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Informanon to USERS INFORMAnON TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly tram the original or copy submitted. Thus, sorne thesis and dissertation copies are in typewriter face, while others may be tram any type of computer printer. The quailly of this reproductio~ is dependent upon the quality of the copy submitted. Broken or indistinct print. colored or poor quality illustrations and photographs, print bleedthrough. substandard margins. and improper alignment can adversely affect reproduction. ln the unlikely event that the author did not send UMI a complete manuscript and there are missing pages. these will be noted. Also, if unauthorized copyright material had to be removed. a note will indicate the deletion. Oversize materials (e.g., rnaps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand corner and continuing from 18ft ta right in equal sections with small overlaps. 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ProQuest Information and Leaming 300 North Zeeb Road, Ann Arbor, MI 48106-1346 USA 800-521-0600 •• Treatment seeking for obsessive-compulsive disorder: role ofocd symptoms and comorbid psychiatrie diagnoses Jamie Isaac Mayeroviteh~ Department ofPsyehiatry, MeGilI University, Montreal, May 3rd 2000 A thesis submitted to the Faculty ofGraduate Studies and Researeh in partial fulfilment ofthe requirements ofthe degree ofMaster ofScience (MSc). © Jamie Isaac Mayeroviteh, 2000. • National Library Bibliothèque nationale 1+1 of Canada du Canada Acquisitions and Acquisitions et Bibliographie SeNÏC8S seNieeS bibliographiques 395 Wellington Street 395. rue Welington Ottawa ON K1A 0N4 oaawa ON K1A 0N4 Canada C8nada The author bas granted a 000­ L'autem a accordé une licence non exclusive licence allowing the exclusive permettant à la National Library ofCanada to Bibliothèque nationale du Canada de reproduce, Joan, distnbute or sell reproduire, prêter, distribuer ou copies ofthis thesis in microform, vendre des copies de cette thèse sous paper or electronic formats. la forme de microfiche/film, de reproduction sur papier ou sur format électronique. The author retains ownership ofthe L'auteur conserve la propriété du copyright in tbis thesis. Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts nom it Ni la thèse ni des extraits substantiels may be printed or otherwise de celle-ci ne doivent être imprimés reproduced without the author's ou autrement reproduits sans son permission. autorisation. 0-612-64406-5 Canadl TABLE OF CONTENTS TITLEPAGE 1 • Tables and Figures Il Acknowledgrnents III ABSTRACT English Abstract 1 French Abstract 2 INTRODUCTION 1.1 Background 3 1.2 Objectives 4 LITERATURE REVIEW 2.1 Diagnostic criteria 5 2.2 Historical developments 6 2.3 Etiology 8 2.4 Epidemiology 9 2.5 Correlateslrisk factors 10 2.6 Comorbidity 12 2.7 Treatment for OCD 12 2.8 Quality oflife 14 2.9 Economie issues 14 2.10 Use ofhealth and mental health services 15 METHODS 3.1 Sample 18 3.2 Instrument: Diagnostic Interview Schedule 19 3.21 Development ofthe DIS 19 3.3 Reliability ofOCD DIS 21 3.4 VaiidityofOCD DIS 22 3.5 QCO section ofthe DIS 22 3.6 FlowChart 23 3.7 Comorbidity 24 3.8 Statistical anaIysis 24 RESULTS 4.1 Descriptive statistics for demographic characteristics and frequency ofsymptoms 27 • 4.2 Frequency ofcomorbid diagnoses 27 4.3 Participant characteristics and treatment seeking 28 4.4 Specifie OCO symptoms and treatment seeking 29 4.5 Comorbid diagnoses and treatment seeking 29 • 4.6 Sequential automated model selection procedures 30 4.7 Baekward elimination procedure on full sarnple 31 4.8 Forward selection procedure on full sample 32 4.9 Backward elimination procedure on reduced sample 32 4.10 Forward selection procedure on reduced sample 33 DISCUSION 5.1 Overview 34 5.2 Conclusion 43 APPENDIX Table 1 44 Figure 1 45 Table 2 46 Table 3 48 Table 4 50 Table 5 51 Table 6 52 Table 7 53 Table 8 54 DIS questions 55 REFERENCES 59 • ii TABLE AND FIGURES • Table 1 Summary ofquestions included the Obsessive-compulsive disorder section ofthe DIS. Figure 1 Probe Flow Chart Table 2 Descriptive statistics for the DIS Obsessive-compulsive questions Table 3 Frequencyand the temporal relationship between OCD and the comorbid disorders Table 4 Treatment seeking for Obsessive compulsive disorder: association with gender, age and illness charaeteristics Table 5 Role ofspecific OCD symptoms and Iikelihood oftreatment seeking Table 6 Role ofcomorbid diagnoses and treatment seeking Table 7 Backward elimination procedure on full sample Table 8 Backward elimination procedure on reduced sample • iii ACKNOWLEDGMENTS • l would like to take this opportunity to extend my utmost thanks and gratitude to Dr. Guillaume Galbaud du Fort for ail his time, help and support in completing this research project. Appreciation is also extended to Ors. Jean-Francois Boivin and Gilbert Pinard for their valuable contnbution. 