University of Groningen Dysfunctional beliefs in the understanding … · 2016. 3. 5. · Submitted for publication as: Polman, A., Bouman, T.K., De Jong P.J., & Den Boer, J.A. (2010)

University of Groningen

Dysfunctional beliefs in the understanding & treatment of obsessive compulsive disorderPolman, Annemieke

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6obsessive-compulsive behaviours and beliefs; a family affair?Submitted for publication as: Polman, A., Bouman, T.K., De Jong P.J., & Den Boer, J.A. (2010). Obsessive-compulsive behaviours and beliefs; a family affair?

Abstract

obsessive-compulsive Disorder (ocD) seems to run in families, and its transmission could involve genetic and environmental factors. so far, family studies mainly fo-cused on obsessive-compulsive behaviour in patients and relatives. considering the importance attributed to appraisals and beliefs in cognitive-behavioural models of ocD, this study investigated the relation-ship between both obsessive-compulsive beliefs and -behaviours of ocD patients and their parents. ocD patients (n =55), their parents (n = 92), and community con-trols (n = 178) completed measures of ocD symptoms and ocD related beliefs. Data were analysed both on group level using (m)AnovA, and triad level (patient, mother, father) using regression analyses. no dif-ferences were found between controls and the patients’ parents regarding ocD symp-toms and beliefs. Analysis on the triad level showed that fathers’ obsessive-compulsive symptomatology was associated with pa-tients’ symptomatology. neither mothers’ nor fathers’ beliefs turned out to be predic-tive of patients’ dysfunctional beliefs or ocD-symptoms. these results underline that family studies investigating parental and maternal factors separately could contribute to revealing intergenerational patterns of psychopathology.

91OCD, A FAMIly AFFAIR?

1. introduction

Several family studies investigated whether OCD is a familial disorder. The avail-able evidence converges to the conclusion that OCD relatives seem to have a higher risk of developing OC symptomatology than controls (e.g., Nestadt, Samuals, Riddle, Bienvenu, Liang, LaBuda, et al. 2000). Accordingly, lifetime prevalence of OCD was shown to be higher for OCD relatives than for control relatives (11.7% vs 2.7%). This relationship was especially pronounced for earlier onset OCD (Nestadt et al., 2000). In a similar vein, the rates of OCD and sub-threshold OCD were found to be relatively high among the relatives of OCD patients (Pauls, Alsobrook, Goodman, Rasmussen & Leckman, 1995). It should be acknowledged, however, that some studies failed to confirm this pattern (e.g., Black, Noyes, Goldstein & Blum, 1992). This apparent inconsistency may at least partly be attributed to the as-sessment techniques used. Apart from direct interviewing, Pauls et al. (1995) and Nestadt et al. (2000) also used family history (informant interviews), whereas Black et al. (1992) did not. Underlining this discrepancy, a recent study found evidence for familial aggregation of OCD when diagnoses were based on informant reports of probands who were affected with OCD, whereas similar evidence was absent when relatives’ diagnoses were made without proband informant reports (Fyer, Lipsitz, Mannuza, Aronowitz & Chapman, 2005; Lipsitz, Mannuza, Chapman, Foa, Franklin, Goodwin et al., 2005).

If OCD or certain subgroups of OCD are familial, one potential pathway for transmission would be heritability of psychopathology either directly or through inheriting personality traits, cognitive- and/or interpersonal styles. Another mechanism for transmission could be environmental influences such as exposure to (negative) cognitions, behaviours, and affect of the affected parent, which can be adopted by the child through social learning/modelling (Goodman & Gotlib, 1999). Previous family studies in OCD focused mainly on obsessive-compulsive (OC) behaviour. However, considering the alleged role of negative appraisals and dys-functional beliefs in cognitive-behavioural models of psychopathology (e.g., Beck, 1976; Salkovskis, 1985, 1989) another pathway that may give rise to familial trans-mission of OCD is adopting parents’ dysfunctional beliefs. In support of the poten-tial influence of dysfunctional beliefs, a recent study found a positive correlation between the threat interpretation scores of anxiety disordered children and the scores of their mothers (Creswell, Schniering & Rapee, 2005).

