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••
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.
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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 specifie symptoms and comorbid diagnoses influence the
decision ofwhether or not to seek treatrnent.
1.2) Objfttives
The objectives ofthis paper are as follows:
1) Ta examine the prevalence oftreatment seeking in patients with OCD.
2) Ta examine the association between the likelihood oftreatment seeking and
ditTerent variables in subjects with a lifetime diagnosis ofOCD. The
following variables will he examined: socio-demograprnc factors, age al
onset, and severity ofthe disorder (as indicated by the number ofsymptoms).
3) To examine the association between specifie obsessive compulsive symptoms
and probability oftreatment seeking.
4) To examine the role ofeo-morbid psychiatrie diagnoses in treatment seeking.
5) Ali of the aforementioned variables found to be signifi~andy associated with
treatment seeking win he analyzed coneomitantly in a multivariate model.
• 5 • LITERATURE REVIEW The fonnalization ofobsessive compulsive disorder has undergone Many changes
throughout the years. As research progressecL new findings emerged and consequently
Many items and criteria were subsequently added and deleted. Ali the years ofscientific
research and accumulated knowledge have manifested themselves in the current accepted
definition ofobsessive-eompulsive disorder which is presented in the fourth edition ofthe
Diagnostic and Statistical Manual ofMental Oisorders (DSM...IV, 1994).
2.1) Diagnostic criteria
The essential features ofDeO are recurrent obsessions, and/or repetitive
behaviours or compulsions that are severe enough to he time consuming, or cause distress
or significant impainnent. The individual recognizes that the obsessions or compulsions
are excessive or unreasonable. Ifanother Axis 1 disorder is present, the content orthe
obsessions or compulsions is not restricted to it. The disturbance is not due to the direct
physiological efTects ofa substance or a general medical condition.
Specifically, obsessions are defined as "persistent ideas, thoughts, impulses, or
images that are experienced, at some time during the disturbance, as intrusive and
inappropriate, and that. cause marked anxiety or distress" (DSM-IV, 1994). These
obsessions have been referred to as ego-dystonic, in lhat the obsessions are not
experienced as voluntarily produced, but rather as thoughts that invade consciousness and
are experienced as senseless or repugnant.
The most common obsessions are repeated thoughts about contamination; • repeated doubts; a need to have things in a particular order; somatic, aggressive, or 6
horrifie impulses; and sexual imagery. Typically the individual attempts to ignore or • suppress such thoughts or impulses or to neutralize them with some other thought or action (i.e., a compulsion).
In contrast, compulsions are defined as ~~repetitive behaviours or mental acts, that
the person feels driven to perform in response to an obsession, or according to rules that
must he applied rigidlf' (DSM-IV, 1994). The compulsive behaviour is not rewarding in
and ofitsel( but is carried out to prevent some fonn ofirnagined disaster from occurring
or to neutralize worry about realistic or potential difficulties.
Compulsions are either clearly excessive or are not connected in a realistic way
with what they are designed to neutralize or prevent. The most common compulsions
involve hand washing and cleaning, countin& checking, requesting or demanding
assurances, symmetry and precision, repeating actions, hoarding, and ordering.
2.2) Historiesl developments
Our contemporary understanding ofobsessiveooCOmpulsive disorder has evolved
from the integration ofclinical observations and scientific research. However, the
historical evolution ofocn demonstrates how the pioneering scholars were constrained
by their lack ofdetailed knowledge in attempting to descrihe the disorder's defining
features and etiology. Descriptions ofOCn date as far back as 4000 years ago in
Mesopotamia (Kolada., Bland, & Newman, 1994). Literary descriptions ofobsessional
and compulsive phenomena cao he round in the works ofEuripides and Shakespeare in
their respective plays Medea and Othello (Sturgis, 1984). Kramer and Sprenger
postulated one ofthe first theories regarding the cause ofobsessive and compulsive • behaviours in their fifteenth-œntury book Ma//eus Ma/eficarum. In examining a patient, 7
they attributed the bizarre thoughts and behaviours to the concepts ofwitchcraft, devils, • and possessions (Nemiah and Uhde, t989). SubsequentJy, throughout the 161h to the ISlh century, OCD was masked under the guise ofreligious melancholy.
However, by the t9th century., a period ofenJightenment occurred and the climate
ofopinion had changed as scientific theorists dismissed the notion ofspiritual beings as
causal factors. Explanations now focused on natural forces witbin the individual such as
thoughts., feelings., impulses., and anxiety. Psychiatrists DOW acknowledged tbat the
obsessional process was involuntary, automatic, and resisted by the patient (Nemiah et
al., 1989). Nevertheless, the etiology ofthe disorder remained elusive.
The commencement ofthe twentieth century was accompanied with intensified
efforts to define and describe this psychiatrie condition (Sturgis, 1984). Perhaps the most
instrumental researcher was Pierre Janet. He designated OCO as one ofthe major classes
ofmental disorder and his concepts were revolutionary (Kolada et al., 1994). Based on
hundreds ofcollected cases, he fonnulated bis theory in bis t903 two-volume work, "Les
Obsessions et la Psychasthenie". Janet hypothesized the central disturbance lay in a
pathological reduction ofmental energy that resulted in the erosion ofthe nonnal
organization ofmental functions (Nemiah et al., 1989).
While Janet disregarded the notion ofunconscious mental process, this concept
achieved some notoriety with the emergence ofSigmund Freud's theory. Freud
postulated that the obsessive state is a manifestation ofpsychological defense against
repressed memories ofsexual guilt, and he emphasized the importance ofthe intrapsychic
conflict these patients experienced. • 8
The pioneering work ofJanet and Freud early this century was augmented by new • theorists and the advent ofbiological research. These influences~ in combination with new emerging knowledge ofobsessive-aJmpulsive phenomena were incorporated into
the DSM-IV.
2.3) Etiology
There have been numerous hypotheses regarding the potential etiology ofOCD.
Currently, the two theories Most subscribed to are biological factors and behavioural
factors.
Biologicalfactors:
The literature indicates that there is an abnonnality in serotonin neurotransmission
among OCD patients. It therefore appears that a dysregulation ofthe neurotransmitter
serotonin is involved in the symptom formation ofobsessions and compulsions. These
conclusions are drawn from the finding lhat patients treated with selective serotonin
reuptake inhibitors (SSRrs) display significant therapeutic improvements. However,
whether serotonin is specifically involved in the cause ofobsessive-eompulsive disorder
is still equivocal at this time (Baumgarten and Grozdanovic~ 1998; Kaplan and Sadoc~
1998; Greist and Jefferson, 1998).
In the past several decades there bas been marked improvement in functional
neuroimaging such as: computerized tomography (CT), magnetic resonance imaging
(MRl), and positron emission tomography (PET). These tests have provided strong
evidence indieating that the pathophysiology ofOCD involves abnormal functioning
along specifie frontal-subcortical brain circuits. Specifically, abnormalities in the • 9
orbitofrontal cortex, anterior eingulate cortex, basal ganglia, and thalamus have been • observed in OCD patients (Saxe~ et al., 1998). Behaviouralfactors:
Leaming theory postulates that obsessions represent a conditional stimulus to
anxiety and the compulsions reduce the anxiety associated with the obsessions.
Consequently the reliefexperienced after performing the ritual then reinforces the leamed
behaviour (Kaplan and Sadock, 1998).
SPecifically, the obsessions are internai stimuli that have become the focus of
anxiety as the result ofPOor leaming experiences. Following traumatie conditioning
experiences, such anxiety would he expeeted to diminish as obsessions reeur unless the
person experiencing them engages in sorne kind ofescape bebaviour (e.g. band washing,
cheeking hehaviours). When these escape behaviours are endorsed, an immediate
reduction in anxiety is experienced preventing exposure and therefore habituation. This
anxiety reliefis negatively reinforcing to the sufferer and inereases the likelihood of
future occurrences ofthe same behaviour (Salkovskis, et al., 1998).
2.4) Epidemiology
Once considered to he a relatively rare disorder, obsessive-compulsive disorder
has been demonstrated to he moderately widespread with a lifetime prevalenee of2.6%
according to the Most recent Epidemiologie Catehment Area (ECA) study (Kamo and
Golding, 1991). This figure is considerably higher than the previously adhered to
prevalence rate of.05 which was the most quoted estimate earlier in the decade (Sasson
et aL, 1997). Recent studies have concluded that the lifetime prevalence ofOCD was • approximately 2% in the United States, Canada, Europe, Germany, Hong Kong, New 10
Zealand, and Puerto Rico. While rates are slightly lower in Korea and Taiwan, the OCD • lifetime prevalence worldwide is roughJy 2% (Sasson et al., 1997; Weissman et al., 1994). These prevalence rates indicate that OCD is the fourth Most common psychiatrie
illness in the United States subsequent to phobias, depression, and substance abuse
(Hollander, 1997). It is interesting to note that the frequency ofthe diagnosis ofOCD
increased noticeably during the 1980's. It is theorized that increased attention given to the
disorder may have 100 to an increased clinical awareness ofOCO, and therefore more
individuals were heing diagnosed correetly (Stoll, Tohen, and Baldessarini, 1992).
