Perceived parental rearing style in obsessive–compulsive disorder: relation to symptom dimensions

Psychiatry Research 127 (2004) 267 – 278 www.elsevier.com/locate/psychres

Perceived parental rearing style in obsessive–compulsive disorder: relation to symptom dimensions Pino Alonso a, Jose´ M. Mencho´n a, David Mataix-Cols b, Josep Pifarre´ a, Mikel Urretavizcaya a, Jose´ M. Crespo a, Susana Jime´nez a, Gema Vallejo a, Julio Vallejo a,* a

Obsessive – Compulsive Disorder Clinical and Research Unit, Department of Psychiatry, Hospital Prı´ncipes de Espan˜a, Ciudad Sanitaria y Universitaria de Bellvitge, c/ Feixa Llarga s/n 08907, Hospitalet de Llobregat, Barcelona, Spain b Department of Psychiatry, Imperial College of Science, Technology and Medicine, Charing Cross Hospital, London, UK Received 2 May 2002; received in revised form 19 November 2002; accepted 18 February 2003

Abstract Obsessive – compulsive disorder (OCD) runs in families, but the specific contribution of genetic and environmental factors to its development is not well understood. The aim of this study was to assess whether there are differences in perceived parental child-rearing practices between OCD patients and healthy controls, and whether any relationship exists between parental characteristics, depressive symptoms and the expression of particular OCD symptom dimensions. A group of 40 OCD outpatients and 40 matched healthy controls received the EMBU (Own Memories of Parental Rearing Experiences in Childhood), a self-report measure of perceived parental child-rearing style. The Yale – Brown Obsessive – Compulsive Scale (Y – BOCS) and the Hamilton Depression Rating Scale (HDRS) were used to assess the severity of obsessive – compulsive and depressive symptoms. The Y – BOCS Symptom Checklist was used to assess the nature of obsessive – compulsive symptoms, considering the following five symptom dimensions: contamination/cleaning, aggressive/checking, symmetry/ ordering, sexual/religious and hoarding. Logistic and multiple linear regression analyses were conducted to study the relationship between parental style of upbringing, depressive symptoms and OCD symptom dimensions. Severe OCD (Y – BOCS: 27.0 F 7.4) and mild to moderate depressive symptoms (HDRS: 14.0 F 5.4) were detected in our sample. Compared with healthy controls, OCD patients perceived higher levels of rejection from their fathers. No differences between the groups with respect to perceived levels of overprotection were detected. The seventy of depressive symptoms could not be predicted by scores on any perceived parental characteristics. Hoarding was the only OCD symptom dimension that could be partially predicted by parental traits, specifically low parental emotional warmth. Social/cultural variables such as parental child-rearing patterns, in interaction with biological and genetic factors, may contribute to the expression of the OCD phenotype. D 2004 Published by Elsevier Ireland Ltd. Keywords: Family; Symptom dimensions; Depression

1. Introduction * Corresponding author. Tel.: +34-0-93-2607659; fax: +34-093-2607658. E-mail address: [email protected] (J. Vallejo).

Obsessive – compulsive disorder (OCD) is defined by the presence of obsessions or compulsions that

0165-1781/$ - see front matter D 2004 Published by Elsevier Ireland Ltd. doi:10.1016/j.psychres.2001.12.002

268

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278

are a significant source of distress or that interfere with the patient’s social functioning (American Psychiatric Association, 1994). Although current neurobiological theories of OCD emphasize the implication of dysfunctional corticostriatal circuits in the etiology of the disorder, behavioral theorists have suggested that social learning factors may also contribute to its development in biologically vulnerable subjects. Parental child-rearing patterns have been proposed as one of these social factors, but no agreement has been reached either on the exact influence of parental behaviors in the development of OCD or on its relationship to specific obsessive – compulsive symptoms (Hoover and Insel, 1984; Rasmussen and Tsuang, 1984). Parental behaviors, especially concerning the ability to express affection and emotional warmth and to avoid excessive protection, control and criticism, seem to be important in the development of a healthy personality. Rejecting and controlling parenting styles have been described as being associated with a variety of forms of psychopathology, including depression, schizophrenia, anxiety disorders, substance abuse, oppositional child behavior and eating disorders (Parker et al., 1987; Gerlsma and Emmelkamp, 1990; De Rutter, 1994; Rapee, 1997). Most of the studies in this area have focused on the relationship between anxiety disorders and depression and parental characteristics. In a review of the literature related to this last issue, Rapee (1997) describes two main child-rearing factors. One, which includes behaviors and attitudes related to negative or hostile feelings toward the child, is termed rejection or criticism. The second factor, which refers to behaviors designed to protect the child from possible harm, is called parental control or protection. A rearing style characterized by low parental affection and high parental control appears to be related to anxiety disorders and depression, with the most consistent results obtained for social phobia. Interestingly, some data appear to indicate a somewhat stronger relationship between parental rejection and depression and between parental control and anxiety. Nevertheless, investigation in this area suffers from great methodological limitations. Most studies have employed retrospective self-report measures given to the offspring, a considerably smaller number of studies have examined child-rearing attitudes by