In the context of OCD, the Obsessive Compulsive Cognition Working Group (OCCWG) (2005) recently identified three dimensions of OCD related beliefs; (a) inflated personal responsibility and the tendency to overestimate threat (Responsibility and Threat estimation), (b) perfectionism and intolerance of un-certainty (Perfectionism and Certainty), and (c) over-importance and over-control of thoughts (Importance and Control of Thoughts). In support of the idea that dysfunctional beliefs of parents might be associated with children’s psychopathol-ogy, results from a non-clinical sample showed weak though significant associa-

92 CHAPTER 6

tions between parents’ beliefs concerning responsibility and threat estimation and importance and control of thoughts on the one hand and their children’s OC symptoms on the other. In a similar vein, a weak significant relationship was found between parents’ OC symptom scores and children’s beliefs concerning responsi-bility and threat estimation (Jacobi, Calamari & Woodard, 2006). Together these findings suggest that parental beliefs are a possible underlying factor in the inter-generational transmission of OCD, which could be explained both from a genetic- as well as an environmental perspective (see Goodman & Gotlib, 1999). Therefore, this study was conducted to further the investigation of intergenerational factors by studying dysfunctional beliefs and OC behaviours in a clinical sample of OCD patients and their parents. If parents’ dysfunctional beliefs are indeed associated with children’s OCD, on a group level, parents’ scores on dysfunctional beliefs should be more similar to OCD patients’ scores than to the scores of community controls. Furthermore, there should be significant associations between parents’ and patients’ OC beliefs and behaviours within the father, mother, patient triad.

2. method

2.1 ParticipantsFifty-five patients who met DSM-IV-TR criteria for OCD (APA, 2000), 92 parents of those OCD patients (39 fathers, 53 mothers), and 178 community controls partici-pated in this study. For 37 patients both parents participated, since not all partici-pating patients had a parent to participate in the study (mostly because patients did not want to ask/bother their parents or because parents were not alive any-more, furthermore some parents did not want to participate), implying 37 com-plete triads. In Table 1, demographic variables of all three samples are presented. The present study is part of a larger project concerning OCD, and the present par-ticipants are also involved in a study on dysfunctional beliefs and OCD subtypes (see chapter 4).

2.2 ProcedurePatients of various mental health organizations in the northern part of The Netherlands were approached in the context of a genetic study into OCD that was approved of by the medical ethics committee of the University Medical Centre Groningen. Patients were selected based on the diagnoses in their medical records, and they received written information and an informed consent form. If patients were willing to participate, they were invited to the clinic and screened for DSM-IV axis-I disorders and OCD severity (see below). Additionally, they were asked to provide DNA by using a mouth-swab. Afterwards, patients received a questionnaire booklet which they could fill out at home and sent back to the researcher.


The parent sample was obtained by asking patients to invite their parents to participate in this study. Parents who decided to participate, received mouth-swab utensils and the questionnaire booklet at home and were asked to return these by mail. An informed consent was obtained form the parents as well. No interviews took place with the parents of OCD patients.

The community control sample was recruited by randomly selecting six hun-dred names and addresses from the phonebook. Control subjects were recruited in the northern part of The Netherlands since the OCD patients were also recruited in this area. If people wanted to participate they could fill out the questionnaire booklet together with their informed consent. We obtained a 30% (i.e., n=178) response rate.

2.3 measuresThe MINI International Neuro-psychiatric Interview (MINI-Plus) (Sheehan, Lecrubier, Harnett-Sheehan, Janavs, Weiller, Bonara, et al., 1997; Dutch version Van Vliet, Leroy & Van Megen, 2000) is a structured DSM-IV/ICD10 interview, that was used for diagnostic purposes. Psychometric properties are satisfactory (Sheehan, Lecrubier, Harnett-Sheehan, Janavs, Weiller, Bonara et al., 1997; Lecrubier, Sheehan, Weiller, Amorim, Bonara, Sheehan et al., 1997).