Clinical research data generally indicate that the majority ofpatients treated for
OCD suffer from both obsessions and compulsions (Kamo et al., 1998). However, data
trom the cross national epidemiology ofOCD study indicated that approximately 41% of
OCD patients endorsed obsessions exclusively, 3t% endorsed only compulsions, and
28% reported bath obsessions and compulsions (pigott, L'heureux, Dubbert, Bernstein,
and Murphy, 1994).
%.5) Correlateslrisk fa~ton
Researchers and clinicians have investigated numerous correlates in an attempt to
ascertain the descriptive characteristics ofindividuals aftlicted with obsessive
compulsive disorder. Factors that have becn examined include: age ofonset, sex ratio,
familial pattern, level ofintelligence, social class, marital status, culture, and co
morbidity with other disorders.
Epidemiological evidence indicates that the Mean age ofOCO onset is the mid-to
late twenties to carly thirties. This finding has becn replicated in numerous studies • (Kolada et al., 1994; Sasson etai., 1997; Weissman, et al., 1994, Kamo, et aL, 1988). Its II
occurrence is presumed to he very rare among children (Kolada et al., 1994). Results • pertaining to sex ratios have been somewhat more equivocal. Sasson, et al (1997) reported that women had a higher lifetime prevalence rate in comparison to men. This
finding was further corroborated by the most rccent Epidemiologie Catchment Area
(ECA) study (Weissman et al., 1994). However, numerous studies have reported little or
no ditTerences between the genders (Kolada et al., 1994). ft is interesting to note that the
mean age ofonset occurs earlier in males then females (DSM-IV).
The clinical literature has previously reported that high levels ofeducational
attainment and marital maladj~tment were two characteristies ofindividuals amicted
with obsessive compulsive disorder. However, these findings were not borne out in the
most recent Epidemiologie Catchment Area (ECA) study (Kama and Golding, 1991).
Moreover, conternPOrary studies examining these eorrelates and their subsequent
relationship to OCD have reported contradictory and often inconclusive results (Sturgis,
1984).
The concordance rate for OCD is higher for rnonozygotie twins than it is for
dizygotic twins. In additio~ the rate ofOCD in first~egreebiological relatives with the
disorder is higher than that in the general population (Kolada et al., 1994). Therefore
there appears to he sorne genetie influence in the emanation ofOCO. Previously it was
hypothesised that OCO was more common among upper and middle-class individuals
(Sturgis, 1984). However recent evidenee bas contradicted this assomption (Kamo and
Golding, 1991). Il appears that there is Httle cultural or cconomic influence on the
prevalence ofOCD). This finding is supported by the reality that <>CD is equally • prevalent in developed and developing countries (Sasson et aL, 1997). 12
2.6) Comorbidity • Obsessive-compulsive disorder has high rates ofco-morbidity with several other disorders. The most prevalent is major depression; the two coexist in 67010 ofcases of
OCD. However, the exact nature oftheir relationship remains elusive. The illnesses often
improve or worsen in synchronicity with each other. OCD also tends to occur with simple
phobia (22%), social phobia (18%), eating disorders (17010), alcohol abuse or dependence,
panic disorder, Tourette's syndrome, and schizophrenia (Sasson et al., 1997; Rasmussen
and Eisen, 1994). The etiological factors, which May predispose an individual to develop
obsessive-compulsive disorder and the aforementioned comorbid disorders, have yet to
he delineated.
2.7) TreatmeDt for OCD
InitialJy, OCD was considered among the most intractable ofthe neurotic
disorders, however recent studies have ascertained that OCD cao he successfully treated
(Holander et al., 1996). Currently, the most predominant fonns oftreatment are
phannacotherapy, cognitive behaviour therapy, and psychotherapy.
Pharmacotherapy:
The effectiveness ofphannacotherapy in treating OCD has been established in
numerous clinical trials. Generally the drugs which strongly inhibit serotonin reuptake (5
HT) have been proven to he the most effective in reducing OCD symptoms (Saxen&, et
al., 1998). Currently, the standard drug for the treatment ofOCD is clomiprarnine (a
serotonin-specific tricyclic drug). It is the gold standard against which other
phannacotherapies are compared (Greist and Jefferson, 1998). In addition, several • serotonin-specitic reuptake inhibitors (SSRI's) such as fluoxetine, sertaline, and 13
paroxetine have also been show to he effective in reducing OCD symptoms. The initial • effects ofphannacotherapy are generally seen after four to six weeks oftreatmen~ however~ eight to sixteen weeks are usually needed in order to obtain the maximum
therapeutic benefit (Kaplan and Sadock~ 1998).
Cognitive hehaviour therapy:
Cognitive behaviour therapy appears to he as effective as phannacotherapies in
the treatment ofOCD. In addition, some data indicates that the beneficial etrects may he
longer lasting with behaviour therapy. Cognitive theory emphasizes the role ofthoughts
in producing emotional disturbances. Therefore, treatment requires modification ofthe
distoned thinking patterns 50 that it produces less distress and is less persistent. The most
effective and most frequently used symptom-intervention in OCD is exposure (both in
vivo and in imagination) to those stimuli that elicit the undesired symptom behaviour.
Once these stimuli bave provoked the typical emotional and cognitive reactïons" coping
skills can he leamed through training (Hand, 1998). Other techniques 5uch as
desensitization, tlooding, and implosion therapy have also been utilised (Kaplan et aL,
1998; Salkovskis, et al." 1998).
Psychotherapy:
Although less prevalen~ psychotherapy has also been used in the treatment of
OCD. With continuous and regular contact with an interested, empathetic, and
encouraging mental health profe5sional, patients May be able to function by virtue ofthat
help, without which their symptoms might have incapacitated them. Since OCD also • effects the patient's family members, psychotherapeutic interventions should ioclude 14
attention to the family members through the provisions ofemotional support, • reassurance, explanation, and advice on how to manage and respond to the patient (Kaplan et al., 1998).
In conclusion. although numerous therapeutic techniques have been undertaken, it
appears that the most beneficial treatment is pharmacologie therapy (utilizing potent
selective serotonin reuptake inhibitors) in cornbination with behaviour therapy that
involves exposure and ritual Prevention techniques (Holander, t997).
2.8) Quality oflire
According to Hollander et al (1996) the emergence ofobsessive-compulsive
disorder can have immense consequences on an individual's quality oflife. It is
frequently chronic and disabling, significantly impacting the lives ofOCO sufferers, their
families, friends, employers, and society. Left untreated, obsessions and compulsions
cause a significant amount ofdistress, are lime consuming, and have a significant
negative impact on the sufferer's interpeTSOnal relationship and career, often culrninating
in isolation.
2.9) Economie issues
In addition to enduring tremendous psychological distress, an immense economic
burden is imposed on OCD sufferers, their families, and on the economy as a whole
(Hollander, 1997). For instance, the total costs ofOCD in the United States were
estimated al 8 billion dollars in 1990. The direct costs were estimated al 2.2 billion
dollars. The direct costs consisted ofcare in specialty institutions, short·stay hospital
care, office·based physicians, and other professional services including psychologists, • social workers and prescription medications. The indirect costs were tabulated to he 5.9 15
billion dollars. Although indirect costs are more difficult to accurately assess, these costs • resulted from work loss, early retirement, and absenteeism (Hollander, et al., 1996). On average, a person with OCD looses three full years ofwages over a lifetime al an average
salary of$24,000 (in li.S. currency). This can he estimated at a total of47 billion in
lifetime costs due to lost wages (Hollander, 1997).
2.10) Use of healtb and mental health services
Paradoxically, despite the immense social and economic costs associated with the
disorder and the availability oftreatment options, studies have shown that individuals
amicted with OCO have a very low rate ofseeking help from mental health professionals
(Whitaker, et al., 1990; Hatch et al., 1992; Hollander, et al., 1996). According to the
National Institute ofMental Health (NIMH) Epidemiological Catchment Area Program
only one-fifth ofindividuals with OCO seeks help from a mental health specialist (Leon
et al., 1995). The aforementioned ECA study found that ORly 34% ofOCD patients had
ever mentioned their symptoms to a doctor (Robins, Locke, and Regier, 1991). Therefore,
OCD lies in the mid range among the anxiety disorders in regard to ~ow frequently its
sufferers seek professional care. Household residents with active OCO have 50ugbt care
more often from a mental health specialist in the past six months than those amicted with
phobie disorders (18% versus 701'0). Conversely, OCO patients have reeeived less mental
health care than those with active panic disorder (26%) have (Kamo and Golding, 1991).
Consequently, an important question pertaining to OCO is ifthe rate of
impainnent is 50 high, why is the rate ofservice utilization low? There are several
potential hypotheses. Firstly, due to the ego-dystonic nature ofthe disorder patients will • often attempt to disguise their syrnptoms because ofthe shame or embarrassment 16
associated with the disorder and will not reveal their symptoms unless they are asked • about them directly (Sasson et al., 1997). Secondly, sufferers May he unaware that mental health professionals are knowledgeable about OCD and that their symptoms are treatable,
and are therefore not inclined to seek treatment (Hollander et al., 1996). Thirdly, primary
care physicians lack validated screening tools to aceurately assess OCD and therefore
many patients will not receive the neœssary care (Higgins, 1996). Fourthly, individuals
with OCD take great effort to hide their anguish and feel that they can eventuallyjust
~~pull themselves together". Lastly, due to the faet that OCD has a high rate of
comorbidity with depression and other anxiety disorders, individuals may he
misdiagnosed or receive treatment only for the comorbid diagnosis (Rasmussen and
Eisen, 1994).