directly questioning parents, and direct observations have been rarely conducted. Other methodological weaknesses include the use of a great variety of methods and more or less reliable measures to assess parental characteristics, small sample sizes and the lack of appropriate comparison groups. Despite all these limitations, results indicate that a small but significant amount of variance in anxiety and depression may be accounted for by perceived parental rejection and control. Few studies concerning the influence of early parenting behaviors and attitudes in the development of OCD have been conducted hitherto. Sub-clinical obsessive – compulsive subjects have been reported to perceive their parents as more rejecting, overprotecting and less emotionally warm than normal controls (Ehiobuche, 1988; Kimidis et al., 1992; Cavedo and Parker, 1994). Results obtained from clinical samples are controversial and often contradictory. Hafner (1988) described high levels of parental overprotection in 81 subjects (mean age 35.7 F 12.5) who were registered as sufferers in the Obsessive –Compulsive Neurosis Support Group of South Australia. Subjects completed the Parental Bonding Instrument (PBI), a self-report measure of an individual’s perception of his or her parents’ rearing practices up to the age of 16 years. Methodological weaknesses of the study include the fact that subjects were not directly interviewed by the author, diagnosis was established only on the basis of the results of the Padua Inventory of Obsessions and Compulsions and the Brief Symptoms Inventory, and the absence of a specific control group. Employing the EMBU, a self-report measure of an individual’s perception of his or her parent’s rearing style during childhood, Hoekstra et al. (1989) compared 119 compulsive checkers and cleaners divided into four groups with 277 nonclinical controls. OCD subjects perceived more rejection and less emotional care from their parents than healthy controls, with higher levels of parental overprotection being reported only by compulsive washers. Vogel et al. (1997) employed the PBI to compare self-reported patterns of parental bonding in 26 OCD (mean age 35.2 F 12.1), 34 depressed (mean age 38.8 F 9.2) and 41 healthy subjects (mean age 37.8 F 11.2). Patients with a principal diagnosis of major depressive disorder experienced significantly lower levels of parental care and significantly higher

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278

levels of maternal overprotection than healthy controls, while no significant difference between OCD and normal subjects was detected. Since the presence of an additional diagnosis of depression in the OCD group (46% of the patients) was associated with significantly lower levels of parental care and higher levels of parental overprotection, the authors suggested that this parental rearing style may act as a vulnerability factor more specifically related to the development of depressive disorders than to OCD. The principal limitation of this study comes from the reduced number of OCD patients included in the analyses. Finally, Turgeon et al. (2002) have recently employed the PBI and the EMBU to compare recalled parental behaviors among 43 out-patients with OCD, 38 out-patients with panic disorder with agoraphobia (PDA) and 120 non-anxious controls. Patients with OCD and PDA did not significantly differ on mean scores on any of the PBI and EMBU scales. Participants with anxiety disorders compared with the non-anxious group rated both their mothers and fathers as more protective. No differences were found between the anxious and non-anxious groups on the Emotional Warmth, Rejection and Care scales. Limitations of this study include the fact that patients were not recruited from hospital settings but through advertisements in the media, so they constitute a selfselected sample, which may not represent general OCD patients. Another possible weakness may come from the recruitment of the control group, since healthy comparison subjects were not directly interviewed by the researchers but just psychiatrically screened by a telephone interview. The specific influence of child-rearing patterns on the development of different obsessive – compulsive symptoms has also been proposed with inconclusive results. Rachman and Hodgson (1980), who reported that parents of OCD patients are frequently described as overprotecting, overcontrolling and overcritical by their children, maintained that a distinction could be established between washers and checkers on this topic. According to these authors, a different fear structure, related to upbringing styles, would underlie the most common forms of ritualistic behavior in OCD: washing behavior would emerge from overprotective and overcontrolling families that produce fearful dependent children, while checking behavior would be related to overcritical and rejecting parents

269

who induce excessive fears of making mistakes in their children. However, this hypothesis has been only partially supported by later studies. While Turner et al. (1979) reported no significant differences between washers and checkers regarding fear of criticism, Steketee et al. (1985) found that checkers more often perceived their mothers as meticulous and demanding than washers did. Neither study found any significant differences regarding overprotection between washers and checkers. Nevertheless, on studying influences of parental behaviors in the development of obsessive – compulsive symptoms, one must not forget that OCD can have a devastating effect on the quality of family life (Steketee and Pruyn, 1998). Many families become dysfunctional as a result of a family member’s OCD symptoms. Frequently, parents and siblings become involved in the sufferer’s avoidance behaviors and compulsions in an effort to relieve the fear and anxiety that the patient is feeling. Family and leisure-time routines and activities are frequently modified to accommodate the OCD sufferer. All these efforts often lead relatives to experience severe feelings of frustration, anger, guilt and loneliness. Childrearing patterns may play a role in the development of OCD, but one should also consider that the primary presence of obsessive – compulsive symptoms in a child may also elicit certain parental behaviors and attitudes, especially a tendency to greater rejection and/or protection towards the affected child. Thus, the role of parental influences in the development of OCD and the relationship between parental child-rearing traits and OCD subtypes are still controversial topics. Previous studies employed categorically defined and mutually exclusive OCD subgroups, and only differences between washers and checkers, the most frequent OCD subtypes, were examined. To our knowledge, no previous studies have addressed the influence of perceived parental characteristics in the development of other frequent obsessive –compulsive symptoms such as hoarding, sexual/religious themes, symmetry or ordering. Since a possible influence of current mood state on the perception of parental rearing style has been postulated and parental rejection has been described as being associated with depression, we decided to study whether parental rearing patterns were related

270

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278

to the severity of depressive symptoms in our sample. The three-fold purpose of the present study was to examine whether (1) there are differences in perceived parental child-rearing patterns between OCD patients and healthy controls, (2) any relationship exists between perceived parental characteristics and previously identified OCD symptom dimensions, and (3) perceived parental traits are related to the presence of depressive symptoms in OCD.

