Original Research
Quality of Life in OCD:
Differential Impact of Obsessions, Compulsions,
and Depression Comorbidity
Mario Masellis, MD, MSc1, Neil A Rector, PhD2, Margaret A Richter, MD3
| |
Objective: An anxiety disorder severely affects the sufferer’s quality of life (QOL), and this may be particularly true of those with obsessive–compulsive disorder (OCD). This study examines the differential impact of obsessions, compulsions, and depression comorbidity on the QOL of individuals with OCD.
Method: Forty-three individuals diagnosed with OCD according to DSM-IV criteria and experiencing clinically significant obsessions and compulsions completed measures of QOL, obsessive–compulsive symptom severity, and depression severity.
Results: Obsession severity was found to significantly predict patient QOL, whereas the severity of compulsive rituals did not impact on QOL ratings. Comorbid depression severity was the single greatest predictor of poor QOL, accounting for 54% of the variance.
Conclusions: Given the importance of these symptoms, treatments that directly target obsessions and secondary depression symptoms in OCD are warranted. However, replication of these findings in a prospective cohort study is required, because although the the current study’s cross-sectional design allows for the examination of the associations among obsessions, depression, and QOL, it cannot establish their temporal framework (that is, causal relations).
(Can J Psychiatry 2003;48:72–77)
Click here for author affiliations.
|
Clinical Implications
-
Clinical obsessions and compulsions are both associated with poor quality of life (QOL). When the covariation between obsessions and compulsions is taken into account, obsessional severity appears to account for the decrements in QOL observed in those with obsessive–compulsive disorder (OCD).
-
The presence of comorbid depression in OCD is the greatest predictor of poor QOL.
-
Treatments that directly target obsessions and secondary depressive symptoms in OCD are required.
Limitations
-
The cross-sectional examination of the relation between obsessions, compulsions, secondary depression, and QOL does not provide the opportunity to determine causal relations among these variables.
|
Key Words: obsessive–compulsive disorder, OCD, obsessions, compulsions, quality of life, QOL, illness intrusiveness
Résumé : La qualité de vie avec le TOC : l’effet différentiel des obsessions, des compulsions et de la comorbidité de la dépression
|
Obsessive–compulsive disorder (OCD) is a severe and debilitating anxiety
disorder afflicting about 1 adult in 40, or approximately 2.5% of the population,
at some time in their lifetime (1–3). It is it twice as prevalent as schizophrenia
and bipolar disorder, and the fourth most common psychiatric disorder (4).
In severe cases, which may define upward of 20% of those with the diagnosis
(5), obsessions and compulsions can occupy the entire day and result in
profound disability. If untreated, the probability of symptom remission
is extremely low (6). Perhaps more than any other anxiety disorder, OCD
is characterized by a chronic waxing and waning of symptoms.
There has been little examination of the extent to which the presence of
persistent obsessions and compulsions impact on the QOL of persons with
OCD. A recent review of the impact of anxiety disorders on QOL enumerated
the profound personal, social, and financial costs associated with anxiety
disorders, although there was a striking dearth of studies conducted on
patients with OCD (7). A survey study by Hollander and others demonstrated
that 73% of OCD patients have impaired family relationships, 62% have impaired
friendships, 58% experience academic underachievement, 47% experience interference
with work, and 40% are chronically underemployed or simply unemployed (8).
Two subsequent studies with more reliable and valid QOL measures have also
found important decrements in the QOL of those with OCD. Koran and colleagues
found that QOL (that is, instrumental role performance and social functioning)
was more severely impaired in those with OCD than in those with chronic
medical conditions (for example, diabetes) or in the general population
(9). Antony and colleagues examined the extent of impairment in multidimensional
aspects of QOL in OCD and other disorders of the anxiety spectrum, including
panic disorder and social phobia, and found that all 3 groups had equivalent
and significantly more impaired scores than did patients experiencing a
range of chronic medical conditions (10). Selective aspects of QOL were
found to be especially affected in OCD, such as the ability to read and
carry out other tasks that require deliberate and sustained focus (10).
To date, no study has examined whether obsessions and compulsions produce
independent effects on QOL. While most patients with OCD experience both
obsessions and compulsions, it may be that individuals with OCD are more
affected by the intrusive, obsessional aspect of the disorder than they
are by the time-consuming, interfering rituals. On the one hand, obsessions
may be particularly disruptive because they interfere in conscious, intentional
activities such as reading, writing, counting, and simply sustaining concentration.
Antony and colleagues found that the QOL dimension that most distinguished
patients with OCD from patients with other anxiety disorders was the level
of impairment in intentional activities (10), an impairment that could
be hypothesized to relate to the occurrence of obsessions, rather than
compulsions.
Conversely, time-consuming overt and covert rituals often prevent the initiation
and pursuit of life goals and, therefore, may be the more pernicious factor.
Getting “stuck” in repetitive hand-washing, checking, and other rituals
leads individuals to miss out on social occasions, to fail to accomplish
tasks within the work setting, to experience distress and tension in their
important relationships, and to experience recurrent embarrassment and
shame. One of this study’s the primary aims was to assess the unique and
additive effects of obsessions and compulsions on QOL in individuals with
OCD.
A second, related aim was to assess the effect of comorbid depression symptoms
on the QOL of persons with primary OCD. This is an extremely important
issue, given that more than any other anxiety disorder, OCD is often complicated
by depression comorbidity. Epidemiologic studies have documented the naturally
occurring high rates of comorbidity between these disorders in the community.