The above factors also aid in explaining the finding that when individuals with
OCD do seek help for their disorder there is a lengthy delay in the application ofthe
apropos treatment. Previous studies have found a 17-year gap between the onset ofOCD
symptoms and appropriate treatment (Hollander et al., 1996; Higgins, 1996).
This 17 year lime gap is likely to decrease in the future as enlightenment
regarding OCO increases among the medical and psychiatrie community, thereby leading
to the commencement ofappropriate treatment upon diagnosis. Screening for OCD is
advised when patients exhibit sorne ofthe following markers: excessive need for
reassurance, unusual concem for cleanliness and safety, and unusual fear ofdisease such
as cancer or IDV. Additionally, several physical findings that raise suspicion are
excessive cleansing (eczematoid bands), hair pulling (trichotillomania), and nail picking • 17
(onychotillomania) (Shahady~ 1994). Improved recognition ofpotential clinical markers • should lead to better and more appropriate medical care. Any discussion pertaining to the reasons why OCD sufferers do or do not seek
professional help must he prefaced by the reminder that there have been no previous
studies on this topie. Prior studies have examined prevalence rates oftreatrnent seeking
and user services, but our literary search revealed that no previous studies have
investigated the potential predictors that may lead individuals to seek treabnent.
Therefore, ascertaining which factors may he responsible for treatment seeking behaviour
would he I)fimportant pragmatie significance.
• 18
METRons • 3.1) Sample The data for this study originated trom a survey ofadult household residents of
Edmonton, the capital city ofthe province ofAlbe~ Canada, using two-stage random
design. Through Dr. Galbaud du Fort's continuing collaboration with Edmonton research
colleagues Dr. Stephen Newman and Dr. Roger BlamL we were able to acquire access to
this data.
During the tirst stage, households were systematically sampled from a
computerized list ofresidential addresses supplied by the city ofEdmonton; at the second
stage one household member was chosen using six versions ofa respondent selection grid
successively. The respondent selection grid ensured that over the course ofMany
interviews, the age and sex composition ofthe survey sample would he representative of
the households participating in the survey.
To he eligible for the survey, respondents had to have been eighteen years ofage
or older at the time ofinterview and a usual occupant at the address. No information was
collected from households refusing to participate in the study. The design and field
methods are described in further detail elsewhere (Oro et al., 1988).
The interviews were completed in two stages: firstly, a sample consisting of3258
individuals were administered the Diagnostic Interview Schedule (DIS version III)
between January 1983 and May 1986; secondly, a sample of3956 individuals were
administered the DIS (version ma) between December 1984 and February 1989 using
identieal methods. Therefore a total of7214 individuals were administered the DIS. A • detailed examination ofthe prevalence ofpsychiatrie diagnoses observed in the first stage 19
indicated that they were quite similar to those found in the aforementioned ECA study • (Bland et aL, 1988). A project manager, who had previously been instructed at Washington University,
in St. Louis, trained interviewers in the Edmonton study on how to appropriately use the
DIS. Therefore the training regimen was standardized to ensure consistency and
accuracy. Each training session consisted oflectures, demonstrations, homework
exercises, mock interviews, and interactive practice sessions. Training sessions lasted
approximately forty-two hours over a seven-day period, with the largest portion ofthe
training rime being spent on the use ofthe probe tlowchart associated with the DIS. After
initial training was completed the interviewers conducted two or three practice interviews
which were reviewed by staffmembers for accuracy and consistency. Feedback to the
interviewer was given weekly through the editing process and through regular meetings
with the project manager. When interviewers contacted potential subjects, il was their
responsibility to explain the purposes ofthe project and to establish a high level of
acceptance and trust so that the interview could take place. The Median time for the
interview was 50 minutes (Orn, Newman, and Blan~ 1988).
3.2) Instrument: Diagnostic Interview Scbedule
3.21) Development ofthe DIS
The DIS was developed at the request ofthe Division ofBiometry and
Epidemiology ofthe National Institute ofMental Health (NIMH) for use in the
Epidemiological Catchment Area (ECA) projects (Robins, et al., 1981). The DIS
instrument is a structured and standardized diagnostic interview which elicits infonnation
• about psychiatrie symptoms at the time ofinterview and during the lifetime ofthe 20
responden~ including questions about onset and offset ofpsychiatrie illness and counts of • symptoms for a panicular illness. In addition, it addressed diagnosis trom a descriptive rather than etiological perspective, it required that symptoms meet a minimum standard
ofseverity, and required that symptoms cannot he explained by physical illness or
another psychiatric diagnosis (Robins et al., 1981, 1985).
The DIS is structured to first identify whether a symptom had becn experienced
and then to detennine whether it was ofclinical significance. Clinical significance is
determined by asking whether the individual has talked to a health professional about the
symptom(s), bas taken any medication because of i~ or feels that it bas substantially
interfered with hislher daily activities. The interviewer then tries to determine whether
the symptoms might be the result ofphysical illness, injury, or the use ofalcohol, drogs,
or medication. Ifthe existence ofthese variables is ruled out and the severity ofthe
symptom bas been established, the possibility that the symptoms represent a psychiatrie
disorder is then considered (Leaf, Myers, & McEvoy, 1991).
One ofthe main advantages ofthe DIS is that it was written in a manner in whieh
individuals without previous clinical training could administer it (thereby reducing costs).
This is made possible by the Probe Flow Chart inherent in the DIS. The interviewer reads
specifie questions and follows positive responses with additional follow-up questions (i.e.
probing). The amount ofdiscretion that is applied by the interviewer, either in wording
questions or deciding when to probe, is reduced to a minimum (Robins et al., 1981). A
further advantage is tbat il was designed 50 'ail questions were simple enough to be
understood regardJess ofthe respondents educationallevel. • 21
The DIS does not cover ail ofthe diagnoses in DSM..ffi. It covers the disorders of • greatest frequency for which diagnosis criteria are explicit and which cao he evaluated solely on the basis offace to face interviews (Leaf, et al., 1991). The diagnosis covered in
the DIS (version m) include obsessive-compulsive disorder, mania, major depression,
dysthymia, phobia, somatization, alcohol abuse or dependence, drug abuse or
dependence, antisocial personality, schizophrenia, and schizophreniform disorder.
Version ma also ineludes items pertaining to generalized anxiety disorder, post-traumatic
stress disorder, and bulimia, and inc0rPOrates slightly revised diagnosis for alcohol
abuse/dependence, dysthyrnia, and schizophrenia.
3.3) Reliability ofOCD DIS
Using a sample of216 participants consisting ofpsychiatry inpatients, outpatients,
and volunteers, a test..retest comparison was made using the OCO section ofthe DIS. In
tbis 'blended study ofboth reliability and validity', the sensitivity ofthe DIS for lifetime
OCD was 0.60, the specificity was 0.95, and the Kappa value was 0.60. In another study,
the reliability ofthe Spanish version ofthe DIS was investigated using a similar test
retest design. The results indicated a kappa value of0.62 for the Spanish speaking sample
(Kamo, Golding, Sorenson, and Bumam, 1988).
The tindings from these two studies seem to endorse the DIS as a reHable
measure. However, a rccent study condueted in t 997 examined the stability ofthe
diagnosis ofobsessive compulsive disorder over a one..year period across several ECA
sites. Pooling the data trom four sites resulted in an average kappa value of0.20. Kappa
values calculated separately for males and females participants were 0.19 and 0.23 • respectively (Nelson and Riee, 1997). 22
3.4) Validity orOCD DIS • Two studies have compared clinician diagnoses with DIS diagnoses in community sub-samples selected from the St. Louis and Baltimore ECA studies. In the St. Louis
study, when compared with physician diagnosis, sensitivity ofthe lay-administered DIS
for the lifetime diagnosis ofOCD was 0.14, specificity was 0.98, and the kappa value
was 0.12.
The Baltimore study used a one-month rather than lifetime diagnosis. For OCD,
comparison ofthe lay DIS diagnoses with those later obtained by physician examiners
blind to the DIS diagnosis produced a sensitivity of0.15, specificity of0.99, and kappa
value of0.05 (Kamo, et al, 1988).
3.5) OCD sectiOD oftbe DIS
A minimum ofthree and a maximum offive OCD symptom questions are asked
ofeach respondent. Table 1 summarizes the questions included in the Obsessive-
compulsive disorder section ofthe DIS. ------_._- - ._--_.._. Insert Table 1 about here
Obsessions:
The DIS includes two stem questions conceming obsessions. The first inquires
whether the respondent bas had any persistent and unpleasant thoughts. The exarnple
given is U ••• the persistent idea tbat you might hann or kill someone you love
though you really didn't want to". Ifthe respondent does not report having such thoughts,
a second question is asked that gives two exarnples ofobsessions-thoughts that one's
bands are dirty or have genns no matter how much they are washed and tbat relatives
• who are away may have been hurt or killed. The same duration (three weeks) and 23
persistence (continued despite attempts to rid ofthem) criteria apply to both questions. • for individuals who report either ofthese obsessions, the age and onset and recency of the obsession are detennined. Ifthe respondent replies affirmatively to the first question
about obsessions, the second question about obsessions is not asked (Kamo, et al., 1988).