2. Methods 2.1. Subjects Study participants were 40 outpatients consecutively admitted to the OCD Clinic of Bellvitge University Hospital (Barcelona, Spain) between 1997 and 1999. All patients met DSM-IV criteria for OCD (American Psychiatric Association, 1994). Diagnosis was independently assigned by two psychiatrists with extensive clinical experience in OCD, who separately interviewed the patients using the Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version (SCID-CV) (First et al., 1997). Patients were eligible when both research examiners agreed on all criteria. All patients gave written informed consent after complete description of the study. Exclusion criteria were the presence of any other comorbid axis I disorder and/or any neurological disorder. During the selection period, 67 outpatients of those referred for examination at the Department of Psychiatry of our hospital fulfilled DSM-IV criteria for OCD and were evaluated by the examiners. Of these patients, 27 were ruled out in accordance with the exclusion criteria: 18 (26.8%) because of concomitant major depression or dysthymia, seven (10.4%) because of comorbid anxiety disorders other than OCD and two (2.9%) because of fulfilling criteria for eating disorders. Forty normal comparison subjects, recruited from residents of the local community, were matched with patients for gender, age, years of education and socioeconomic status. They were asked to participate in a study on psychological health with no payment offered. They had no past or current history of psychiatric or neurological diagnoses as determined in a brief interview based on the Structured Clinical

Interview for DSM-III-R: Non-Patient Version (SCIDNP) (Spitzer et al., 1989) and the guidelines established by Shtasel et al. (1991) to exclude psychiatric disorders. 2.2. Clinical assessment Information was obtained on both sociodemographic—age, sex, years of education, years living at parents’ home and socioeconomic level following the Hollingshead and Redlich (1958) classification— and clinical variables (age at onset of OCD defined as age when symptoms became a significant source of distress and interfered with the patient’s social functioning). The severity of OCD was assessed using a clinician-administered version of the Yale – Brown Obsessive –Compulsive Scale (Y – BOCS) (Goodman et al., 1989), which establishes the following severity levels: subclinical (scores of 0 – 7), mild (8 – 15), moderate (16 – 23), severe (24 – 31) and extreme (32 –40). A clinician-administered version of the 21item Hamilton Depression Rating Scale (HDRS) (Hamilton, 1960) was used to assess the severity of depressive symptoms (scores of 0 – 63). The nature of OCD symptoms was ascertained via a clinician-administered version of the Y –BOCS Symptom Checklist (Goodman et al., 1989). This is a comprehensive list of more than 50 examples of obsessions and compulsions that can be grouped into 13 major categories. Despite some differences, recent factor-analytic studies have been fairly consistent in reducing the symptoms of OCD into a few clinically meaningful dimensions (Baer, 1994; Leckman et al., 1997; Mataix-Cols et al., 1999; Summerfeldt et al., 1999) that at least in adult patients, tend to remain stable over time (Mataix-Cols et al., 2002b). These dimensions are the following: (1) symmetry obsessions and repeating, counting and ordering compulsions; (2) hoarding obsessions and compulsions; (3) contamination obsessions and cleaning compulsions; (4) aggressive obsessions and checking; and (5) sexual/religious obsessions. Following the methodology of previous studies (Baer, 1994; Mataix-Cols et al., 1999), for each of these categories, if a patient identified at least one of the specific symptoms under that category as a principal or major problem, that category was assigned a score of 2. If a patient endorsed at least one of the specific symptoms but

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278

did not consider it to be a major problem, that category was assigned a score of 1. Finally, a score of 0 was assigned if a patient did not endorse any of the symptoms under that category. In this study, the patients’ scores on the five symptom dimensions identified in a previous study (Mataix-Cols et al., 1999), namely ‘Symmetry/ordering’, ‘Hoarding’, ‘Contamination/cleaning’, ‘Aggression/checking’ and ‘Sexual/Religious obsessions’, were computed by summing the scores of the symptom categories under each dimension and then used in all subsequent analyses. 2.3. Measurement of parental rearing-style The EMBU (Egna Minnen av Barndoms Uppfostran or Own Memories of Parental Rearing Experiences in Childhood) was used to assess the study participants’ memories about their parents’ rearing practices. The EMBU is an 81-item self-report measure of an individual’s perception of his or her parent’s rearing style during childhood (no specific reference is made to any time frame for which subjects are requested to remember their parent’s attitudes). All items are separately scored for the father and the mother on 4-point scales ranging from 1 (‘no, never’) to 4 (‘yes, most of the time’). The EMBU, initially developed in Sweden by Perris et al. (1980), has been adapted for use in over 25 countries and validated for different national contexts (Arrindell et al., 1986). The validated Spanish version of the EMBU was employed in the present study (Arrindell et al., 1988). The EMBU consists of 14 subscales, each of which contains items that give an indication of the degree to which each parent was described as abusive, depriving, punitive, shaming, rejecting, overprotective, overinvolved, tolerant, affectionate, performance oriented, guilt engendering, stimulating, favoring siblings and favoring the subject. In addition to these a priori dimensions, the EMBU contains two general questions that are also separately scored for the father and the mother: one concerned with the degree of consistency in parental rearing behavior and the other with the degree of strictness of parental rearing style. Factor analysis of the original EMBU version identified the following four primary dimensions: rejection, emotional warmth, overprotection and favoring subject, which are determined for both parents