To establish OC symptom severity, the Padua Inventory-Revised (PI-R) (Sanavio, 1988; Dutch version Van Oppen, 1992; Van Oppen, Hoekstra & Emmelkamp, 1995b) was administered. The PI-R is a self-report questionnaire consisting of five sub-scales; impulses, washing, checking, rumination and precision. The validity, reli-ability and sensitivity to change are satisfactory (Van Oppen et al, 1995b).

The Obsessive Beliefs Questionnaire (OBQ-44) (Obsessive Compulsive Cognitions Working Group, 1997; Dutch version Emmelkamp, Van Oppen & Wieringa, 1998) was administered to assess OC relevant beliefs. The OBQ-44 consists of 44 assumptions which can be subdivided into three domains; Responsibility and Threat estima-

Table 1. Demographic variables of 3 samples.

variable Patientsn=55

Parentsn=92

controlsn=178

Age 32.2 (7.1) 60.5 (8.1) 50.1 (15.5)

% Female 63.6% 57.6% 48.3%

% Single 41.8% 12.0% 20.8%

Education

low 29.1% 54.0% 21.9%

Medium 40.0% 21.7% 34.3%

High 30.9% 20.7% 43.3%

Missing 3.3% .6%

94 CHAPTER 6

tion, Perfectionism and Intolerance for Uncertainty, and Importance and Control of Thoughts. Psychometric validation of the OBQ-44 showed good internal consist-ency and criterion-related validity in clinical and non-clinical samples (OCCWG, 2005).

The Spielbergers State-Trait Anxiety Inventory DY-2 (STAI-DY-2) (Spielberger, 1983; Dutch version Van der Ploeg, Defares & Spielberger, 1980) and the Beck Depression Inventory (BDI) (Beck, Rush, Shaw & Emery, 1979; Dutch version by Bouman, Luteijn, Albersnagel & Van der Ploeg, 1985) were used to establish anxiety and depressive symptomatology.

2.4 statistical analysisData were analysed separately both at group level (patients, family, and controls) and at triad level (mother, father, and OCD patient). At group level, the patient, family and control groups were compared using MANOVA with post hoc ANOVA’s to test whether family members scored more like patients or more like community controls. Demographic variables (age, gender, civil status, educational level) were entered as covariates. Since the patient- and the family samples are not independ-ent, paired t-tests were used to compare family members to OCD patients, as well.

Table 2. Comparison of mean scale scores in patients-, parents-, and controls- samples

Patients Parents controls f

PI-R

Impulses 4.4 (5.1) 1.1 (2.1) 1.6 (2.1) 8.1**

Washing 10.7 (10.8) 1.9 (3.3) 2.8 (3.7) 19.8**

Checking 12.1 (6.8) 5.1 (4.8) 5.1 (4.3) 20.6**

Ruminating 21.7 (7.9) 8.6 (7.1) 9.6 (6.1) 23.8**

Precision 6.3 (5.9) 2.1 (3.0) 2.4 (2.9) 11.2**

OBQ-44

ICT 33.7 (16.4) 23.0 (12.3) 22.1 (10.4) 13.6**

RT 53.7 (25.5) 34.3 (18.1) 34.7 (17.2) 15.2**

PC 59.6 (21.4) 41.8 (19.4) 43.7 (18.1) 6.3*

BDI 15.8 (9.9) 7.6 (7.1) 6.2 (5.9) 15.5**

STAI 56.1 (9.9) 36.5 (11.7) 34.8 (9.2) 33.2**

*p


Sidak-Bonferroni correction was used to correct for multiple testing, which is more sophisticated than a Bonferroni correction, since it does not lead to severe loss of power (cf. Keppel & Wickens, 2004).