In our analysis, symptoms were considered as present ifthe criteria ofseverity and
duration were met.
Compulsions:
The DIS contains three stem questions concerning compulsions. The tirst question
asks U some people have problems with feeling that they have to do something over and
over again even though they know it is really foolish-but they can't resist doiog it - things
like washing their bands apin and again or going back several limes to he sure they've
locked a door or turned offthe stove. Have you ever had to do something like that over
and over?" Ifthe respondent replies negatively, another question is asked-whether shelhe
has to do something in a particular order, sueh as getting dressed, and has to do it over if
it was done out oforder. Ail respondents are then asked a third question pertaining to
compulsive counting despite trying to prevent sueh behaviour. The example ofeounting
f100r tiles is presented (Kamo, et aL, 1988). In our analysis, symptoms were considered
as present ifthe criteria ofduration (three weeks) were met.
3.6) Flow Ch.rt
As previously stated., the DIS is based on a hierarehical structure. Ifa participant
responds positively or negatively to a question he/she may he exempt from other
questions or conversely he/she might have to answer more questions on that topie. • Consequently,. not ail participants will he asked the same questions. A list detailing the 24
number ofparticipants that responded to each question and the categorical structure of • the DIS are presented in Figure t. Insert Figure 1 about here
3.7) COlDorbidity
Previous research has demonstrated that comorbidity can increase the likelihood
oftreatrnent utilization (Galbaud du Fort, et al., 1993). It was therefore assumed that the
likelihood oftreatment seeking for OCD could he influenced by the existence ofa
comorbid disorder. Furthermore, we postuIated that the likelihood oftreatment seeking
for OCD would presumably he higher ifthere was evidence ofa lime overlap between
the two disorders. Using the criteria for the DSM-m diagnosis ofeach disorder we
assigned diagnosis (present versus absent) for mani~ phobi~ antisocial personality, drug
abuse or dependence, depression, panic, scbizophrenia, schizophreniform, somatizatio~
generalized anxiety, post-traumatic stress, bulimia, and alcohol abuse or dependence. For
the PurPOse ofthis study we detined disorders as comorbid with OCD ifthe age ofonset
ofthe later disorder was lower or equal to the age ofoffset ofthe earHer disorder,
indicating a temporal overlap between the two disorders.
3.8) Statistical analysis
Data analysis was conducted using SPSS version 9.0. Statistical analysis included
descriptive, followed by bivariate and muitivariate tests. Comparisons ofproportions and
means in the treabnent seeking and non-treatrnent seeking groups were made using the
chi-square test and independent samples t-test, respectively. Treatment seeking was
• defined as having ever told a doctor (including Medical doctors, psychiatrists, osteopaths, 2S • and students in training to he doctors) about their OCD symptoms. A non-treabnent • seeker was defined as individuals who are afflicted with the disorder, but never discussed their symptoms with a doctor.
Multivariate logistic regression, consisting ofbackward elimination procedure
and forward selection procedure were conducted with treatment seeking (defir.ed as yes
or no) as the dependent variable, and a number ofindependent variables including ail of
the symptoms and comorbid diagnoses associated bivariatly with treatment seeking with
a p value ofO. 10 or Jess. The variable age and gender were included as control variables
in the multivariate anaIysis.
The backwards elimination procedure involves running the model with ail the
variables present and subsequently identifYing and removing the variables which were the
least useful predictor(s) (Iowest F-to remove). Variables are removed until an established
criterion for the F no longer holds.
In the forward selection procedure, variables are entered iota the model one by
one. The first variable entered into the model at step 1 is the one with the strongest
positive (or negative) simple correlation with treabnent seeking. At each subsequent step,
the variable with the strongest partial correlation is entered With each step, the
hypothesis that the coefficient ofthe entered variable is 0 is tested by using the F statistic.
No more variables are entered into the model when the established criterion for the F no
longer holds.
The multivariate logistic regression was carried out on two separate groups of
subjects. Firstly, with the eotire sample of172 subjects with a DIS diagnosis ofOCD, and • secondly with the subset of69 participants who were administered version IlIa ofthe 26
ors. This was done in order to investigate those diagnoses not contained in DIS version • III~ i.e.~ generalized anxiety disorder~ post-traumatic stress disorder~ and bulimia.
• 27
RESULTS
4.1) Descriptive statistics for demographic characteristies and frequency • ofsymptoms
Table 2 provides the descriptive statistics for the DIS obsessive-compulsive
questions indicating the participants~ responses. In order to meet the criteria for OCO, the
participant must have had been amicted with al least one obsessive-compulsive
symptom. In total, 172 participants out ofthe 7214 individuals (2.4%) achieved this
criterion and were therefore included in our sample. The frequency distribution revealed
that 138 participants (80.2%) had one obsessive-compulsive symptom, 23 participants
(13.4%) had two symptoms and 11 participants (6.4%) had three OCD symptoms. The
sample was composed of60 males (35%) and 112 females (65%). The Mean age at
interview was 36 years ofage, the Mean age ofonset was 20 years ofage~ and the
average recency ofsymptoms was 4.5 months.
Insert Table 2 about here ------~------~,_....._._.._--,----
4.2) FrequeDcy ofcomorbid diagnoses
The frequency distribution for the total number ofcomorbid disorders in our
sampie were as follows: 19% (32/172) had no comorbid disorders, 24% (42/172) had
one, 24% (42/172) had two, 14% (24/172) had three~ 8% (13/172) had four, 5% (9/172)
had five, 4% (6/172) had six, and 2% (3/172) had seven or more comorbid disorders.
The frequency in which OCD co-occurred with other DIS/DSM DI psychiatrie
diagnosis was analyzed. Lifetime rates in our OCD sample in order ofprevalence were as • follows: depression 470.1.. (80/172), generalized anxiety 38% (26/69), antisocial 28
personality 40% (691172), alcohol36% (67/172), drug abuse/dependence 24% (42/172), • post traumatic stress disorder 13% (9/69), panic disorder 11% (19/172), schizophrenia 10% (18/172), phobia 9.3 (16/172), mania 7010 (12/172), bulimia 4%% (3/69),
schizophrenifonn 0.6% ( 11172), and somatization 0.6% (11172). Table 3 provides the
frequency and the temporal relationship between OCD and the comorbid disorders. As
evidenced by the table, the preponderance ofcases involved temporal overlap between
the comorbid disorder and OCD. Therefore, our decision that that the existence ofa
temporal overlap between the disorders was fundamental in our definition of
comoribidity is fitting, as only a small number ofsubjects were excluded due to this
criteria.
---.....-----_.....------._------_..._.--- Insert Table 3 about here
4.3) Participant cbaracteristics and treatment seeking
Ofthe 172 participants with OCD sYmptoms in our sample, 63 (37%) consulted a
doctor or other professional for their OCD symptoms. As shown in Table 4, treatment
seekers were amicted with a significantly greater number ofOCD symptoms (p=.OOI)
and comorbid diagnoses (p=.003). The variables, age at interview (p=.841), age ofonset
(p=.668), and recency ofsymptoms (p=.659) were not statistically significant. In
addition, there were no significant gender ditTerences in treatment seeking behaviour
(.512). • Insert Table 4 about here 29
• 4.4) Specifie OCO symptoms and treatment seeldng As shown in Table 5, which looks at specifie OCO symptoms and likelihood of
treabnent seeking, participants inflicted with severe obsessions ofviolence and other
unpleasant thoughts, and those inflicted with severe obsessions ofcontamination and/or
doubt were significantly more likely to consult a doctor regarding their symptoms
(p=.003 and .043, respectively). The variables for hand washing and checking for a
lengthy period oftime (p=.712), compulsions pertaining to symmetry and precision for a
lengthy period oftime (p=.5S0), and those pertaining to counting (.914) were not
significantly related to treatment seeking.
--,---~------,~------,-,,----- Insert Table S about here
4.5) Comorbid diagnoses and treatment seeking
As demonstrated in Table 6, which looks at comorbid diagnoses and likelihood of
treatment seeking, those in the treatment seeking group were significantly more likely to
have a comorbid diagnosis ofdepression (p=.004), generalized anxiety disorder (p=.OOS),
mania (p=.019), post traumatic stress disorder (p=.021), and panic disorder (p=.OS5).
Insert Table 6 about here ~_.....~------_._-----
For the multivariate analysis two variables had to be modified. The variable
'total number ofpresenting symptoms' origjnally had a ftequency distribution coded as 1, • 2, and 3. The distribution was as follows: 80% ofparticipants were in group 1, 13% were 30
in group 2, and 6% were in group 3. The number ofsymptoms was then dichotomized; • participants in groups two and three were combined, resulting in the final coding and distribution of 1 (80%) and 2 (20%).
The variable "total nomber ofcomorbid disorders' was also recoded. Initially it
had a frequency distribution ranging ftom 0 to 9, however the variable was modified and
coded into three groups in order to reduce the wide dispersion. The final distribution was
as follows: 1901'0 were in group 1,4901'0 were in group 2, and 33% were in group 3. Two
dummy variables were subsequently created with group 1 (no comorbid syrnptoms)
designated as the reference group.