271

independently (Arrindell and Van der Ende, 1984). Nevertheless, because it was not possible to reach a sufficient level of cross-national constancy in the favoring subject dimension, only the other three factors were considered in the translated versions. The EMBU has been widely used in studies of rearing style and different psychopathological conditions in several countries, and its psychometric properties have been found to be adequate (Anasagasti and Denia, 1988; Benjaminsen et al., 1990; Khalil and Stark, 1992). Although results on the EMBU dimensions are usually independently determined for the father and the mother, we decided to consider a global parental score (defined as the sum of father’s and mother’s scores) to assess not only the rearing style associated with one parent or another, but the influence of parental rearing practices jointly. 2.4. Statistical analysis Differences between the OCD and control groups in demographic and clinical variables—including the three subscales of the EMBU for both parents jointly and each parent separately—were investigated with one-way analyses of variance (ANOVAs) for continuous variables and chi-square tests for categorical variables. Mann – Whitney U tests were used for continuous variables when the Levene test for homogeneity of variances was significant. To control for error derived from multiple comparisons, the Bonferroni correction was employed (significance level was established at 0.016 when comparing both groups on the three main dependent variables, i.e. the subscales of the EMBU). Multiple linear regression analyses (stepwise method) were conducted to assess whether certain parental child-rearing patterns predicted the presence of specific obsessive –compulsive symptom dimensions. In these models, the patients’ scores on each of the subscales of the EMBU were entered as independent variables and the scores on the five previously identified OCD symptom dimensions (Mataix-Cols et al., 1999) as dependent variables. To control for the effect of symptom severity and depression, all analyses were repeated entering the total Y – BOCS and HDRS scores first in the models (enter method). Correlations between scores on perceived parental child-rearing patterns and clinical variables such as

272

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278

age at onset of OCD, severity of OCD and presence of depressive symptoms were examined with Pearson correlation coefficients. In order to further examine the possible relationship between perceived parental child-rearing patterns and the presence of depressive symptoms in OCD, patients were classified into the following two groups according to their scores on the HDRS: those with at least moderate depression (HDRS z 17; n = 14) and those with sub-clinical or mild depression (HDRS < 17; n = 26). This dichotomous variable was then used as the dependent variable in a logistic regression analysis (stepwise method) where patients’ scores on each of the subscales of the EMBU were entered as independent variables. The significance level was set at 0.05, and all analyses were conducted using the SPSS statistical package (version 10.0).

3. Results The demographic and clinical variables of the patient and control groups are shown in Table 1. There were no differences between the two groups with respect to sex, age, years of education, years living in the parental home or socioeconomic level. Patients’ scores on the Y –BOCS suggested the presence of severe OCD symptoms in our sample.

Patients’ scores on the HDRS were in the mild to moderate range. No patient met DSM-IV criteria for major depression, since the presence of a comorbid axis I disorder was an exclusion criterion. Frequencies of the major symptom dimensions of the Y –BOCS Symptom Checklist are listed in Table 2. As shown in Table 3, OCD patients perceived their fathers as more rejecting (U = 458.5, Z = 3.0, P = 0.003) than controls. Lower paternal emotional warmth was also described by OCD patients, but differences did not reach statistical significance since the use of the Bonferroni correction raised the level of significance to 0.016. When considered jointly, OCD patients perceived their parents as less emotionally warm than controls did, although this difference was not statistically significant after application of the Bonferroni correction. No difference between the groups could be detected regarding parental overprotection. In the OCD group, multiple linear regression analyses revealed strong negative partial correlations between scores on the hoarding dimension and perceived parental emotional warmth (R 2 = 0.24, beta = 0.49, t = 3.46, P = 0.001). These results remained unchanged when total Y – BOCS and HDRS scores were forced first into the models. None of the other OCD symptom dimensions were significantly related to perceived parental child-rearing patterns. No significant correlations were observed between scores on perceived parental traits and age at onset of

Table 1 Demographic and clinical characteristics of OCD patients and healthy comparison subjects OCD (n = 40)

Controls (n = 40)

Variable

N

%

N

%

v2

Sex, male Socioeconomic level Low-medium Medium Medium-high

20

50.0

20

50.0

0.00 0.00

12 18 10

30.0 45.0 25.0

12 18 10

30.0 45.0 25.0

Mean

S.D.

Range

Mean

S.D.

Range

F

d.f.

P

29.2 10.9 25.4 16.8 27.0 13.6 13.3 14.0

9.6 2.7 6.4 6.2 7.4 4.1 4.4 5.4

17 – 55

31.0 11.0 25.2

7.7 2.8 5.2

19 – 53

0.77 0.02 0.02

1.78 1.78 1.78

0.38 0.87 0.87

Age, years Education, years Living at parents’ home, years Illness onset, years Y – BOCS, total Y – BOCS, obsessions Y – BOCS, compulsions HDRS

6 – 38

d.f. 1 2

P 1.00 1.00

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278 Table 2 Frequencies of the major symptom dimensions of the Yale – Brown Obsessive – Compulsive Checklist in a group of 40 OCD patients

Hoarding Aggressive/checking Contamination/cleaning Sexual/religious Symmetry/ordering

Absent symptom

Present symptom

Major symptom

N

%

N

%

N

%

30 10 20 26 20

75.0 25.0 50.0 65.0 50.0

8 15 11 8 12

20.0 37.5 27.5 20.0 30.0

2 15 9 6 8

5.0 37.5 22.5 15.0 20.0

OCD, OCD severity or presence of depressive symptoms (Table 4). Logistic regression analysis showed that the severity of depressive symptomatology could not be predicted by perceived parental child-rearing patterns.