Subsequently, we tested whether parents’ psychopathology was associated with patients’ OC beliefs and behaviours in the 37 complete triads, using multiple regression analysis. The dependent variables were the patients’ PI-R total score and their OBQ-44 total score, respectively. As independent variables, parents’ OC behaviours and –beliefs, and general distress were used. To test whether results differed for male or female patients (sons or daughters), patients’ gender was used as independent variable as well. First, analyses were conducted for mothers and fathers separately. Subsequently, predictors of fathers and mothers were combined to test their relative influence. Considering the limited sample size, a stepwise procedure was used to find the best simple model. Hence, results will be sample dependent and should be interpreted carefully. However, a forced entry procedure would lead to a more complex model, which would not be appropriate considering the sample size.

3. results

3.1 comparison of 3 samples; patients, family and controlsResults of the MANOVA showed a significant effect for group F(20,518)=5.1, p

96 CHAPTER 6

Table 3. Comparison of mean scale scores in patient and parent samples.

Patient

n=55

mothers

n=53

t patients-mothers

fathers

n=39

t patients-fathers

PI-R

Impulses 4.4 1.4 -4.2** .7 -4.5**

Washing 10.7 2.2 -5.9** 1.4 -4.8**

Checking 12.1 5.7 -5.5** 4.3 -5.9**

Ruminating 21.7 9.7 -8.3** 7.1 -10.2**

Precision 6.3 2.5 -4.3** 1.6 -4.2**

Total 55.3 21.6 -8.7** 15.2 -10.1**

OBQ-44

Importance and Control of Thoughts

33.7 23.4 -3.5** 22.5 -4.2**

Responsibility and Threat estimation

53.7 34.7 -4.2** 33.9 -5.0**

Perfectionism and Certainty

59.6 40.4 -5.1** 43.6 -4.9**

BDI 15.8 8.6 -4.9** 6.2 -5.4**

STAI-trait 56.1 38.1 -8.3** 34.2 -9.8**

*p


associated with patients OBQ-44 total score. Remarkably, parents OBQ-44 total scores were neither significantly associated with patients PI-R scores, nor patients’ OBQ-44 scores. When the significant variables of both parents were combined in the analysis, only fathers’ variables were still significant: Fathers’ PI-R checking was significantly related to patients’ PI-R total score, and fathers’ PI-R total score was significantly associated with patients OBQ-44 total score. The associations found between parents and patients were irrespective of patients’ gender. In Table 4, results of the regression analyses are presented.

Since mothers’ STAI-total score was neither a significant predictor of patients’ OBQ-44 total scores nor PI-R scores when combined with fathers variables, we in-vestigated the relationship between variables in mothers’ and patients’ OC beliefs and behaviours in the total mother-patient sample (n=53). Results of these analyses showed that none of the mothers’ variables were predictive of patients’ OBQ-44 and PI-R scores. These results support the findings of the combined analysis, meaning that mothers’ STAI-total score was not a significant predictor of patients’ OC beliefs and behaviours.

4. Discussion

The aim of this study was to investigate the role of dysfunctional beliefs as a po-tential pathway for transmission of OCD within families. Results of comparisons at group level indicated that levels of psychopathology and beliefs of OC patients’ parents were similar to those of community controls. Differences between the patient and parent groups were all significant. Considering relationships between parents’ beliefs and symptomatology, and the OCD patients’ beliefs and symptoma-tology, results showed that in the separate analyses, anxiety in mothers was sig-nificantly associated with both patients’ OCD and OC beliefs. Checking behaviour in fathers was significantly related to patients OCD, and fathers’ OC behaviours in general were significantly associated with patients’ OC beliefs. However, when mothers’ and fathers’ variables were combined in the analysis, only fathers’ vari-ables appeared to be significantly related to respectively patients’ beliefs and OC symptomatology, which was supported by the findings based on the total mother-patient group.