4.6) Sequentialautomated model selection procedures
In order to attain the best model and select the variables that brought about the
most influence on treatment seeking for OCD, a multivariate analysis was performed.
The backward elimination and forward selection were canied out. The p value for
inclusion into the model was set at .05, and the p value of.051 represented the requisite
to stay in the moder. The p value of.05t was used to ensure that variables achieving a
borderline level ofsignificance would he included in our model. In addition, point
estimates were examined in conjonction with the p values to further ensure that ail
confounding variables were eliminated from the model. Although not significant at the
bivariate level, the variables sex and age was forced ioto the models, as it was
hypothesised that they may act as potential confounders.
Initially the variable, 'severe obsessions ofcontamination and/or doubt'
was included in the multivariate models. However, due to the • hierarchical nature ofthe DIS, only 66 participants were asked the question 31
• regarding that variable. When we ran the model~ SPSS subtracted 172 (our total
sample size) from 66, and mistakenly believed 106 participants were missing. We
nevertheless ran the model with the 66 participants (and therefore our reduced sample
size) and examined the results for the variable 'severe obsessions ofcontamination and/or
doubt'. However~ it did not attain a level ofsignificance 50 as to he retained in the final
model. Based on this finding a decision was made to exclude the variable from further
analysis at the multivariate level.
4.7) Baekward eliminatioD proeedure OD full sample
The backward elimination procedure was perfonned using the eotire sarnple of
172 participants interviewed with DIS version In~ thereby excluding comorbid
generalized anxiety di50rder and comorbid post-traumatic stress di5Order. This procedure
resulted in a final model containing four variables: sex and age (both forced into the
model), 'total nwnber ofOCD symptoms', and 'severe obsessions ofviolence and other
unpleasant thoughts ~. The Cox and Snell R-squared for the final model was Il%. Prior to
the removal ofany variables, the chi-square goodness offit was 23.78 and reached a
significance level of.003, thereby indicating the model did not fit weil. The final model
containing the four aforementioned variables yjelded a chi-square goodness offit of9.77
and did not attain a level ofstatistical significance (p=.28), thereby indicating the model
was a 'goOO' fit.
In the final model, the variable 'severe obsessions ofviolence and other
unpleasant thoughts' had an odds ratio of2.63~ and a 95% confidence interval ranging • ftom 1.28 to 5.38. It had a level ofsignificance of.008. The variable total nwnber of 32
symptoms had an odds ratio of3.44, and the 95% confidence limits were t 55 and 7.66 • with ap value of .003. The first variable that was removed from the model was comorbid panic, followed
successively by the number ofcomorbid disorders (two dummy variables), comorbid
mania, and comorbid depression. See Table 7 for the final backward elimination model
using the entire sample.
---,------_---...... Insert Table 7 about here
4.8) Forward selection procedure on lull saDlple
The forward selection procedure was also perfonned in an attempt validate our
findings from the backward elimination procedure. Using the full sample of t 72
participants interviewed with DIS version III, the results were identical to those ofthe
backward elimination procedure using the full sample.
4.9) Baekward eliDlination procedure on redueed saDlple
The backward elimination procedure was a1so performed exclusively on the 69
participants who were interviewed with DIS version III~ thereby including the diagnoses
ofgeneralized anxiety disorder and post-traumatic stress disorder. The results were
similar to those obtained on the entire sample. The final model consisted offour
variables: sex and age (both forced in), "severe obsessions ofviolence and other
unpleasant thoughts', and 'total number ofsymptoms'; and the model was able to explain • 21 % ofthe variance according to the Cox and Snell r-squared. Initially, the chi-square 33
goodness oftit test was 14.4 with a .045Ievel ofsigniticance. For the final model the • goodness oftit test decreased to 7.51 with a significance level of.48. The variable 'severe obsessions ofviolence and other unpleasant thoughts' had an
odds ratio of5.69 with confidence intervals (95%) ranging from 1.63 to 19.8. The
variable total number ofsymptoms had an odds ration of8.62 with confidence intervals
ranging from a low of 1.66 to a high of44.67. The variables comorbid panic disorder,
comorbid post traumatic stress disorder, comorbid mania, and comorbid depression, total
number ofcomorbid disorders (two dummy variables) were not included in the final
model. Sec table 8 for the final backward elimination procedure on the reduced sample.
~-...... ------,------Insert Table 8 about here
4.10) Forward selection procedure on redueed sample
The forward selection procedure was also performed exclusively on the 69
participants who were interviewed with the DIS version Ina, thereby including the
diagnoses ofgeneralized anxiety disorder and post-traumatic stress disorder. The results
were identical to those obtained using the backward elimination procedure on the reduced
sample.
• 34
DISCUSSION • 5.t) Overview In our study, 2.4% (172/7214) ofindividuals met the criteria for obsessive
compulsive disorder according to the Diagnostic Interview Schedule. This finding is
congJ1Jent with the recent literature indicating that lifetime prevalence ofOCO is
generally believed to he between 2 to 3% (Nelson and Riee, 1997). In addition, the
finding that participants tirst experienced their obsessions or compulsions in early
adulthood (mean age of20 in our sample) and that females were more likely to suifer
from the disorder, are also congruent with the latest ECA findings (Kamo and Golding,
1991). Most OCO studies report a greater prevalence amongst females, and in our sample
females were almost twice as likely to he diagnosed with the disorder in comparison to
males (65% to 35% respectively). This appears to be somewhat ofa divergent fmding as
it is outside the general range reported in the literature.
To the best ofour knowledge, this is the first study to examine which specific
symptoms and comorbid psychiatric diagnoses influence treatment seeking for obsessive
compulsive disorder. Since previous studies examining treatment seeking have not
examined these specific variables they are unable to conclude that the symptoms ofOCD,
rather than nonspecific symptoms ofdistress or comorbid disorders, led to their
utilisation ofhealth care resources (Kamo and Golding, 1991).
In our study, 31010 (63/172) ofthe participants with obsessive-compulsive
symptoms consulted with a doctor or health professional over the course oftheir lifetime.
This finding is highly congruent with that ofthe ECA study, in which it was reported that • 35
34% ofindividuals with a lifetime diagnosis ofOCD consulted with a doctor or health • professional regarding their symptoms (Robins, et al., 1991). Obsessive compulsive disorder generally lies in the mid range amongst disorders
regarding how frequently its sufferers consult a doctor regarding their symptoms.
According to the ECA studies, somatization disorder (100%), panic disorder (73%),
depression (61 %), and schizophrenia (47OA.) have higher rates oftreatrnent seeking in
comparison to OCD. The disorders mania (22%), phobia (22%) drug abuse (1 SOA.),
a1cohol abuse (15%) and antisocial personality (11%) have lower rates (Robins, et al.,
1991 ).
It is interesting to note that in our sample there was no significant gender
difference regarding treatment-seeking behaviour. This finding was unanticipated due to
the established finding that wornen in general exhibit a greater propensity to seek
professional help for psychiatrie problems (Kessler, Brown and Broman, 1981).
At the bivariate level, several variables were significantly associated with
treatment seeking behaviour. These included; total number ofsymptoms, number of
comorbid diagnosis, severe obsessions ofviolence and other unpleasant thoughts, severe
obsessions ofcontamination and/or doubt, and OCO comorbidity with panic disorder,
mania, generalized anxiety, post traumatic stress disorder, and depression.
Il is somewhat intuitive that the total number ofsymptoms and total number of
comorbid diagnosis would lead to an increase in treatlnent seeking behaviour. Both
variables would be associated with tremendous psychological distress. Despite the fact
that Den sutTerers tend to mask their discomfort and illness, it is probable they would at • sorne point attempt to alleviate their discomfort and seek Medical help. 36
It is also not surprising that the variables 'severe obsessions ofviolence and other • unpleasant thoughts', and 'severe obsessions ofcontamination and/or doubt' were positively associated with treatment seeking. Given that the obsessions are persistent and
cause distress or significant impainnent, and the individual recognizes that the obsessions
are excessive or unreasonable, it seems likely that the individual would eventually resort
to treatment seeking.
What is somewhat unexpected is the finding that the three primary compulsive
symptoms (pertaining to hand washing and checking for a lengthy period oflime,
symmetry and precision for a lengthy period oftime, and those pertaining to counting)
were not significantly related to treatrnent seeking behaviour. The label obsessive
compulsive disorder May mislead the clinician into thinking this disorder always presents
with both obsessions and compulsive features, however, this appears to he a misnomer
(Kolada et aL, 1994). Although it is somewhat equivocal, individuals generally sutTer
from either obsessions or compulsion but rarely the two ofthem together (Kamo and
Golding, 1991). However, there is no previous literature examining ifindividuals
sutTering from compulsions are less likely to seek treatment than those suffering from
obsessions are. Based on this finding however, we can hypothesize that subjects sutfering
only from compulsions are probably rarely seen in treatment settings.