4. Discussion Patients with OCD perceived higher levels of rejection from their fathers than healthy controls. Lower levels of emotional warmth from their fathers and both parents considered jointly were also described by OCD sufferers, although these differences did not reach statistical significance. No significant difference regarding parental overprotection was detected between the groups. The presence of hoard-

273

ing symptoms was the only clinical dimension that could be partially predicted by perceived parental traits. Specifically, patients with high scores on the hoarding dimension perceived their parents as being less emotionally warm than patients with other symptoms. The severity of depressive symptoms in OCD patients could not be predicted by scores on any perceived parental characteristics. Previous research on the contribution of parental rearing practices to the development of OCD had yielded mixed results. While some authors described high levels of parental overprotection in OCD patients (Hafner, 1988; Merkel et al., 1993; Turgeon et al., 2002), others reported more rejection and less caring than in normal controls (Hoekstra et al., 1989) or no significant differences between patients and healthy subjects (Vogel et al., 1997). Our results support previous reports on the existence of differences in perceived parental styles of upbringing in OCD, mainly concerning rejection and emotional care, but do not support the previously reported relationship between parental overprotection and OCD. The influence of parental overprotection in the development of anxiety disorders or depression is still a controversial topic. An affectionless, controling rearing style (low parental affection and high parental control) has been reported to be associated with different anxiety disorders and depression (Gerlsma and Emmelkamp, 1990). Some studies have suggested that a specific

Table 3 Parental rearing style assessed by the EMBU in OCD patients and healthy controls Variable

OCD (n = 40) Mean

S.D.

Father Rejectiona Emotional warmth Overprotectiona

39.8 43.1 32.6

15.4 11.8 10.2

31.0 49.2 30.0

7.6 10.6 5.5

458.5 5.82 711.5

3.0 1.78 0.4

0.003 0.019b 0.62

Mother Rejectiona Emotional warmth Overprotectiona

38.2 49.8 34.1

12.2 11.7 9.6

33.7 53.5 34.3

6.7 9.0 5.5

685.0 2.40 732.0

1.1 1.78 0.6

0.26 0.12 0.51

Parents Rejectiona Emotional warmth Overprotectiona

78.0 92.9 66.7

26.9 21.9 19.4

65.1 102.1 64.8

11.1 18.4 8.7

580.0 3.99 713.0

1.8 1.78 0.47

0.07 0.04b 0.63

a b

Controls (n = 40) Mean S.D.

Mann Whitney U-tests were used when variances were not homogeneous. Application of the Bonferroni correction raised the significance level to 0.016.

F/U

d.f./Z

P

274

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278

Table 4 Correlations between scores on perceived parental child-rearing patterns assessed by the EMBU and clinical variables (age at onset of OCD, severity of OCD and depression) in a group of 40 OCD patients Age at onset of OCD

Y – BOCS

r

r

P

HDRS P

r

P

Father Rejection Emotional warmth Overprotection

0.18 0.07 0.01

0.26 0.66 0.9

0.11 0.28 0.01

0.48 0.07 0.92

0.03 0.25 0.09

0.81 0.10 0.57

Mother Rejection Emotional warmth Overprotection

0.24 0.19 0.04

0.12 0.23 0.78

0.01 0.18 0.001

0.94 0.24 0.99

0.07 0.25 0.12

0.66 0.11 0.45

Parents Rejection Emotional warmth Overprotection

0.21 0.06 0.03

0.18 0.69 0.84

0.07 0.25 0.008

0.66 0.11 0.96

0.01 0.27 0.10

0.94 0.08 0.50

relationship may exist between particular child-rearing patterns and specific emotional traits: parental control may be more closely related to anxiety whereas parental rejection may be more specifically related to depression. Other authors (Parker, 1979) have suggested that the interaction between these two child-rearing factors may be more important in the development of anxiety or depression than the separate influence of each one of them. Further studies are needed to clarify whether rejection and overprotection play a distinct role in the origins of anxiety and depression. Regarding the relationship between parental childrearing patterns and the development of specific OCD symptoms, our results do not support previous hypothesized differences between washers and checkers (Rachman and Hodgson, 1980). We found no significant associations between contamination/cleaning or aggressive/checking dimensions and any of the three parental rearing style factors defined by the EMBU. The presence of hoarding obsessions or compulsions was the only OCD symptom dimension that could be significantly predicted by perceived parental traits, specifically by low parental emotional warmth. The presence of hoarding obsessions and compulsions in OCD appears to be related to some particular clinical characteristics. Hoarding OCD is associated with higher levels of comorbidity (i.e. anxiety, depression, personality disorders), as well as work and

social disability compared with non-hoarding OCD and other anxiety disorders (Frost et al., 2000; MataixCols et al., 2000). Furthermore, these patients are less likely to be married (Frost and Gross, 1993) and a substantial number of treatment-seeking hoarders are socially phobic (Steketee et al., 2000). Hoarding OCD has also been associated with poorer treatment response to serotonergic agents and cognitive-behavioral therapy (Black et al., 1998; Mataix-Cols et al., 2002a). Alsobrook et al. (1999) have recently reported that a significant greater genetic component can be established in OCD patients with symmetry/ordering symptoms. The results of the current study may suggest that social variables such as parental childrearing style could especially contribute to the development of other OCD symptoms such as hoarding obsessions and compulsions. As previously discussed, a relationship between parental child-rearing style and the development of disorders other than OCD has also been proposed. Perceived parental overprotection and rejection have been linked to the development of agoraphobia (De Rutter, 1994), and Parker et al. (1987) reported that neurotic depressives perceived their parents as less caring and more protective than melancholic depressives and healthy subjects did, and that this ‘affectionless control’ style of upbringing was highly discriminating for neurotic depression. We found no significant relationship between perceived parental