The finding that parents scored comparable to normal controls, and scored significantly lower on all variables compared to OCD patients, was not supportive of a familial relationship related to OCD nor OC beliefs. In comparison with the results of previous family studies, it can be seen that Black et al. (1992), who also only used direct information (instead of informant interviews), did not find strong associations between patients and family either. Studies that reported stronger associations were based on informant interviews (e.g., Pauls et al., 1995; Nestadt et al. 2000), which indicates that results are related to the methodology used.

98 CHAPTER 6

Furthermore, certain subtypes, such as age at onset, and patients with pure obses-sions seem to represent more familial traits than others. However, these subgroups were too small in our sample to investigate separately.The finding that behav-ioural characteristics of fathers could be an aetiological factor in the development of OCD in offspring is in line with preliminary (unpublished) findings indicating significant relationships between the fathers’ parental styles, expressed emo-tion, several cognitive schemas and OCD severity of the patient (Fama, Wilhelm, Steketee, McNally & Golan, 2004). Furthermore, paternal autonomy-overprotection has been found to be predominantly related to child anxiety, whereas maternal autonomy-overprotection was predominantly related to maternal anxiety (Bögels & Van Melick, 2004). Interestingly, Bögels and Siqueland (2006) reported that after a family cognitive-behavioural treatment, fathers reported less anxiety them-selves, whereas mothers did not. These recent findings highlight the influence of behavioral characteristics of fathers, and the effect that the symptomatology of affected children may have on fathers. However, it should be noted that fathers’ OC symptomatology only explained 14 percent of patients’ OC symptomatology. In line with the findings of Jacobi et al. (2006) these results suggest that the influence of parental factors is limited.

Contrary to previous findings (e.g., Creswell et al., 2005; Jacobi et al. 2006) and the expectations based on the cognitive-behavioural model of OCD, we did not find parents’ OC beliefs to be associated with patients’ beliefs or OCD symptoms. These differences could be attributed to our small sample size. However, it should be noted that Jacobi et al. (2006) only found modest correlations between parents’ and adolescents’ belief subscales, and that subsequent regression analyses did not re-veal significant relations between parents’ OC beliefs and children’s OC beliefs and behaviours either (Jacobi et al., 2006).

In view of the developmental model on mechanisms of transmission, as pro-posed by Goodman and Gotlib (1999), neither the results on group level, nor the results on triad level provided support for intergenerational transmission of cer-tain cognitive styles. With regard to the social learning/modelling mechanism, we found some indications that fathers’ OC behaviour is related to patients OC beliefs and symptomatology. However, no firm conclusions can be inferred be-cause of the limited sample size of the present study. Furthermore, because of the cross-sectional nature of the present study, the data are indeterminate with re-spect to causality of the relationships between parental factors and patients’ OCD symptomatology.

Future studies could benefit from studying parent and patient factors within OCD subtypes, like early age at onset, and OCD symptom subtypes, amongst which patients who only report obsessions. Possibly, OCD may be heterogeneous with regard to familial transmission, and differences with respect to familiality could also contribute to defining OCD subtypes. The question remains whether inclusion of proband reports increases or decreases diagnostic validity in family studies. An OCD patient may be better at detecting real symptoms in their relatives, but


this might also reflect a bias of the affected individual (Lipsitz et al., 2005). Finally, future research could benefit from the inclusion of other factors that might be involved in the aetiology of OCD, like rearing styles.

In sum, results of the current study provided some preliminary clues for as-sociations between parental factors and patients’ OCD. Furthermore, they high-light the importance of studying maternal and paternal factors separately. The influence of parenting behaviours of mothers and fathers may also differ across lifespan (Bögels & Brechman-Toussaint, 2006). More knowledge of these factors would not only contribute to our understanding of OCD, but could also have im-portant clinical implications, for instance in the implementation of prevention programs for high risk families.

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University of Groningen Dysfunctional beliefs in the understanding … · 2016. 3. 5. · Submitted for publication as: Polman, A., Bouman, T.K., De Jong P.J., & Den Boer, J.A. (2010)