In the Epidemiologic Catchment Area (ECA) study, 31.7% of OCD patients
were diagnosed with a concurrent comorbid major depressive disorder (MDD)
(1). In the National Collaborative Group study, the lifetime comorbidity
of MDD and OCD extended to 60.3%, depending on the country (11). Similarly,
rates of concurrent major depression in those presenting to treatment clinics
with OCD have been in the range of 28% to 38% (4,6,12–14). In addition
to categorical assessment of diagnosable comorbid major depression, it
has been estimated that upward of 75% of patients with OCD experience subclinical
depressive states (15). Studies have also linked depression to greater
chronicity (16,17) and severity (16,18) of the course of OCD.
In summary, this study aimed to examine the QOL of individuals with OCD
and the specific impact of the obsessions, compulsions, and depression
comorbidity. We hypothesized that the severity of obsessions and compulsions
would directly impact on QOL ratings, so that the more severe these symptoms,
the poorer the patient’s QOL. We also hypothesized that the presence of
depression would impact negatively on QOL.
Methods
Clinical Sample
For this study, we recruited 43 consecutively referred patients meeting
DSM-IV (19) criteria for OCD, based on the Structured Clinical Interview
for Axis 1 Disorders (SCID-1/P, version 2.0) (20). All patient participants
were recruited from the Anxiety Disorders Clinic at the Centre for Addiction
and Mental Health, Clarke Site (a large, university-based, teaching hospital
in Toronto, Ontario). To be eligible for inclusion, participants had to
be between the ages of 18 and 65 years and experiencing clinically significant
obsessive and compulsive symptoms. Patients were excluded if they had a
concurrent diagnosis of schizophrenia, bipolar disorder, or current substance
use disorder. Table 1 summarizes the demographic and clinical characteristics
of the patient sample.
Clinical Measures
All participants completed the clinician version of the Yale-Brown Obsessive
Compulsive Scale (Y-BOCS) (21,22), the Illness Intrusiveness Rating Scale
(IIRS) (24), and the Beck Depression Inventory (BDI) (27). The Y-BOCS is
a standardized, clinician-administered scale for assessing severity of
clinical obsessions and compulsions. It comprises 10 items pertaining to
obsessions and compulsions, rated on a 5-point Likert scale ranging from
0 (no symptoms) to 4 (severe symptoms); it has been shown to possess high
internal consistency and validity (21,22). The IIRS is designed to measure
objective and perceived interference of symptoms across 13 life domains
considered important to QOL. These domains include health, diet, work,
active and passive recreation, financial situation, relationship with spouse,
sex life, family and other social relationships, self-expression, self-improvement,
religious expression, community involvement, and civic involvement. Ratings
are according to a 7-point Likert scale ranging from 1 (not very much)
to 7 (very much). Individual item ratings are summed to provide an overall
index of illness intrusiveness. The total scale ranges from 13 (minimum
intrusiveness) to 91 (extreme intrusiveness) (23,24). The IIRS has been
the measure of choice in other studies examining QOL in OCD (10). It has
also received psychometric validation in the spectrum of anxiety disorders
(25). Finally, the BDI is a 21-item (4-point scale), self-report instrument
designed to assess depressive symptom severity. The BDI has been shown
to be a reliable and well-validated measure of depressive symptomatology
(26,27).
Statistical Methods
To identify the symptoms predicting illness intrusiveness in OCD, we conducted
linear regression analyses with the Statistical Package for the Social
Sciences (SPSS), version 10.0 (28). Two regressions were conducted. The
first aimed to determine whether any of the clinical or demographic variables
predicted illness intrusiveness. In the second analysis, the independent
variables in the multiple regression equation included BDI, Y-BOCS obsession,
and Y-BOCS compulsion scale scores. Not only did we expect the Y-BOCS obsession
and compulsion scores to correlate highly, we also anticipated that the
Y-BOCS scales would correlate positively with depression severity. Thus,
the linear regression analysis would control for the multicolinearity among
these variables.
|
Table 1 Demographic and clinical characteristics of the study participants
with OCD (n = 43)
|
|
|
n (%)
|
|
Sex
|
|
|
Male
|
18 (41.9)
|
|
Female
|
25 (58.1)
|
|
Ethnicity
|
|
|
European
|
42 (97.7)
|
|
East Indian
|
1 (2.3)
|
|
Marital status
|
|
|
Single
|
25 (58.1)
|
|
Married or cohabiting
|
16 (37.3)
|
|
Separated, divorced, or widowed
|
2 (4.7)
|
|
Level of education completed
|
|
|
Did not complete high school
|
3 (7)
|
|
Completed high school
|
17 (39.5)
|
|
Completed college or university
|
17 (39.5)
|
|
Completed graduate or profess. degree
|
6 (14)
|
|
|
Mean (SD)
|
|
Age (years)
|
34.9 (8.0)
|
|
Onset-age (years)
|
14.4 (9.0)
|
|
Y-BOCS obsessions
|
9.9 ( 4.5)
|
|
Y-BOCS compulsions
|
9.7 (4.2)
|
|
Y-BOCS total
|
19.7 (8.4)
|
|
BDI
|
16.7 (12.0)
|
|
IIRS
|
45.7 (17.7)
|
|
BDI = Beck Depression Inventory; IIRS = Illness Intrusiveness Rating Scale;
OCD = obsessive–compulsive disorder; Y-BOCS = Yale-Brown Obsessive Compulsive
Scale
|
1 | 2
| 3
|
