S.A., 2005. Obsessive–compulsive disorder: clinical characteristics, diagnostic difficulties, and treatment. Annals of Clinical Psychiatry 17, 197–207. Markowitz, F., 1998. The effects of stigma on the psychological well-being and life satisfaction of persons with mental illness. Journal of Health and Social Behavior 39, 335–347. Pirutinsky, S., Rosmarin, D.H., Pargament, K.I., 2009. Community attitudes towards culture-influenced mental illness: scrupulosity vs. non-religious OCD among orthodox jews. Journal of Community Psychology 37, 949–958. Pollak, J.M., 1979. Obsessive–compulsive personality: a review. Psychological Bulletin 86, 225–241. Reavley, N.J., Jorm, A.F., 2013. Willingness to disclose a mental disorder and knowledge of disorders in others: changes in Australia over 16 years. Australian and New Zealand Journal of Psychiatry, http://dxdoi.org/10.1177/ 0004867413495317, in press. Riedel-Heller, S.G., Matschinger, H., Angermeyer, M.C., 2005. Mental disorders— who and what might help? Social Psychiatry and Psychiatric Epidemiology 40, 167–174. Rogler, L.H., Cortes, D.E., 1993. Help-seeking pathways: a unifying concept in mental health care. American Journal of Psychiatry 150, 554–561. Sai, G., Furnham, A., 2013. Identifying depression and schizophrenia using vignettes: a methodological note. Psychiatry Research 210, 357–362. Schomerus, G., Matschinger, H., Angermeyer, M.C., 2013. Continuum beliefs and stigmatizing attitudes towards persons with schizophrenia, depression and alcohol dependence. Psychiatry Research 209, 665–669. Taylor, S., Asmundson, G.J., Jang, K.L., 2011. Etiology of obsessive–compulsive symptoms and obsessive–compulsive personality traits: common genes, mostly different environments. Depression and Anxiety 28, 863–869. Ullrich, S., Farrington, D.P., Coid, J.W., 2007. Dimensions of DSM-IV personality disorders and life-success. Journal of Personality Disorders 21, 657–663. Williams, M.T., Mugno, B., Franklin, M., Faber, S., 2012. Symptom dimensions in obsessive-compulsive disorder. Psychopathology 46, 365–376.
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Mental health literacy and obsessive–compulsive personality disorder Iakovina Koutoufa a, Adrian Furnham a,b,n a b
Research Department of Clinical, Educational and Health Psychology, University College London, 26 Bedford Way, London WC1H 0AP, UK Norwegian Business School, Nydalsveien, Oslo, Norway
art ic l e i nf o
a b s t r a c t
Article history: Received 7 May 2013 Received in revised form 18 October 2013 Accepted 21 October 2013 Available online 6 November 2013
An opportunistic sample of 342 participants completed a vignette identification task that required them to name the possible psychological problem of an individual described in vignettes describing people with depression, schizophrenia, OCD and OCPD. Participants rated the degree to which they believed the individual experienced distress, they felt sympathetic towards the described individual, and the degree to which they believed the individual was well-adjusted in the community. There were very low recognition rates of OCPD, with participants more likely to identify depression, schizophrenia and OCD. Analysis of distress, sympathy and adjustment ratings also revealed significant differences between the disorders. The findings highlight the necessity of greater mental health awareness and the importance of psycho-education in order to increase successful treatment seeking of OCPD patients. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Mental health literacy OCD OCPD
1. Introduction Mental Health Literacy (MHL) is defined as ‘the knowledge and beliefs about mental disorders which aid their recognition, management or prevention’ (Jorm et al., 1997). Jorm's (2000) review highlighted that a great majority of members of the public could not recognise mental disorders or pathological distress. For example, Jorm et al. (1997) found that 39% of the participants were able to label depression, but only 27% of them correctly identified schizophrenia. More recent studies have reported higher recognition rates on depression and schizophrenia: namely 97% for depression and 61% for schizophrenia but only 39% for anti-social personality disorder (Furnham et al., 2009). However, this increase in mental health literacy may not reflect an increase in awareness, but may be the result of methodological differences in the assessment and measurement of mental health literacy in different samples (Furnham and Dadabhoy, 2012). Yet recent longitudinal research has provided evidence of real positive changes over time in MHL (Reavley and Jorm, in press). Various demographic variables have also been found to have an effect on mental health literacy. Fischer and Goldney (2003) found that younger and more educated people have more informed beliefs about mental illnesses. Gender has also been found to have a significant effect on identification of disorders (Furnham et al., in press). Riedel-Heller et al. (2005) found that females were more likely to suggest psychotherapy as a treatment for depression and schizophrenia than psychotropic drugs. Culture may also have an n Corresponding author at: Research Department of Clinical, Educational and Health Psychology, University College London, 26 Bedford Way, London WC1H 0AP, UK. Tel.: þ44 2076795395. E-mail address: [email protected] (A. Furnham).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.10.027