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278

characteristics and the presence of depressive symptoms in OCD patients. Nevertheless, our negative results may be explained by the fact that patients in this study were ‘pure’ obsessive – compulsive subjects; none of them satisfied DSM-IV criteria for major depressive disorder or dysthymia, and they only showed mild or moderate depressive symptoms secondary to the distress caused by their OCD symptoms. From a clinical perspective, these results support the importance of involving family members in the treatment of obsessive – compulsive children. OCD often produces severe stress on family members of affected children, because of their involvement in the patient’s compulsions or avoidance behaviors as well as because of modification of family and leisure time routines to accommodate the patient. Parents of OCD patients often feel confused and anxious when faced with their children’s obsessive – compulsive behaviors, and their responses to OCD symptoms are frequently inconsistent or erratic. Rigid, demanding and highly critical families generate feelings of guilt, increase anxiety in affected children, and discourage them from engaging in active treatment for OCD. Thus, altering family communication style and learning alternative responses to the patient’s OCD symptoms may be an important issue especially to facilitate gains of cognitive-behavioral treatment (Steketee and Van Noppen, 1998). Several limitations of the present study need to be addressed. Although the dimensional approach adopted in this study has the potential advantage of overcoming the difficulty of recruiting a sufficient sample size of each OCD clinical subtype, some symptom dimensions (i.e. sexual/religious, symmetry/ordering, hoarding) were present in a reduced proportion of patients. So, the sample size might have been insufficient to detect a significant relationship between some of these clinical dimensions and parental rearing factors. The results of the current study need to be replicated in larger samples to address this issue as well as to confirm the stability of the detected association between hoarding and perceived parental emotional warmth. On the other hand, the presence of personality disorders was not specifically assessed in our study. Comorbid personality disorders have been reported to be present in approximately 50% of OCD patients (Baer et al., 1990). Moreover, two recent studies have

275

reported a close association between hoarding symptoms and comorbid axis II diagnoses, especially from the anxious– fearful cluster (Frost et al., 2000; MataixCols et al., 2000). Therefore, the association between perceived parental emotional warmth and hoarding detected in our study may be confounded by the presence of abnormal personality traits. Future studies would benefit from the assessment of personality disorders to control for their effect. This study was only based on retrospective reports of parental rearing style, so a memory bias cannot be disregarded. Direct observational studies of parent – child interactions or studies combining data from offspring, parents and siblings on perceived childrearing practices may increase validity of the results in this area, although each source of information has its own limitations and biases. As specific mood-congruent memory biases associated with depression have been described, the presence of depressive symptoms and overall illness severity were taken into account in the statistical analyses, and results were not confounded by correlation with either of the two factors. On the other hand, previous findings with the EMBU suggest that evaluating retrospective data does not threaten the reliability and validity of the information obtained since it can be interpreted as a measure of the phenomenological impact of parental behaviors (Arrindell et al., 1983). Although normal comparison subjects were carefully selected and screened to rule out any past or current history of psychiatric or neurological disorder, the presence of subthreshold obsessive –compulsive symptoms was not assessed in the control group. Several studies have reported that a high percentage of the normal population have some obsessions and compulsions, and it has been postulated that obsessive –compulsive phenomena form a continuum with few symptoms and minimal severity at one end, and many symptoms and severe impairment at the other (Rachman and DeSilva, 1978). Therefore, some of our healthy control subjects may exhibit subclinical obsessive – compulsive symptoms, which could influence the results of the study. Finally, the presence of obsessive – compulsive traits or any other psychiatric conditions in the parents of the OCD group was not studied. Clinical and subclinical obsessional features as well as other anxious and affective disorders have been reported in parents

276

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278

of OCD patients (Rasmussen and Tsuang, 1986), and they may play an important role in parental rearing practices. Future studies should take into account this factor, since the study of the relationship between parental psychopathology and child-rearing patterns would increase our understanding of family influences on the development of OCD. In conclusion, OCD patients perceive their fathers as being more rejecting than control subjects. Patients with hoarding symptoms perceive their parents as less emotionally warm than patients without these symptoms. Whether this reflects actual rearing practices or the patients’ biased perception needs to be further investigated using more objective measures. If replicated, the current findings would suggest that parental style of upbringing, as well as other social variables, may interact with genetic and biological factors to shape the OCD phenotype in vulnerable subjects. Recent published articles have focused on the relationship between functional and anatomical variability of different brain areas and behavioral styles (Sugiura et al., 2000; Pujol et al., 2002). Parental child-rearing practices may contribute to the development of distorted beliefs about responsibility, threat estimation, perfectionism, control or tolerance for ambiguity, which are frequently exhibited by patients with OCD (Steketee et al., 1998). Parental behaviors and attitudes may also be related to the development of patterns of temperament and character described in OCD (high harm avoidance, low novelty-seeking and cooperativeness) (Lyoo et al., 2001). Studies on the relationship between parental bonding styles and cognitive domains or personality characteristics in OCD patients, and between these aspects and the morphology or function of different brain regions, may constitute a way to analyze the interaction of social/cultural variables and biological factors in OCD. Further research on this interaction could help us to understand the complex etiology and heterogeneity of OCD.

Acknowledgements This study was supported in part by grant FIS 99/ 1260 from the Spanish Ministerio de Sanidad y Consumo and grant 010210 from Fundacio´ La Marato´ TV3. PA was funded by the Generalitat of Catalonia

(1999FI-00726). DM-C was funded by a Marie Curie grant from the EU.