Il is conceivable that compulsions do not produce the same level ofsutfering and
impainnent that is associated with obsessions. Perhaps patients do not conceive of
compulsions as being 'abnonnal' or something deserving oftreatment. Altematively,
patients May he more successful and better equipped at resisting or suppressing • 37
compulsions then they are with obsessions. Evidently further research is needed to help • elucidate these issues. Regarding comorbid psychiatric diagnoses, five variables were significantly
associated with treatment seeking al the bivariate level. Based on previous literature, the
finding that the comorbidity between OCO and panic disorder, mania, generalized
anxiety, post traurnatic stress disorder, and depression led to an increase in treatment
seeking is not unexpected These disorders are debilitating and cause significant distress
in their own right, compounded with OCD would further increase the psychological
distress and reduce the etTectiveness ofcoping mechanisms. [t is somewhat surprising
that the variables 'phobia' and 'alcoholldrug abuse or dependence' were not associated
with treatment seeking. Both variables have high rates ofco-occurrence with OCD and
cause serious psychological distress.
Although the aforementioned comorbid conditions might incite the individual to
seek treatment, paradoxically, those sante comorbid disorders May delay the attainment
ofappropriate medical care. It is conceivable that the comorbid disorders May mask the
OCO symptoms and therefore lead to misdiagnosis. As a resul~ the patient May
(inadvertently) only receive treatment for the secondary disorder. Hopefully, this
potential problem will dissipate in the near future, as there bas becn a concerted effort to
bettereducate primary care workers regarding the symptomatology ofOCO (Higgins,
1996).
At the multivariate level, two variables were significantly related to treatment
seeking; total number ofsymptoms and severe obsessions ofviolence and other • unpleasant thoughts. As previously mentioned, this is somewhat ofan expected finding. 38
Since both the backwards elimination and forward selection procedure resulted in the • same identical model~ it appears to he a fairly robust finding. It is interesting to note that in our study~ treatment seeking behaviour was explained primarily by OCD symptoms
and not by comorbid disorders. This finding contrasts from an earlier study exarnining
depression, comorbidity~ and treatment seeking. Using a similar methodology, Galbaud
du Fort, et al (1999) reported that comorbidity rather than depressive symptoms primarily
detennined treatment seeking among patients with lifetime major depression. Despite
their significance at the bivariate level, Perhaps comorbid factors were not significant in
our final model due to eonfounding. Hypothetically ~ it is conceivable that the severity of
OCO symptoms plays a confounding role by being associated with both comorbidity and
treabnent seeking. For example, in the case ofdepressio~ it is likely that the severity of
OCO symptoms results in sufferers feeling depressed. As a result, the depression may
lead the individual to seek treatment. this effect however is being masked by the OCD
symptoms.
This study had several interesting strengths. Firstly~ this study examined the
prevalence oftreatment seeking for OCD using a large sample size of 172 participants.
Secondly, unlike prior studies, we examined which specifie factors May lead individuals
to seek treatment. Thirdly, we corroborated the previous literature with our findings
regarding OCO and its comorbid disorders. Fourthly, by utilizing the highly structured
DIS, we ensured that the potential for misdiagnosis was held to a minimum.
This study had several significant limitations. We were not able to
investigate several potential confounding variables. Employment status, racelethnicity~ • housing (urban versus rural), and marital status have ail been hypothesised to play a role 39
in the manifestation ofOCD (Kamo et al, 1991) and hypothetically could influence • treabnent seeking behaviour as weil. However due to limitations in our data set we were unable to examine these variables. Perhaps the greatest potential confounder in our study
is socio-economic status (SES). Previous studies have demonstrated a relationship
between SES and treatment seeking. Specifically, low SES was demonstrated to he
inversely related to treatment seeking (Katz, Hofer, and Manning, 1996). Therefore, since
this variable was not monitored in our study we cao not conclusively determine that
treatment-seeking behaviour was influenced by <:>cO and comorbid symptoms,
irrespective ofSES.
The second limitation concems the DIS. Although highly structured and modeled
after the DSM-m-~ in theory the schedule will Dever he as good at diagnosing
individuals as a trained clinician. The previously referred to studies examining the DIS'
reliability and validity appears to support this hypothesis. While the specificity ofthe
instrument appears to he satisfactory, the sensitivity values and subsequent low KapPa
scores are less impressive. The low sensitivity scores indicate that individuals who do in
fact have OCD are not being correctly diagnosed by the DIS, thereby creating nurnerous
false negative cases. However, there is no reason to believe that the degree of
misclassification is influeneed by the decision ofwhether or not to seek treatment. The
impact ofthis non-ditrerential misclassification is that it potentially decreases the
likelihood offinding significance but does not alter the validity ofour findings.
In addition, the OCD section ofthe DIS contains few questions conceming which
specifie symptoms might he present. This factor may partiaily explain the low sensitivity • results. The symptoms that are inquired about in the DIS include: thoughts ofviolence, 40
contamination and/or doubt, band washing and checking, symmetry and precision, and • compulsions regarding counting. However, other prevalent symptoms such as sexual imagery, pathologie doubt, and hoarding are not investigated and therefore individuals
sutTering from these symptoms may he incorrectly diagnosed. Further confounding the
problem is that syrnptoms tend to he clustered together. Therefore, subjects are asked if
they have ever sutTered from obsessions ofcontamination and/or doubt, and compulsions
pertaining to hand washing and/or checking. Ry grouping symptoms together it cao not
he detennined which specifie symptom (ifany) are present and its POtential to influence
treatment-seeking behaviour.
A further drawback ofthe DIS is its criteria regarding duration. A period ofthree
weeks is used, however, perhaps a more meaningful value would be to examine the
number ofhours per day in which the subject has been plagued with symptoms and the
impact it bas on an individuals global functiomng. In our study, it could be hypothesized
that individuals would he more likely to consult their doctor iftheir symptoms occurred
over a period offew hours each day or iftheir symptoms significantly interfered with
their way ofHfe (i.e. job, family).
Furthennore, the DIS, like any diagnostic instrument, is susceptible to issues such
as recall bias and social desirability. The aforementioned issues do not necessarily negate
the significance ofour findings; however, they should he given careful consideration
when examining prevalence rates for the various disorders and treatment seeking
behaviour. Lastly, sorne research suggests that older and less educated participants may
have more difficulty with DIS questions (Nelson and Rice, 1997). In our sample nearly • 80/0 ofparticipants (t3/172) were aged sixty years or older. 41
The third limitation concems our selected outcome variable" treatment seeking. • We have examined whether individuals consulted with a doctor regarding their symptoms. The fact that subjects report their symptoms to a doctor does not necessarily
imply that they will be correctly diagnosed and treated.
Tremendous advances have been made in the study and treatment ofnumerous
mental disorders over the years. However it should be remembered that a linle over a
decade ago, OCD was thought to be amongst the most rare and intraetable disorders.
Therefore, research ioto OCD and treattnent seeking is still in the embryonic stages.
While this study is a good start in examining specific symptoms and their relation to
treatment seeking, several questions remain unanswered.
Firstly, why is the rate ofservice utilization 50 low considering the rate of
impainnent is so high? Recently, there has been a plethora ofliterature and media
campaigns regarding OCD awareness and treatment possibilities. It is conceivable that
this increased attention and optimism about its treatability will encourage more
individuals to seek help. Boistering tbis hypothesis is the finding that simply reading
about OCD or hearing about it on the radio or TV can lead to treatlnent seeking
behaviour (Hollander, 1997). It appears that the primary barrier interfering with treatment
seeking is the manner in which individuals attempt to conceal their symptoms. It is
imperative that sufferers realize there is no shame in being amicted or diagnosed with
OCD. Ofequal importance" society must exemplify this beliefas weil and not treat these
individuals with scom or as pariahs.
Secondly, why is there a seventeen·year lag lime between onset ofsymptoms and • appropriate treatment (Higgins, 1996; Hollander, et al., 1996)? This is likely related to 42
two intertwined factors. Patients are averse to discussing their problems and the primary • health care workers lack validated screening tools to tests for OCD. Further complicating matters is the possibility that OCD sufTerers are being misdiagnosed due to
accompanying comorbid disorders. With increased awareness, improvements in
treatlnent, and better recognition and screening tools among physicians, the time lap
between onset ofsymptoms and appropriate treatment should decrease in the near future.
Thirdly, does the use ofmental health services for OCO vary by location? Boyd
( 1986) reported use ofhealth services for OCD across five ECA sites during the early
1980's. The results were as follows: New Haven (19%), Baltimore (23%), St. Louis
(33%), Durham (29%), and Los Angeles (15%). It is interesting to note that there is an
18% difTerence between the St Louis and Los Angeles site in the use ofmental health
services among OCD sufTerers. These discrepancies are difficult to explain; however, it is
interesting to theorize how similar the treatment seekers in the Edmonton sample are to
their American counterparts. The health care system in Canada is more accommodating
to those individuals seeking treatment due to its uoiversal health care coverage. [n the
United States individuals would have to pay for use ofmental health services (unJess they
are insured). Therefore, perhaps use ofmental health services for the treatment ofOCD
would he slightly higher in Canada then the US.
The majority ofstudies examining OCD and use ofmental health services are
based on data colleeted in the 1980's. [t is interesting to note that during the past decade
there has been an abundance ofarticles pertaining to OCD and favourable treatment
outcome. Coinciding with this research has been a concerted effort to infonn individuals • about OCD through the use ofpublic campaigns. Therefore, perhaps ifthese studies were 43
conductcd today, thcre would be an increase in the use ofhealth services duc to increascd • attention and public awareness ofocn and its potential treabnent.