1cao not bestow enough gratitude on Ritz Kakuma, Shari Mayerovitch, Cannelle Goldberg and my family and friends for their indispensable contribution and support. • ABSTRACf • Background: Previous research has indicated that although obsessive compulsive disorder (OCD) is associated with immense suffering, and social and economic costs, individuals amieted with the disorder have a very low rate ofseeking help from mental health professionals. Methods: From standardized psychiatrie interviews of7214 Edmonton residents we identified 172 subjects with a lifetime diagnosis ofOCD; 37% (63/172) had consulted a doctor about their syrnptoms. Resu/ts: Total number ofsymptoms (odds ratio, OR= 3.44) and severe obsessions ofviolence and other unpleasant thoughts (OR=2.62) were significantly associated WÎth treatment seeking in the multivariate analysis. Conclusion: This study was an important step in examining whieh specifie symptoms and comorbid conditions are associated with treatrnent seeking. It was somewhat surprising that neither comorbid disorders nor any compulsive symptoms were related to treatment seeking behaviour. This study May be ofbenefit to future public education programs especially by teaching the public about compulsions. • 2 • RESUME État de connaissances: Les recherches antérieures ont indiqué que, bien que le trouble obsessif~ompulsif(TOC) soit associé à beaucoup de souffrance et des coûts économiques et sociaux élevés, la prévalence de recherche de traitement pour ce problème est faible. Méthodes: À partir d'entrevues psychiatriques standardisées réalisées sur un échantillon de 7214 résidents d'Edmonton, nous avons identifié 172 sujets qui avaient un diagnostic de TOC sur la vie entière; 37010 (63/172) avaient parlé à un médecin de leurs symptômes. Résultats: Le nombres total de symptômes (odds ratio, OR=3.44) et la présence d'obsessions sévères de violence ou d'autres pensées désagréables (OR=2.62) étaient associées de manière significative à la recherche de traitement. Conclusion: Cette étude représente une contribution importante pour comprendre quels symptômes et quels diagnostics comorbide sont associés à la recherche de traitement chez les sujets souffrant de TOC. Il est intéressant de noter qu~ aucune compulsion et aucun diagnostic comorbide n'étaient associés à la recherche de traitement. Les résultats plaident en faveur du développement de Programmes d'éducation du public sur les compulsions. • 3 INTRODUCTION • 1.1) BaekgrouDd Once thought to he a relatively rare disorder, reeent epidemiological evidenee indieates that obsessive compulsive disorder (OCD) is in fact the fourth most common psychiatrie illness in the United States subsequent to phobias, depressio~ and substance abuse (Hollander, 1997). The most recent Epidemiologie Catchment Area (ECA) study found a lifetime prevalence of2.6% (Kamo and Golding, 1991). ln addition to being thought ofas a rare illness, the diagnosis ofOCO was also associated with a poor prognosis. However, in the PaSt few deeades there bas been a period ofenlightenment regarding OCD. Theories have emerged, new hypotheses have been fonnulated, and the emergence offunctional neuroimaging bas facilitated our understanding ofthis potentially debilitating disease. The advent and success ofselective serotonin re-uptake inhibitors (SSRI's) in the treatment ofOCO has creatcd a sense of optimism. Despite this renewed sense ofhopefulness, previous studies have indicated that very few individuals with OCO seek hclp from mental health professionals. A recent study by Leon et al., (1995) indicated that approximately one-fifth ofindividuals with OCD seek help ftom a mental health specialist. The disorder thereby lies in the Mid range among the anxiety disorders in regard to how frequently its sufferers seek professional care (Kamo and Golding, 1991). It is perplexing that few individuals with OCD seek treatrnent, despite the debilitating nature ofthe disorder and the availability oftreatment. Although prior studies have examined rates oftreatrnent seeking in OCD, literary • searches have not divulged any studies that have examined potential factors which may 4 he predictive oftreatment seeking behaviour. The attainment ofsuch infonnation could • he ofhenefit to sufferers, researchers, clinicians, and health programs. This study will attempt to ascertain which
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