impact on the explanatory models and attitudes towards mental health literacy (Kleinman, 1988) and can determine motivations and treatment decisions (Rogler and Cortes, 1993). Jorm et al. (1997) also suggested that contact with a mental patient affects the lay beliefs in the sense that they become better informed about the cause and manifestation of mental illnesses. Lauber et al. (2003) also found that previous contact with a mental patient increased recognition of depression. Schomerus et al. (2013) investigated the consequence of what they called continuum beliefs (as opposed to categorical beliefs) about people with various mental illnesses. They found, as predicted, that continuum beliefs were associated with less stigmatising attitudes, particularly with regard to schizophrenia and alcohol dependence suggesting the importance of educating people about the continuous nature of most psychopathological phenomena. Furnham and Winceslaus (2012) found the majority of their participants failed to recognise the personality disorders. The disorder that yielded the highest recognition rate was paranoid personality disorder, identified by only 36% of participants. Similarly, Furnham et al. (2011) found that a large proportion of their participants perceived a psychological problem as present, but very few of them were able to ‘correctly’ label the personality disorders. One of their hypotheses was that Obsessive–Compulsive Personality Disorder (OCPD) would be identified more due to its extensive projection in the media compared to other disorders. Although it yielded one of the highest scores in correct labelling, OCPD was recognised as a psychological problem by less than half of their participants. A highly salient paper for this research area is a study by Coles et al. (2013) on the public's knowledge of OCD. In all 575 American adults took part in a telephone interview study and they found 90% reported that they symptoms were a cause of concern and
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that the person described should seek professional help. They noted that only a third of the respondents labelled the disorder correctly as OCD, Better educated, higher social class and younger people were better at correctly labelling the symptoms. Interestingly the respondents were more hopeful of the success of psychotherapy than medication as a cure. This study concerned the recognition of OCPD which is a Cluster C personality disorder, according to the DSM classification system. It is, according to DSM-V (American Psychiatric Association, 2013) one of the most common of the personality disorders with an estimated prevalence from 2.1 to 7.9% of the population, diagnosed twice as often in males compared to females. There has been a heated debate regarding OCPD's relation to obsessive–compulsive disorder (OCD), with the two extreme standpoints claiming either that OCPD is completely unrelated to OCD or that OCPD is a prerequisite for the development of OCD. However, most individuals with OCD do not have a pattern of behaviour that fulfils the criteria for OCPD (Mancebo et al., 2005). Additionally, it is argued that OCPD is an egosyntonic disorder, implying that the symptoms are in congruency with the individual's goals and desires, whereas OCD is egodystonic, which means that symptoms cause distress and anxiety to the individual who recognises the abnormal nature of the symptoms (Taylor et al., 2011). Few studies have looked specifically at the mental health literacy of OCD and OCPD particularly how they compared with one another and the more commonly researched schizophrenia. It is suggested by MHL researchers that recognition of mental illness has benefits because people with particular conditions are more sympathetically dealt with and offer more and better (more professional) help. This seems to be the case where there are evidence-based treatments but the same may not be the case for OCPD. Indeed there seems to be very little evidence for the availability, feasibility or proven efficacy of any treatment for OCPD (de Reus and Emmelkamp, 2010) which would make the task near impossible for a person eager to help themselves and/or others who they suspected had the condition. However given the fact that many people with personality disorder fail to recognise their symptoms it often behoves others like family members who, with better MHL, may offer help and advice. This study aims to investigate the ability of lay people to identify OCPD as a psychological illness and to evaluate the individual's adjustment in the community. The first hypothesis (H1) was that OCPD will be significantly less recognised than depression, schizophrenia and OCD (Furnham et al., 2011). The second hypothesis (H2) was that lay ratings of distress and sympathy will be lower and adjustment ratings of the individual will be higher for OCPD individuals than other disorders (Furnham et al., 2011). The third hypothesis (H3) is that higher sympathy and adjustment but lower distress scores will predict increased obsessive symptoms due to the egosyntonic nature of OCPD and the theory that obsessive thoughts are in a continuum in the population and it is frequency and intensity that defines clinical pathology of obsessions and compulsions (Berry and Laskey, 2012). The fourth hypothesis (H4) is that gender (H4a), personal experience of mental illness (H4b), study of psychology (H4c) and contact with a mental patient (H4d) would predict mental health literacy of OCPD and ratings of distress, sympathy and adjustment.