5.1) Conclusion
To the oost ofour knowledge, this is the first study to examine potential predictors of
treatlnent seeking, and therefore marks an important first step ioto this realm ofresearch.
Our findings indicate thal at the multivariate level, the variables ~total number of
symptoms' and 4severe obsessions ofviolence and other unpleasant thoughts' are
associated with higher likelihood oftreatment seeking behaviour in Persons with OCD.
These results may help ongoing and future public health education programs, especially
by teaching the public about compulsions. People suffering with only compulsions (no
obsessions) are presumably seldom seen in treatment settings.
• 44
Table 1: Summary ofquestions included in the Obsessive.compulsive disorder section ofthe DIS.
• Glossary orOIS questions DIS # AND TOPle W0 RI"IRa 0 f.Question DIS 172 Have you ever been bothered by having certain unpleasant thoughts ail the time? An example 1 Related ta: obsaIioas ofviolence would he the persistent idea that you might harm or kiU someone you lovecl even though you reaJly didn't want 10? DIS 173 Other thoughts that keep bothering some people. even when they know tbey are silly. are that their Related to: obseaioas of bands are dirty or have germs on ~ no matter contamination and/or doubt how much they wash them, or that relatives who are away bave been bwt or killed. Have you ever bad any kind ofunreasonable thouahts like that? DIS 174 How old were you when you tint had a problem with Ibis kind ofthought orwony? Related to: age at onset
DIS 175 How reœntly bave you been bothered by thoughts Iike tbis that keep comiog back DO matter how Relaced to: r~.y ofsymploms ridiculous you thought tJiey were? DIS 176 Some people bave problems with feeling that they have 10 do something over and overagain even Related to: co.pulsioas pertaining 10 though they know il is really foolish-but they can'I band washing. and checking resiSl doing it-things like washing their bands apin and again or going back severa! limes to be sure they've locked a doorortumed offtlle stove. Have you ever had to do something like that over and over'! DIS 176a Was there a time when you always had to do sometbing-like getting dresscd perhaps-in a certain Relaled to: compulsiods penaining ta order, and had to start ail over again ifyou got the symmerry and precision wrona order? DIS 171 Did you have to do tbis only for a short time, or did you Ceel you had to do this over a period ofseveral Related to: the course ofthe disorder weeks? DIS 178 Ras there ever been a period ofseveral weeks when yC.lU felt you had to count something. like the Related to: compulsiod pertaining to squares in a tile floor, and couldn't resisl doing it countina even when vou tricd ta? DIS 179 How old were you when you tint hBd to (do something. over and over/check on things/countlor Related to: age al onset ofobsession do thïnas in a SPeCial order)? DIS 180 How recently bave you bœn bothered by having to do things like this (do something over and Related to: recency ofobsession over/check on thingslcountlor do things in a special order)? • 45
Figure 1: Probe Flow Chart
yes DI5172 ------1.... DI51728 • (n=172) n=116) ~uralion> 3 "'eeks no DIS l72b -+ DISINTZIDISINTAA (n=109) (0=109) l(n=I09)
·ifOIS172b ·ifD[SI72b * 5 =; 0lSI73 (0=66)
no
DISl73a (n=18)
-ifduration < 3 ks~duratiœis > 3 wceks
DIS173b .. DlSINTBB (n"'14) (0=14)
- ifDISI73b *5 DI5174 (n=120) DISI75~ (n=120) .ifduralion is> 1y______DISI75a ~ (0=54)
DIS 176 .. DISINTDD (0=172) (0=172) ~*5 DISI76a -----1... DISINTEE (n=119) (n=119) -if= 5 ·if~ 5
DIS 177 (n=63) DI 78 .. DISINTFF (0=172) (n=172) 'if_~~_P;~V:I~
.(n=87) ~ • DI5180 (0-87) ~ 46
Table 2: Descriptive statistics for the DIS Obsessive-compulsive questions
• Descriptive statistics oertainina ta obsessive-compulsive Questions Age (N=112) Mean =36.3 Min. = II Max. =13 Gender (N= 112) Male (1) = 60 (35-4). Female (2) = 112 (65.%)
Total number ofsymptoms of 1= 138 (10.2%). 2 = 23 (13.4%) obsessive compulsive neurosis or 3 = 1t (6.4-4) disorder (N= 172)
DIS 112 (N= 112) No (1) = 56 (32.6%), Yes (5) = 116 (67.4%) Related to: obsessions of violence and other unpleasant thouKhts DIS 112a (N= 116) Less than 3 (1) = 7 (6-4). 3 weeks or more (5) = 109 (94%) Related to: duration ofsvmDtoms DIS 112b (N=109) No (1) =: 1, Yes, but not severe (2) = %, Related to: severitv ofsymptoms Yes. present and severe = t «Hi DIS 173 (N= 66) No (1) = 41 (73%), Yes (5) = 18 (27.3%) Related to: obsessions of contamination and/or doubt DIS 173a (N=18) Less than 3 weeks (1) = 4 (22.2%) Related to: duration ofsvmDtoms 3 weeks or more (5) = 14(78%) DIS 173b (N=14) 1 = 0, 2 = 0, S = 14 (100%) Related to: severity ofsvmptoms DIS 174 (N= 120) Mean = 21.8 Min. = 1 Related to: age at which symptoms Max. =51 occurred DIS 175 (N= 120) Within last 2 weeks or current (1) =34 (21.3%) Related to: recency ofsymptoms Last month 9 (2) = 7 (5.'%~ Last 6 months (3) = 16 (13.3%) Last year (4) =9 (1%) More than 1 year ago (5) = SI (45-4) DIS 115a (N= 54) Mean=28.7 Min. = 12 Related to: age since last symptoms Max. =49 occurred DIS 176 (N= 172) 1 = 110 (64%). 2 = 9 (S.2",_), S =53 (30.'-4) Related to: compulsions pertaining to hand washinR and checking DIS 176a (N= 1(9) 1 = 109 (92-4~ S = 10 (1.4%) Related to: compulsions penaining 10 symmetry and prec:ision DIS 177 (N=63) Short time (1) = 5 (1%), Related to: the course ofthe disorder Several weeks (S) =51 (92.1%) DIS 118 (N= 172) 1 = 129 (75%),2 = 4 (2.3"'-), S = 39 (22.7%) Related to: compulsions pertaining to countina DIS 119 (N= 87) Mean= 19.2 Min- = 1 Related to: age al onset of Max. =75 compulsions • 47
DIS 180 (N= 87) Last 2 weeks or current (1) =39 (45%) Related to: reœncy ofcompulsions Last month (2) = 6 (6..'%). 6 months (3) = 1 (9.2%) Last year (4) =1 (1") • More than 1 year ago (5) = 27 (31%)
When in the last year did the subject have lut compulsion orobsession = 107 • Did ....jedad MD i. question 112b =109 Does estion 172b=5 = 109 • Did sabject tell MD ia quatien 173b = 14 Does esrion 173b=5 Does uestion 176 =5 Does uestion 176a = 5 = 119 • Did subject tell MD in question 17 17611 or 17. - 172 Age tint had obsession or Mean= 20.2 Min. = 1 compulsion ifever met DSM criteria Max. =5 = 172 Age subjec:t Iast had obsession or Mean= 67.s Min. =, cam Ision = 172 Max. =94 • question pertains to treatment seeking
• 48
Table 3: Frequency and the temporal relationship between OCD and the comorbid • disorders Comorbid disorder Prevalence of A % B% C% D% E% B~C-D% Comorbidity (o/oIN)
Depression 47 55 23 21 0 99 (0=80)
Antisocial personality 40 3 58 19 17 3 94 (n=69)
Alcohol 36 0 55 Il 29 5 95 (n=62)
Drug abuse/dependence 24 7 38 7 40 7 86 (0=42)
Generalized anxiety· 15 8 27 19 38 8 85 (n=26)
Panic 13 4 52 17 26 0 96 (n=19)
Schizophrenia 10 0 22 33 39 6 94 (n=18)
Phobia 9 0 94 0 6 0 100 (n=16)
Mania 7 0 58 17 17 8 92 (0=12)
Post-traumatic stress· 5 11 22 33 33 0 89 (0=9)
Bulimia* 2 0 0 0 67 33 100 (n=3)
Schizopbreniform .6 0 0 tOO 0 0 100 (n=l)
Somatization .6 0 0 100 0 0 100 • (0=1) 49
• DIS-Ina group only
A - There is no temporal overlap and the offset ofthe comorbid disorder occurs • before the onset ofOCD B - There is a temporal overlap in which the onset ofthe comorbid disorder occurs before the onset ofOCO C - There is a temporal overlap in which the onset ofthe comorbid disorder and OCD commence at approximately the same time (within the same year) D - There is a temporal overlap in which the onset ofOCO occurs before the onset ofthe comorbid disorder E - There is no temporal overlapand the offset ofOCn occurs before the onset ofthe comorbid disorder A ..,.- B-C - Total sum oftemporal overlap
• 50
Table 4: Treatment seeking for Obsessive compulsive disorder: association with gender, age, and illness characteristics • Characteristic treatment seeking treatment seeking p value Yes No (N=63) (N=I09)
Gender (0/0 female) 68 63 .512
Age al interview 36.5±10.3 36.1±15.7 .841 (mean±s.d.)