References Alsobrook, J.P., Leckman, J.F., Goodman, W.K., Rasmussen, S.A., Pauls, D.L., 1999. Segregation analysis of obsessive – compulsive disorder using symptom-based factor scores. American Journal of Medical Genetics (Neuropsychiatric Genetics) 88, 669 – 675. American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Author, Washington, DC. Anasagasti, J.I., Denia, M., 1988. Opiate addicts and their perceived parental rearing. Acta Psychiatrica Scandinavica 78 (Suppl. 344), 121 – 126. Arrindell, W.A., Emmelkamp, P.M.G., Brilman, E., Monsma, A., 1983. Psychometric evaluation of an inventory for assessment of parental rearing practices. Acta Psychiatrica Scandinavica 67, 163 – 177. Arrindell, W.A., Perris, C., Eisemann, M., Perris, H., Van der Ende, J., Ross, M., Benjaminsen, S., Gaszner, P., del Vecchio, M., 1986. Cross-national generalizability of patterns of parental rearing behavior: invariance of EMBU dimensional representations of healthy subjects from Australia, Denmark, Hungary, Italy and The Netherlands. Personality and Individual Differences 7, 103 – 112. Arrindell, W.A., Perris, H., Denia, M., Van der Ende, J., Perris, C., Kokkevi, A., Anasagasti, J.I., Eisemann, M., 1988. The constancy of structure of perceived parental rearing style in Greek and Spanish subjects as compared with the Dutch. International Journal of Psychology 23, 3 – 23. Arrindell, W.A., Van der Ende, J., 1984. Replicability and invariance of dimensions of parental rearing behavior: further Dutch experiences with the EMBU. Personality and Individual Differences 5, 671 – 682. Baer, L., 1994. Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders. Journal of Clinical Psychiatry 55 (Suppl. 3), 18 – 23. Baer, L., Jenike, M.A., Ricciardi, J.N., Holland, A.D., Seymour, R.J., Minichiello, W.E., Buttolph, M.L., 1990. Standardized assessment of personality disorders in obsessive – compulsive disorder. Archives of General Psychiatry 47, 826 – 830. Benjaminsen, S., Krarup, G., Lauritsen, R., 1990. Personality, parental rearing behavior and parental loss in attempted suicide: a comparative study. Acta Psychiatrica Scandinavica 82, 389 – 397. Black, D.W., Monahan, P., Gable, J., Blum, N., Clancy, G., Baker, P., 1998. Hoarding and treatment response in 38 non-depressed subjects with obsessive – compulsive disorder. Journal of Clinical Psychiatry 59, 420 – 425. Cavedo, L.C., Parker, G., 1994. Parental Bonding Instrument: exploring links between scores and obsessionality. Social Psychiatry and Psychiatric Epidemiology 29, 78 – 82. De Rutter, C., 1994. Anxious attachment in agoraphobia and obsessive – compulsive disorder: a literature review and treatment

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278 implications. In: Perris, C., Arrindell, W.A., Eisemann, M. (Eds.), Parenting and Psychopathology. John Wiley and Sons, Chichester, UK, pp. 281 – 301. Ehiobuche, I., 1988. Obsessive – compulsive neurosis in relation to parental child-rearing patterns among Greek, Italian and AngloAustralian subjects. Acta Psychiatrica Scandinavica 78 (Suppl 344), 115 – 120. First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., 1997. Structured Clinical Interview for DSM-IV Axis I Disorders-Clinician Version (SCID-CV). American Psychiatric Press, Inc, Washington, DC. Frost, R.O., Gross, R.C., 1993. The hoarding of possessions. Behaviour Research and Therapy 31, 367 – 381. Frost, R.O., Steketee, G., Williams, L.F., Warren, R., 2000. Mood, personality disorder symptoms and disability in obsessive – compulsive hoarders: a comparison with clinical and non-clinical controls. Behaviour Research and Therapy 38, 1071 – 1081. Gerlsma, C., Emmelkamp, P.M.G., 1990. Anxiety, depression and perception of early parenting: a meta-analysis. Clinical Psychology Review 10, 251 – 277. Goodman, W.K., Price, L.H., Rasmussen, S.A., Mazure, C., Delgado, P., Heninger, G.R., Charney, D.S., 1989. The Yale – Brown Obsessive – Compulsive Scale (Y – BOCS). Part I: development, use and reliability. Archives of General Psychiatry 46, 1006 – 1011. Hafner, R.J., 1988. Obsessive – compulsive disorder: a questionnaire survey of a self-help group. International Journal of Social Psychiatry 34, 310 – 315. Hamilton, M., 1960. A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 23, 56 – 61. Hoekstra, R.J., Visser, S., Emmelkamp, P.M.G., 1989. A social learning formulation of the etiology of obsessive – compulsive disorders. In: Emmelkamp, P.M.G., et al. (Eds.), Fresh Perspectives on Anxiety Disorders. Swets and Zeitlinger, Amsterdam, pp. 115 – 123 (Annual Series of European Research in Behavior Therapy, vol 4). Hollingshead, A.B., Redlich, F.C., 1958. Social Class and Mental Illness. Wiley, New York. Hoover, C., Insel, T., 1984. Families of origin in obsessive – compulsive disorder. Journal of Nervous and Mental Disease 172, 207 – 215. Khalil, N., Stark, P.M., 1992. Do perceived parental rearing patterns influence social behavior dimensions and disease severity in schizophrenia? Acta Psychiatrica Scandinavica 86, 146 – 152. Kimidis, S., Minas, I.H., Ata, A.W., Stuart, G.W., 1992. Construct validation in adolescents of the brief current form of the Parental Bonding Instrument. Comprehensive Psychiatry 33, 378 – 383. Leckman, J.F., Grice, D.E., Boardman, J., Zhang, H., Vitale, A., Bondi, C., Alsobrook, J., Peterson, B.S., Cohen, D.J., Rasmussen, S.A., Goodman, W.K., McDougle, C.J., Pauls, D.L., 1997. Symptoms of obsessive compulsive disorder. American Journal of Psychiatry 154, 911 – 917. Lyoo, I.K., Lee, D.W., Kim, Y.S., Kong, S.W., Kwon, J.S., 2001. Patterns of temperament and character in obsessive – compulsive disorder. Journal of Clinical Psychiatry 62, 637 – 641. Mataix-Cols, D., Rauch, S.L., Manzo, P.A., Jenike, M.A., Baer, L., 1999. Use of factor-analyzed symptom dimensions to predict