2. Method
11.7% (N¼40) held a postgraduate degree, 2.6% (N¼ 9) held other higher qualifications, 2.4% (N¼8) held GCSEs/American 10th grade, 2.9% (N¼ 10) had graduated a foundation course and 3.8% (N¼ 13) held no academic qualifications. Regarding their occupational status, many of the respondents were students (75.4%, N¼ 258), but there were also some participants in professional occupations (9.6%, N¼ 33), intermediate occupations (10.5%, N¼ 36), skilled occupations (1.8%, N¼6), semi-skilled occupations (0.9%, N¼ 3), unskilled occupations (0.3%, N¼1), or other types of occupations (i.e. Armed Forces) (1.5%, N¼ 5). The minority of participants had not studied Psychology (26.0%) or Psychiatry (7.5%). Additionally, most of the participants had not been diagnosed with a mental disorder (95.0%, N¼ 325). The most common disorders among participants who had been diagnosed with a mental disorder (5.0%, N¼ 17) were depression (41.2%, N¼ 7) and anxiety disorders including OCD (35.3%, N¼ 6). More than half of the respondents (53.2%, N¼182) had known someone who has been diagnosed with a mental disorder. The majority had known someone who has been diagnosed with depression (48.4%, N¼ 88).
2.2. Measures Vignettes. The questionnaire consisted of five vignettes, describing one case of depression, one case of OCPD, one case of schizophrenia and two cases of OCD to check for reliability given that this is an issue in this research area (Sai and Furnham, 2013). The data for the two OCD cases were combined to attempt to ensure greater reliability in the analysis. The vignette describing a depressive patient was adapted from Jorm et al. (2006) and the vignette describing the schizophrenia case was adapted from Link et al. (1999). The OCPD vignette was adapted from Furnham and Winceslaus (2012). The first OCD (OCD1) vignette was adapted from Pirutinsky et al. (2009) and the second OCD (OCD2) vignette was adapted from a training programme developed by Coyle (2002). All of the vignettes were typical cases in order to demonstrate the criteria of each disorder in an easily comprehensible manner. The vignettes' length ranged from 71 to 205 (words). Half the participants completed the male version and the other half the female version of each vignette (see Appendix). In both versions the vignettes were presented in the order of depression, OCPD, schizophrenia, OCD1 and OCD2. After each vignette participants were asked to answer an open-ended question ‘What, if anything, would you say is X's main problem?’ There was a qualitative content analysis on the participant's responses for maximal response identification. Participants' responses to this question were also categorised as either ‘correct’ or ‘incorrect’ in order to determine how many participants correctly identified each vignette. For the depression vignette, correct answers were considered to be ‘depression’ and ‘depressed’. For the schizophrenia vignette, ‘paranoid schizophrenia’, ‘schizophrenia’ and ‘schizophrenic’ were deemed correct. For the OCPD vignette, ‘obsessive–compulsive personality disorder’ and ‘OCPD’ were deemed correct. Finally, for the OCD vignette, ‘compulsive disorder’, ‘OCD’, ‘obsessive’ and ‘obsessive–compulsive behaviour’ was deemed correct. There were essentially two ways to get either a correct or incorrect score: if the answer used the above labels or suggested the person understood the condition the answer was considered correct; if there was no response, or an incorrect label or description was used the response was considered incorrect. After each vignette there were five questions based on a Likert scale ranging from 1 (Not at all) to 7 (Extremely). These questions' scope was to evaluate the degree to which participants felt sympathetic towards the described patient and whether they found the patient's condition distressing. Additionally, they evaluated the degree to which they thought the patient was happy, successful at their work or school, and satisfied with their personal relationships.
2.3. Procedure The study was approved by the appropriate college ethics committee. The questionnaire was distributed either in its online form (mass emails) or in person using an opportunistic sampling method, in an effort to obtain a representative sample. Non-student participants were recruited by the second author at various non-academic conferences he attended. Approximately half completed the study on-line and half by paper copy. Analysis showed fewer than chance significant differences in either the demographics or responses of the two groups. All participants signed a consent form prior to their participation and they were all informed of the anonymous and confidential nature of the questionnaire. No remuneration was offered. Participants were informed that the questionnaire was regarding their beliefs and attitudes towards the mentally ill. Those who completed the paper copy were debriefed and thanked for their participation.