Total number ofsymptoms 1.44±.69 1. 16±.45 .001 (mean±s.d.)
Age ofonset 20.7±9.0 20.0±11.9 .668 (mean±s.d.)
Recency ofsymptoms 4.38±3.4 4.63±3.70 .659 (mean±s.d.)
Number ofcomorbid 2.63±2.00 1.80±1.61 .003 diagnoses (mean±5.d.)
• SI
Table 5: Role ofspecific OCD symptoms and likelihood oftreatment seeking
Treatment seeking p value • Symptom yes no 48 (45%) 58 (55%) .003 Present
1) Severe oblasions ofviolence .ad o'lIer aapleasaat tlloapts (0=172) Absent 15 (23%) 51 ('70/0)
Present 6(43%) 8 (570/0) .043
1) Severe obsessions .f~ontamia.lion .ad/ordoubt (a=66)
Absent 9 (1 "/0) 43 (83%)
Present 19 (39%) 30 (61%) .712
3) Compulsioal: h.ad ".hiag .nd cbeclûnglor .Iea....y pcriod .flime (0=172) Absent 44 (36%) 79(64%)
Present 4(44%) 5 (56%) .550
4) Compulsions: Symmetry .nd precision for. leagthy period .ftime (0=119) Absent 38 (35%) 72 (66%)
Present 14 (36%) 25 (64%). .914 5) compulsions pertaining to countiag (0=172) • Absent 49 (37"10) 84(63%) 52
Table 6: Role ofcomorbid diagnoses and treatment seeking
Treatment seeking for obsessive Depression 60.3 37.6 .004 Antisocial personality 11.1 8.3 .535 Alcoholabuse/dependence 33.3 34.9 .839 Drug abuse/dependence 17.5 22.9 .395 Panic disorder 11.1 3.7 .055 Schizophrenia 14.3 7.3 .141 Phobia 44.4 33.9 .171 Mania 20.6 8.3 .019 Schizophreniform 0.0 0.9 .446 Somatization 1.6 0.0 .187 Generalized anxiety* 22.2 7.3 .005 PTSD* 9.5 1.8 .021 Bulimia* 1.6 .9 .693 * DIS-IlIa group only • 53 • Table 7 :Backward elimination procedure on full sample Variables in the Equation Variable B S.E. Wald df Sig R sax .1841 .3569 .2661 1 .6060 .0000 Age .0068 .0123 .3045 1 .5811 .0000 Severe .9663 .3655 6.9919 1 .0082 .1488 obsessions ofviolence and .tber un""nt thoapts Total 1.2356 .4083 9.1596 1 .0025 .1782 number of symtolns Constant -1.8114 .6187 8.5728 1 .0034 95% cr for Exp(B) Variable Exp (B) Lower Upper Bex 1.2021 .5973 2.4194 Age 1. 0068 .9828 1.0315 Severe 2.6283 1.2841 5.3796 obsessions... Total number 3.4404 1.5456 7.6580 of eymptcms Model if Term Removed Term Log Significance Removed Likelihood -2 Log LR df of Log LR Severe -107.132 7.412 1 .0065 obsessions of violence and other unpleasant thouqhts Total number -108.160 9.470 1 .0021 of symptoms Variables not in the Equation Residual Chi Square 5.526 with 5 df Sig .3551 Variable Score df Sig R Cornorbid depression 2.9554 1 .0856 .0651 Comorbid mania 1.9877 1 .1586 .0000 Comorbid panic 1.8094 1 .1786 .0000 Dummy 1 .5706 1 .4500 .0000 • Dummy 2 3.3808 1 .0660 .0782 54 Table 8: Backward elimination procedure on reduœd sample Variables in the Equation • Variable B S.E. Wald df Sig R sez -.4245 .5839 .5286 1 .4672 .0000 Age .0294 .0210 1.9496 1 .1626 .0000 Obsessions 1.7386 .6365 7.4601 1 .0063 .2398 of violence and other unpleasant thoughts Total 2.1540 .8395 6.5837 1 .0103 .2197 number of symptonus Constant -2.4155 1.0899 4.9117 1 .0267 95% cr for Exp(B) Variable Exp(B) Lower Upper Sex .6541 .2082 2.0544 Aqe 1.0298 .9882 1.0731 Obsessions 5.6894 1.6340 19.8102 of violence... Total 8.6194 1.6630 44.6732 number of symptOlllll Model if Term Removed Term Log Significance Removed Likelihood -2 Log LR df of Log LR Obsessions -44.083 8.827 1 .0030 of violence._ Total -43.855 8.372 1 .0038 number of symptoms Variables not in the Equation Residual Chi Square 11.923 with 7 df Sig .1031 Variable Score df Sig R Comorbid depression 1.9730 1 .1601 .0000 Comorbid generalized .4811 1 .4879 .0000 anxiety disorder Comorbid post- 1.9516 1 .1624 .0000 traumatic stress disorder comorbid mania 3.2264 1 .0725 .1137 comorbid panic 3.5012 1 .0613 .1257 Dummyl .5195 1 .4711 .0000 Dummy2 3.4022 1 .0651 .1215 • 55 DIS QUESTIONS 172. 1 want to ask you next about whether you have ever been bothered by having • certain unpleasant thoughts ail the lime. An example would he the persistent idea that you might harm or kilt someooe you lovecL even though you reaUy didn't want to. Have you ever been bothered by that or by any other unpleasant thoughts and persistent tboughts? No (SKIP TO Q. 173) 1 Yes , , '" (ASK A) 5 A. Was this only for a short lime or was it over a period ofseveral weeks? Less than 3 weeks (SKIP TO Q.173) , 1 Three weeks or more , .. , (ASK B) 5 B. Did these thoughts keep coming ioto your mind no matter how bard you tried to get rid ofthem 2 5 INTERVIEWER: DIO R TELL MD IN Q.172B? NO 1 YES 5 INTERVIEWER: OOES Q. t 728 = S ~ NO (ASKQ.173) 1 YES (SKIP TO Q.174) S t 73. Other unpleasant thoughts that keep bothering sorne people, even when they know they are silly, are that their bands are dirty or have genns on them, no matter how much they wash them, or that relatives who are away have been hurt or kiUed. Have you ever had any kind ofunreasonable thought like that? No (SKIP TO Q.176) 1 YES '" (ASK A) .5 A. Was this only for a short lime or did these thoughts keep coming into your • mind over a period ofseveral weeks? 56 Less than 3 weeks (SKIP TO Q.176) 1 • Three weeks or more (ASK B) , .5 B. Did these thoughts keep coming into your rnind no matter how hard you tried 10 get rid ofthem? 1 2 5 INTERVIEWER: DID R TELL MD IN Q. t 738? M NO , 1 YES , , " 5 INTERVIEWER: DOES Q.173B = 5? ~ NO , (SKIP TO Q.176) , '" 1 YES '" .(ASK Q.174) .5 174. How old were you when you tirst had a problem with this kind ofthought or worry? IF R SAYS WHOLE LIFE, CODE 02 !Tl ENTER AGE & GO TOQ.175 A. Do you think it was before you were 40 or later than that? Before 40 (RECODE 01) 40 or more '" (RECODE 95) Still DK (RECODE 98) 175. How recently have you been bothered by thoughts like this that kept coming back no matter how ridiculous you thought they were? Within last 2 weeks or current , 1 Within last month , 2 Within last 6 months 3 Within last year 4 • More than 1 year aga " 5 57 176. Sorne people have problems with feeling that they have to do something over and over again even though they Imow it is really foolish - but they can't resist doiog il-things like washing their hands again and again or going back • several rimes to he sure they've locked a door or turned offthe stove. Have you ever had to do something like that over and over? 1 2 S INTERVIEWER: IS ·-5" CODED IN Q.176 ABOVE? IQQJ NO ' (ASK A) ' 1 YES , (SKIP TO Q.177) '" 5 A. Was there a time when you always had to do something - like getting dressed perhaps - in a certain order, and had to start ail over &gain ifyou gel the order wrong? INTERVIEWER: IS ··5" CODED IN Q.176A ABOVE? g] NO (SKIP TO Q.178) 1 YES ' '.' (ASK Q.177) '" 5 177. Did YOU ever have to do this only for a short period oftimc, or did you feel you bad to do this over a period ofseveral weeks? Short time , ., 1 Several weeks " 5 178. Has there ever been a period ofseveral weeks when YOD feft you had to count something, Iike the squares in a lile tllor~ and couldn't resist doiog il even when you tried to? 1 2 5 • 58 INTERVIEWER: DIO R TELL MD IN Q.176, 176A OR 1781 rn YES , , 5 • NO ,, '" ..,,,) INTERVIEWER: lF Q.176, 177, OR 178 CODED ~~5'J': ASK Qs. 179-180. ALL OTHERS, SKIF TO Q.181. )79. How old were you when you first had to (do something, over and over/check on thingslcount/or do thongs tjjCial arder)? ENTER AGE & GO TO Q.180 A. Do you think: it was before you were 40 or later than that? BeCore 40 '" ., ,..(RECORD 01 ) 40 or more ,".(RECORD 95) Still DK ,, (RECODE 98) 180. How recently have you been bothered by having to do things like this (do something over and aver/check on things/countlor do things in a special order?) 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