277

outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive – compulsive disorder. American Journal of Psychiatry 156, 1409 – 1416. Mataix-Cols, D., Baer, L., Rauch, S.L., Jenike, M.A., 2000. Relation of factor-analyzed symptom dimensions of obsessive – compulsive disorder to personality disorders. Acta Psychiatrica Scandinavica 102, 199 – 202. Mataix-Cols, D., Marks, I.M., Greist, J.H., Kobak, K.A., Baer, L., 2002a. Obsessive – compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychotherapy and Psychosomatics 71, 255 – 262. Mataix-Cols, D., Rauch, S.L., Baer, L., Eisen, J.L., Shera, D.M., Goodman, W.K., Rasmussen, S.A., Jenike, M.A., 2002b. Symptom stability in adult obsessive-compulsive disorder: data from a naturalistic two-year follow-up study. American Journal of Psychiatry 159, 263 – 268. Merkel, W.T., Pollard, C.A., Wiener, R.L., Staebler, C.R., 1993. Perceived parental characteristics of patients with obsessive – compulsive disorder, depression and panic disorder. Child Psychiatry and Human Development 24, 49 – 57. Parker, G., 1979. Reported parental characteristics of agoraphobics and social phobics. British Journal of Psychiatry 195, 555 – 560. Parker, G., Kiloh, L., Hayward, L., 1987. Parental representations of neurotic and endogenous depressives. Journal of Affective Disorders 13, 75 – 82. Perris, C., Jacobsson, L., Lindstro¨m, H., von Knorring, L., Perris, H., 1980. Development of a new inventory for assessing memories of parental rearing behavior. Acta Psychiatrica Scandinavica 61, 265 – 274. Pujol, J., Lopez, A., Deus, J., Cardoner, N., Vallejo, J., Capdevila, A., Paus, A., 2002. Anatomical variability of the anterior cingulate gyrus and basic dimensions of human personality. Neuroimage 15, 847 – 855. Rachman, S., DeSilva, P., 1978. Abnormal and normal obsessions. Behaviour Research and Therapy 16, 233 – 248. Rachman, S., Hodgson, R., 1980. Obsessions and Compulsions. Prentice Hall Inc, Englewood Cliffs, NJ. Rapee, R.M., 1997. Potential role of childrearing practices in the development of anxiety and depression. Clinical Psychology Review 17, 47 – 67. Rasmussen, S., Tsuang, M., 1984. The epidemiology of obsessive – compulsive disorder. Journal of Clinical Psychiatry 45, 450 – 457. Rasmussen, S., Tsuang, M., 1986. Clinical characteristics and family history in DSM III obsessive – compulsive disorder. American Journal of Psychiatry 143, 317 – 322. Shtasel, D.L., Gur, R.E., Mozley, P.D., Richards, J., Taleff, M.M., Heimberg, C., Gallacher, F., Gur, R.C., 1991. Volunteers for biomedical research. Recruitment and screening of normal controls. Archives of General Psychiatry 48, 1022 – 1025. Spitzer, R.L., Williams, J.B.W., Gibbon, M., 1989. Structured Clinical Interview for DSM-III-R: Non-Patient Version (SCID-NP). New York State Psychiatric Institute, New York. Steketee, G.S., Grayson, J.B., Foa, E.B., 1985. Obsessive – compulsive disorder: differences between washers and checkers. Behaviour Research and Therapy 23, 197 – 201.

278

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278

Steketee, G.S., Frost, R.O., Rheaume, J., Wilhelm, S., 1998. Cognitive theory and treatment of obsessive – compulsive disorder. In: Jenike, M.A., et al. (Eds.), Obsessive – Compulsive Disorders. Practical Management, 3rd ed. Mosby, Inc, St. Louis, pp. 368 – 399. Steketee, G., Frost, R.O., Wincze, J., Greene, K.A.I., Douglass, H., 2000. Group and individual treatment of compulsive hoarding: a pilot study. Behavioral and Cognitive Psychotherapy 28, 259 – 268. Steketee, G.S., Pruyn, N.A., 1998. Families of individuals with obsessive – compulsive disorder. In: Swinson, R.P., et al. (Eds.), Obsessive – Compulsive Disorder. Theory, Research and Treatment. The Guilford Press, New York, pp. 120 – 140. Steketee, G.S., Van Noppen, B.L., 1998. Group and family treatment for obsessive – compulsive disorder. In: Jenike, M.A., et al. (Eds.), Obsessive – Compulsive Disorders. Practical Management, 3rd ed. Mosby, Inc, St. Louis, pp. 443 – 468. Sugiura, M., Kawashima, R., Nakagawa, M., Okada, K., Sato, T.,

Goto, R., Sato, K., Ono, S., Schormann, T., Zilles, K., Fukuda, H., 2000. Correlation between human personality and neural activity in cerebral cortex. Neuroimage 11, 541 – 546. Summerfeldt, L.J., Richter, M.A., Antony, M.M., Swinson, R.P., 1999. Symptom structure in obsessive – compulsive disorder: a confirmatory factor-analytic study. Behaviour Research and Therapy 37, 297 – 311. Turgeon, L., O’Connor, K.P., Marchand, A., Freeston, M.H., 2002. Recollections of parent – child relationships in patients with obsessive – compulsive disorder and panic disorder with agoraphobia. Acta Psychiatrica Scandinavica 105, 310 – 316. Turner, R.M., Steketee, G.S., Foa, E.B., 1979. Fear of criticism in washers, checkers and phobics. Behaviour Research and Therapy 17, 79 – 81. Vogel, P.A., Stiles, T.C., Nordahl, H.M., 1997. Recollections of parent – child relationships in OCD out-patients compared to depressed out-patients and healthy controls. Acta Psychiatrica Scandinavica 96, 469 – 474.