2.1. Participants
3. Results A total of 342 participants took part in this study, of whom 129 were male (37.7%) and 213 were female (62.3%). The age range of participants was between 18 and 65 years (M¼23.31, S.D.¼ 12.03). The majority of participants were White (69.0%, N¼ 236), with the remainder being Asian (21.3%, N¼ 73), mixed (4.7%, N¼ 16), Black AfricanCaribbean (1.2%, N¼ 4), Hispanic (0.6%, N¼ 2), or other (3.2%, N¼11). The majority held a high-school diploma (43.0%, N¼ 147), 33.6% (N¼ 115) held an undergraduate degree,
3.1. Vignette identification analysis Gender of patient described in the vignette was counterbalanced successfully as there were no significant differences in the
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two types of questionnaire (F (1, 340)¼ 0.10, p¼ 0.75). Depression was identified by 79.0% of the participants, schizophrenia by 59.0%, OCD by 63.0% of the participants and OCPD by only 2.0%. Thus if OCD and OCPD were combined and considered equivalently ‘correct’ it meant just under two thirds of the population were able to detect/label the disorder correctly. Depression was significantly more identified than OCPD (x2 (1, N ¼342) ¼261.00, p o0.001). Schizophrenia was also significantly more identified than OCPD (x2 (1, N ¼342)¼ 188.24, p o0.001). Results from the two OCD cases were similar and not statistically different. Finally, OCD was also significantly identified more than OCPD (x2 (1, N ¼342) ¼202.12, p o0.001).
3.2. Vignette labelling analysis A content analysis was further conducted in order to identify the most common lay labels of OCPD. Table 1 shows the rankings of answers provided by participants in the open-ended question ‘What do you think is X's main problem?’ The label ‘perfectionism/ perfectionist’ was most common in participants’ responses. Interestingly, 14.9% of participants identified OCPD as OCD. Ratings of Distress, Sympathy and Adjustment. The results showed that the differences in the means of the ratings for patient distress were significant between the different disorders (F (2.8, 937.8)¼ 134.28, po0.001). Post hoc pairwise comparisons of the distress means of each disorder, with Bonferroni adjustments was conducted in order to identify where the significant differences lay. Depression (M¼ 5.98) differed significantly from OCPD (M¼4.92) (t (341)¼12.60, po0.001), schizophrenia (M¼6.30) (t (341)¼4.85, po0.001) and OCD (M¼ 5.50) (t (341)¼6.88, po0.001). Schizophrenia also yielded significantly higher distress scores than OCPD (t (341)¼17.14, po0.001) and OCD (t (341)¼12.92, po0.001). OCD differed significantly from OCPD (t (341)¼ 7.73, po0.001). Overall, OCPD ratings yielded the lowest distress ratings. Sympathy ratings towards vignette characters were also compared among mental disorders using a one-way repeated measure ANOVA. The results showed that the differences between ratings of sympathy towards the different cases of mental disorders were significant (F (2.8, 950.5) ¼186.76, po 0.001). Additional post hoc pairwise comparisons with Bonferroni adjustments indicated that depression (M¼ 5.32) had significantly higher sympathy ratings than OCPD (M¼3.67) (t (341) ¼ 17. 76, p o0.001), but lower than schizophrenia (M¼5.51) (t (341) ¼2.37, p ¼0.019) and OCD (M¼4.79) (t (341)¼6.76, po0.001). Schizophrenia differed significantly from OCPD (t (341)¼18.80, po0.001) and OCD (t (341)¼ 9.67, po0.001). OCD also yielded significantly higher sympathy scores than OCPD (t (341)¼ 13.31, po0.001). Overall, participants felt lowest sympathy for OCPD patients.
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Adjustment ratings of each person described in the vignettes were also compared between the different disorders. Adjustment scores were computed by adding up the participants’ ratings on the patient’s happiness, quality of relationships and success at work (Fig. 1). The rationale for this computation was that the ratings were highly significantly correlated (r 40.50) within and between vignettes. The results indicated that the differences between lay adjustment ratings for each disorder were significant (F (3, 1023)¼ 456.47, p o0.001). Further post hoc pairwise comparisons with Bonferroni adjustments indicated that depression (M ¼5.82) had significantly lower adjustment ratings than OCPD (M¼ 10.47) (t (341) ¼28.31, p o0.001) and OCD (M ¼9.83) (t (341) ¼24.39, p o0.001). Schizophrenia (M ¼5.89) differed significantly from OCD (t (341) ¼23.25, p o0.001) and OCPD (t (341) ¼ 26.79, p o0.001). OCD showed significantly lower adjustment ratings than OCPD (t (341) ¼ 3.85, p o0.001). However, depression and schizophrenia patients did not differ significantly in their adjustment ratings (t (341) ¼ 0.417, p ¼0.667). 3.3. Demographic variables One-way independent samples ANOVAs were conducted for each control variable with OCPD identification and ratings of distress, sympathy and adjustment as dependent variables. In terms of gender, females’ mean rating of distress for the OCPD vignette was 5.08 whereas the males’ mean rating was 4.67. This difference was significant (F (1, 340) ¼7.06, p ¼0.008). Additionally, females yielded a lower average score of sympathy ratings (M ¼3.67) compared to males (M¼4.43) and this difference was also significant (F (1, 340) ¼4.75, p¼ 0.030). Finally, there was also a significant difference between genders in adjustment ratings (F (1, 340) ¼12.35, p o0.001) with females (M ¼10.10) scoring lower in the adjustment scale of the OCPD vignette than males (M ¼11.08). Participants who have studied psychology and mental illnesses yielded significantly higher scores on distress (M¼ 5.22) than participants who have not studied psychology (M¼ 4.81) (F (1, 340)¼5.82, p¼0.016). Similarly, participants who had studied psychology scored significantly higher in sympathy (M¼4.30) than the ones who had not (M¼3.45) (F (1, 340)¼20.92, po0.001). Finally, those who knew someone with a mental illness yielded significantly higher scores on sympathy towards OCPD patients (M ¼3.83) than the ones who did not (M¼ 3.49) (F (1, 340) ¼3.92,
Table1 Ranking of lay beliefs of obsessive–compulsive personality disorder. Label category Perfectionism/perfectionist ‘Workaholic’/addicted to work/works too hard/too focused on work Obsessive compulsive disorder Other/non-specific (i.e. selfish, indecisive) Anxiety disorder/stress/unable to relax ‘Control freak’/need to control/controlling Obsessions/compulsions Obsessive compulsive personality disorder Retentive personality/type A personality/neurotic Nothing/do not know Mania/autism Total
Participants (%) 20.5 15.8 14.9 14.5 12.6 11.1 3.8 2.0 1.8 1.5 1.5 100.0
Fig. 1. Mean lay ratings of adjustment for depression, OCPD, schizophrenia and OCD.
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p ¼0.048). They also scored the OCPD case with significantly lower adjustment score (M ¼9.97) than the participants who did not have contact with someone with a mental disorder (M¼ 11.02). A multiple regression was computed to test the fourth hypothesis but was not significant. Personal experience of a mental disorder did not predict ratings of distress, sympathy or adjustment. None of the demographic variables predicted OCPD identification, but this could be due to the highly skewed responses and the very low percentage of correct responses.
4. Discussion This study addressed the mental health literacy of lay people in terms of the obsessive–compulsive personality disorder. It is evident from the results that this relatively well-educated sample had very little understanding of OCPD and the majority of them were unable to identify it as a mental illness. The first hypothesis that OCPD would be less recognised than depression, schizophrenia and OCD (Furnham et al., 2011) was supported. The analysis of the vignette identification task revealed that depression yielded the highest identification score, fitting in line with previous research (Jorm et al., 1997; Furnham et al., 2009). This could be explained by the fact that the other disorders are much more common in everyday language and mass media (Furnham and Buck, 2003). Additionally, the vignette labelling analysis showed that participants most commonly labelled OCPD patients as ‘perfectionists’. Perfectionism is the primary and most consistent factor associated with OCPD (de Reus and Emmelkamp, 2010). This could imply that participants may have an understanding of the symptomatology of OCPD but may not know the psychological term for it (Link et al., 1999). This could also be argued due to the fact that approximately 15% of the participants labelled OCPD as OCD, showing an understanding of the obsessive nature of OCPD. This could possibly correspond to the academic view of obsessive compulsive spectrum disorders, implying that OCPD and OCD are both part of a continuum (Pollak, 1979). Consistent with the second hypothesis, ratings of distress and sympathy were lower for OCPD than any other disorder. Additionally, adjustment ratings were significantly higher for OCPD than the other disorders. Furnham et al. (2011) suggested that the more likely a participant was to identify a psychological problem in a vignette, the less likely they were to rate the described individual as well adjusted. Additionally, low recognition of OCPD as a mental illness could explain the low ratings of distress and sympathy. The fact that OCPD is an egosyntonic disorder may account for the higher perceived adjustment ratings (Cullen et al., 2008), though requires further exploration. It has also been argued that OCPD may enhance life functioning and employment success in certain circumstances (Ullrich et al., 2007). Therefore, participants may not perceive OCPD as a mental disorder but more as a trait (i.e. perfectionism) that does not have a severe impact on their adjustment and does not cause a significant amount of distress. It was predicted that higher sympathy and adjustment ratings but lower distress ratings will predict increased obsessive thoughts due to the egosyntonic nature of OCPD. Results indicated that only adjustment significantly contributed to the explanation of the variability in sub-clinical obsessive thoughts. Clearly people have relatively little understanding of OCPD. Results indicated that females rated higher distress and sympathy but lower adjustment in OCPD individuals. These results are consistent with previous literature. Females tend to show higher social empathy, which may affect their perceptions of emotion (Furnham et al., 2009, 2011; Furnham and Manning, 1997). Also participants who had contact with an individual with a mental disorder rated significantly higher sympathy and lower adjustment for OCPD
individuals (Lauber et al., 2003). Regression results showed however that none of the demographic variables predicted OCPD identification, but it is speculated that it is due to the highly skewed responses in vignette identification. This study has several implications of mental health literacy of OCPD. The fact that the vast majority of participants failed to recognise the disorder implies that lay people have very little understanding of the nature of OCPD as a mental illness. This could have detrimental implications on the treatment seeking behaviour of patients. Cullen et al. (2008) found that increased symptomatology of OCPD is correlated with lower treatment seeking primarily due to the egosyntonic nature of OCPD. Farrer et al. (2008) suggested that help-seeking can be improved with better recognition of mental disorders and increased understanding of causes and treatments. Lauber et al. (2001) suggested that help-seeking behaviour of mental patients is greatly affected by the recommendations of their social network. This implies that if their social network, family and peers, are adequately informed of the nature of OCPD, they encourage the person to seek treatment (Furnham et al., 2011). The nature of OCPD also causes difficulty in the therapeutic alliance. Very often patients believe they have no reason for being treated. However, an improved OCPD literacy could allow the patient to recognise the pathological nature of their condition and build an effective and co-operative relationship with the therapist (Cummings et al., 2011). Recognition of OCPD has also a great influence on the attitude and behaviour towards OCPD patients and it is, thus, crucial in the context of anti-stigma campaigns and measures against discrimination towards the mentally ill (Lauber et al., 2003). Interestingly, it has been found that stereotypes of dangerousness are on the increase and that the stigma of mental patients remains a detrimental feature of the lives of people with such conditions (Markowitz, 1998). Link et al. (1999) also found that social distance towards a mentally ill person is not caused solely because of their undesirable traits but also because they induce fear. Therefore, better mental health literacy will aim to inform the public of the true behavioural manifestations of OCPD and reduce stigmatisation. Mental health literacy for OCPD could be improved by mass media campaigns, school-based programmes or educational interventions within families. Other ways of enhancing mental health literacy of OCPD could potentially include the promotion of Mental Health First Aid Training aiming to inform the public of the nature of mental disorders (Kitchener and Jorm, 2002). There are however several limitations to this study. First of all, the sample cannot be considered representative, as participants tended to be young and well educated, which may affect the knowledge of psychiatric literacy. Further, their choice to participate could lead to inherent biases such that it yields an over optimistic view of MHL. Further there may well be significant culture differences in MHL with regard to this topic such that OCPD is rated a more serious and distressing problem in some cultures rather than others. Personality disorders have been highly debated in the western psychiatry and their classification and diagnosis have changed throughout the years. Next, it could also be argued that the vignette methodology presents limitations in terms of the extent to which the vignettes describe salient behaviours of each disorder (Williams et al, 2012). It is important to equate the severity of the disorder when comparing vignettes which must have a direct affect on the ratings of distress and adjustments. This suggests the importance of pilot work to ensure severity equivalence. Also an improvement could be the presentation of supplementary material to the vignettes, for example, a video tape recording of patients. Also in this study we did not have another personality disorder to examine whether there is a difference in ratings of AXIS I and AXIS II disorders. In this study we only had AXIS I disorders for comparison thus
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we could not know whether there was a difference in the MHL with respect to the different axes. Riedel-Heller et al. (2005) pointed out that in real-life people are forced to act and make informed decisions in terms of psychological treatments. Therefore, it may be important to focus on the decision-making process of individuals in terms of their action plan when a member of their social network is diagnosed with a mental disorder in real-life circumstances. Regardless of their beliefs, decision-making takes into account a number of other factors (i.e. cost of therapy, temperament of the patient) before choosing the right treatment option. Future research could potentially investigate the motives behind the beliefs of participants. It would also be interesting to investigate potential causal relationships between social and psychological circumstances and mental health literacy. It is also possible that by describing the study as ‘beliefs about and attitudes towards the mentally ill’ the results are biased in that participant’s were primed to think the individuals in the vignettes had some sort of mental illness. A different label may have overcome this problem. Finally the study did not look at help-seeking beliefs: namely what participants described in each vignettes might or should do to get help for their problems. This may yield a particularly useful insight into the perceived aetiology and prognosis for OCPD.
Appendix 1. The five vignettes 1. Jane has been feeling down recently, she finds it difficult to get out of bed in the morning and has been having difficulty sleeping. She cannot find the energy or motivation to do anything, including going to work or seeing her friends. Even walking around the house feels like an effort. She has lost her appetite and subsequently lost weight. She frequently thinks about death, and sometimes considers committing suicide. (DEPRESSION) 2. Laura is a married 45-year old lawyer. She was the youngest full partner in the firm’s history and is known as the hardest driving member of the firm. She is too proud to turn down a new case and too much of a perfectionist to be satisfied with the work done by her assistants. Displeased by their writing style and sentence structure she finds herself constantly correcting their briefs and therefore is unable to keep up with her schedule. When assignments get backed up, she cannot decide which to address first, starts making schedules for herself and her staff, but then is unable to meet them and starts working 15 h a day. Laura never seemed to be able to relax. Even on vacations, she develops elaborate activity schedules for every family member and gets angry and impatient if they refuse to follow her plans. Her husband is fed up with their marriage and can no longer tolerate the emotional coldness, rigid demands and long working hours. (OCPD) 3. Up until a year ago, life was pretty okay for Jack. But then, things started to change. He thought that people around him were making disapproving comments and talking behind his back. Jack was convinced that people were spying on him and that they could hear what he was thinking. Jack lost his drive to participate in his usual work and family activities and retreated to his home, eventually spending most of his day in his room. Jack was hearing voices even though no one else was around. These voices told him what to do and what to think. He has been living this way for six months. (SCHIZOPHRENIA) 4. Ben is 19 years old and lives at home while learning at a college town. Ben has difficulty with his front door. Whenever leaving his house, he thinks that he has not locked the door and he
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feels compelled to return to his door over and over again to check that it is locked. He also feels unable to leave his home unless he looks over his front windows five times, to check that they are not broken. Consequently, it can take Ben an extra hour to leave his house and get to college, and yet, when he leaves, he is still concerned that his door is not locked. Recently, Ben saw a sign in the street warning about open manhole covers during construction. Since then, he has become preoccupied with ensuring that all the manhole covers in the street are closed, that they are lying flat and level with the road, and that there are no gaps between the covers and the holes. Ben checks manhole covers whenever he goes to college and he finds himself worrying about them throughout his way to college. These worries increasingly consume his daily life and those around him have become concerned. (OCD) 5. James is a 15-year old African American male who lives with his mother in a lower middle class neighbourhood bordering a major metropolitan area. James's mother has a history of generalised anxiety disorder (GAD). In fact, when she is particularly anxious and tense, his mother occasionally verbally berates James and then apologizes when she is feeling somewhat calmer. James has no known medical problems. James has a great deal of difficulty concentrating on and completing any of his school work. He wants to do well and his mother supports his educational success. However, he is constantly distracted by powerful and strange thoughts, such as counting how many times he blinks and how many steps it takes to get to the hallway. The possibility that germs could be on door handles or windows also forces him to avoid touching them unless he first uses a cloth (which he carries with him always) to clean them off. In fact, if he misplaces or forgets to bring a clean cloth with him, he feels a great deal of anxiety, feels paralyzed, and may get physically ill. James realizes that his behaviour does not make sense, and it frustrates him a lot that he cannot overcome these powerful thoughts. (OCD)
References American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. American Psychiatric Association, Washington DC. (DSM-5). Berry, L.M., Laskey, B., 2012. A review of obsessive intrusive thoughts in the general population. Journal of Obsessive-Compulsive and Related Disorders 1, 125–132. Coles, M.E., Heimberg, R.G., Weiss, B.D., 2013. The public's knowledge and beliefs about obsessive compulsive disorder. Depression and Anxiety 30, 778–785. Coyle, S., 2002. Anxiety and related disorders in children and adolescents: a training outline, the Pennsylvania child welfare training program. University of Pittsburgh, Pittsburgh, PA. Cullen, G., Samuels, J.F., Pinto, A., Fyer, A.J., McCracken, J.T., Rauch, S.L., Murphy, D.L., Greenberg, B.D., Knowles, J.A., Piacentini, J., Bienvenu, O.J., Grados, M.A., Riddle, M.A., Rasmussen, S.A., Pauls, D.L., Willour, V.L., Shugart, Y.Y., Liang, K.Y., HoehnSaric, R., Nesdadt, G., 2008. Demographic and clinical characteristics associated with treatment status in family members with obsessive-compulsive disorder. Depression and Anxiety 25, 218–224. Cummings, J.A., Hayes, A.M., Newman, C.F., Beck, A.T., 2011. Navigating therapeutic alliance ruptures in cognitive therapy for avoidant and obsessive-compulsive personality disorders and comorbid axis I disorders. International Journal of Cognitive Therapy 4, 397–414. de Reus, R.J.M., Emmelkamp, P.M.G., 2010. Obsessive-compulsive personality disorder: a review of current empirical findings. Personality and Mental Health 6, 1–21. Farrer, L., Leach, L., Griffiths, K.M., Christensen, H., Jorm, A.F., 2008. Age differences in mental health literacy. BMC Public Health 8, 125. Fischer, L.J., Goldney, R.D., 2003. Differences in community mental health literacy in older and younger Australians. International Journal of Geriatric Psychiatry 18, 33–40. Furnham, A., Abajian, N., McClelland, A., 2011. Psychiatric literacy and personality disorders. Psychiatry Research 189, 110–114. Furnham, A., Buck, C., 2003. A comparison of lay-beliefs about autism and obsessive-compulsive disorder. International Journal of Social Psychiatry 49, 287–307.
228
I. Koutoufa, A. Furnham / Psychiatry Research 215 (2014) 223–228
Furnham, A., Dadabhoy, H., 2012. Beliefs about causes, behavioural manifestations and treatment of borderline personality disorder in a community sample. Psychiatry Research 197, 307–313. Furnham, A., Daoud, Y., Swami, V., 2009. “How to spot a psychopath”. Lay theories of psychopathy. Social Psychiatry and Psychiatric Epidemiology 44, 464–472. Furnham, A., Manning, R., 1997. Young people's theories of anorexia nervosa and obesity. Counseling Psychology Quarterly 10, 389–415. Furnham, A., Winceslaus, J., 2012. Psychiatric literacy and the personality disorders. Psychopathology 45, 29–41. Furnham, A., Annis, J., Cleridou, K., Gender differences in the mental health literacy of young people. International Journal of Adolescent Medicine and Health, http://dx.doi.org/10.1177/0004867413495317, in press. Jorm, A.F., 2000. Mental health literacy: public knowledge and beliefs about mental disorders. British Journal of Psychiatry 177, 396–401. Jorm, A., Christensen, H., Griffiths, K.M., 2006. The public's ability to recognize mental disorders and their beliefs about treatment: changes in Australia over 8 years. Australian and New Zealand Journal of Psychiatry 40, 36–41. Jorm, A., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B., Politt, P., 1997. Mental health literacy: a survey of the public's ability to recognize mental disorder and their beliefs about the effectiveness of treatment. The Medical Journal of Australia 166, 182–186. Kitchener, B.A., Jorm, A.F., 2002. Mental health first aid training for the public: evaluation of effects on knowledge, attitudes and helping behaviour. BMC Psychiatry 2, 10. Kleinman, A., 1988. Rethinking Psychiatry: from Cultural Category to Personal Experience. Free Press, New York. Lauber, C., Nordt, C., Falcato, L., Rossler, W., 2001. Lay recommendations on how to treat mental disorder. Social Psychiatry and Psychiatric Epidemiology 36, 553–556. Lauber, C.V., Nordt, C., Falcato, L., Rossler, W., 2003. Do people recognize mental illness? Factors influencing mental health literacy. European Archives of Psychiatry and Clinical Neuroscience 253, 248–251. Link, B.G., Phelan, J.C., Bresnaham, M., Stueve, A., Pescosolido, B.A., 1999. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89, 1328–1333.
Mancebo, M.C., Eisen, J.L., Grant, J.E., Rasmussen, S.A., 2005. Obsessive–compulsive disorder: clinical characteristics, diagnostic difficulties, and treatment. Annals of Clinical Psychiatry 17, 197–207. Markowitz, F., 1998. The effects of stigma on the psychological well-being and life satisfaction of persons with mental illness. Journal of Health and Social Behavior 39, 335–347. Pirutinsky, S., Rosmarin, D.H., Pargament, K.I., 2009. Community attitudes towards culture-influenced mental illness: scrupulosity vs. non-religious OCD among orthodox jews. Journal of Community Psychology 37, 949–958. Pollak, J.M., 1979. Obsessive–compulsive personality: a review. Psychological Bulletin 86, 225–241. Reavley, N.J., Jorm, A.F., 2013. Willingness to disclose a mental disorder and knowledge of disorders in others: changes in Australia over 16 years. Australian and New Zealand Journal of Psychiatry, http://dxdoi.org/10.1177/ 0004867413495317, in press. Riedel-Heller, S.G., Matschinger, H., Angermeyer, M.C., 2005. Mental disorders— who and what might help? Social Psychiatry and Psychiatric Epidemiology 40, 167–174. Rogler, L.H., Cortes, D.E., 1993. Help-seeking pathways: a unifying concept in mental health care. American Journal of Psychiatry 150, 554–561. Sai, G., Furnham, A., 2013. Identifying depression and schizophrenia using vignettes: a methodological note. Psychiatry Research 210, 357–362. Schomerus, G., Matschinger, H., Angermeyer, M.C., 2013. Continuum beliefs and stigmatizing attitudes towards persons with schizophrenia, depression and alcohol dependence. Psychiatry Research 209, 665–669. Taylor, S., Asmundson, G.J., Jang, K.L., 2011. Etiology of obsessive–compulsive symptoms and obsessive–compulsive personality traits: common genes, mostly different environments. Depression and Anxiety 28, 863–869. Ullrich, S., Farrington, D.P., Coid, J.W., 2007. Dimensions of DSM-IV personality disorders and life-success. Journal of Personality Disorders 21, 657–663. Williams, M.T., Mugno, B., Franklin, M., Faber, S., 2012. Symptom dimensions in obsessive-compulsive disorder. Psychopathology 46, 365–376.