Stressful Life Events and the Clinical Expression of Obsessive–Compulsive Disorder (OCD): An Exploratory Study
Abstract
:1. Introduction
2. Experimental Section
2.1. Methodology
- Dimensional Yale–Brown Obsessive–Compulsive Scale (DY-BOCS) [44]—the DY-BOCS assesses OCS by specific dimensions, allowing the severity of each dimension to be independently quantified. This scale has some advantages, for example, avoidant behaviors, as well as rituals (physical or mental), are investigated within each dimension. As a result of this more detailed evaluation process, this scale provides a more precise evaluation of symptom severity. The DY-BOCS evaluates the time spent on OCS, as well as the level of anxiety and the impact of the symptoms, with scores ranging from 0 to 5 with a maximum of 15 for each dimension. The negative impact of OCS on the lives of subjects is also quantified on a scale, with a maximum score of 15. Combining the two scores mentioned before, the maximum total DY-BOCS score is 30.
- Yale OCD Natural History Questionnaire [45]—this questionnaire consists of a comprehensive semi-structured interview. This questionnaire focuses on the course and onset of OCS, relating to life events and situations. It addresses whether specific life events could trigger, worsen, or improve OCS. Part I of this questionnaire addresses OCS onset, exploring the age at onset, whether the symptoms began abruptly or gradually, and whether they started after personal problems, emotional problems, drug use, family problems, financial problems, or the onset of a clinical disease. Part II evaluates the course of OCS and includes questions regarding environmental factors that could affect OCS (e.g., mood, fatigue, sleep, alcohol, coffee, tobacco, certain kinds of food, and weather). These factors are organized in a table where the patient may answer “no effect,” “worse OCS,” “improved OCS,” or “nonapplicable” (a specific paper on these aspects is in preparation); a second table is also provided that indicates the severity of OCS according to the age of the patient. Part III investigates the period with the most OCS, comprising questions similar to those mentioned above but specifically related to the worst period regarding symptom presentation. In the present study, Part I questions were used. To each of the questions, there are two possible responses: “yes” and “no.” When the response was “yes,” complementary questions were asked (e.g., “If yes, describe it better” or “If yes, choose one example option listed below”). If the answer to these questions was considered satisfactory by the interviewer, the participant was assigned to the “SLE” group.
- Structured Clinical Interview for Diagnosis of Axis I Psychiatric Disorders (SCID-I) [40,41]—additional modules evaluating tic and impulse-control disorders were administered [41]. All DSM-IV axis I disorders, except for schizophrenia, which was an exclusion criterion, were included in the analysis. Attention-deficit/hyperactivity disorder (ADHD) and separation anxiety disorder were assessed utilizing the Kiddie Schedule for Affective Disorders and Schizophrenia [46].
- The University of São Paulo Sensory Phenomena Scale (USP-SPS) [49]—this is a semi-structured scale designed to investigate the presence and severity of different types of sensory phenomena occurring before or during the performance of repetitive behaviors. The USP-SPS is divided into two parts: achecklist (including different types of sensory phenomena, i.e., body sensations, “just right,” “inner tension,” and “urge only”) and a severity scale. The USP-SPS severity scale measures the severity of sensory phenomena on three 6-point anchored ordinal scales that focus on the frequency of the sensory phenomena (0 to 5), the amount of distress they cause (0 to 5), and the degree to which they interfere with patient functioning (0 to 5). The total score (ranging from 0 to 15) is obtained by combining these scores.
- The Brown Assessment of Beliefs Scale (BABS) [50]—the Portuguese version of the Brown Assessment of Beliefs Scale (BABS) was used to assess participants’ insight into several dimensions, including beliefs, perception of others’ views and explanations of different views, fixity of the belief, attempts to disprove it, insight into the cause of the belief, and presence of the idea of reference. Higher scores indicate poorer insight.
2.2. Statistical Analysis
3. Results
3.1. Describing SLEs in OCD Patients
3.2. Comparing OCD Patients Who Have or Have Not Experienced an SLE
3.3. Intrinsic Psychopathological Features
3.4. Extrinsic Psychopathological Features
3.5. Logistic Regression Analysis
4. Discussion
4.1. Sociodemographic Features Related to Stressful Life Events—Self-Declared Nonwhite Skin Color
4.2. Comorbidity with Separation Anxiety, ADHD, and PTSD
4.3. Sensory Phenomena Related to Stressful Life Events
4.4. Psychiatric Hospitalization
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
Appendix A
List of SLEs |
---|
Emotional problems in the family |
Moving to another city/neighborhood |
Relative moving to another city/neighborhood |
Family with financial problems |
Being in love/starting a significant relationship/marrying |
Health problems in the family |
Pregnancy (own) |
Pregnancy (of spouse/girlfriend/partner) |
Childbirth (own child) |
Childbirth (child of a relative) |
Death of a relative/friend |
Having any type of clinical disease |
Significant relative moving to another city/neighborhood |
Ending a significant relationship/divorcing |
Family with housing problems |
Started using illicit drugs |
Family with legal problems |
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SLE Group (n = 605) | Non-SLE Group (n = 396) | Statistics Test (p) (φ Effect Size) | |||
---|---|---|---|---|---|
n | % | n | % | ||
Female | 353 | 58.3 | 216 | 54.5 | χYates = 1.26 (0.26) |
Marital status | χPearson = 2.36 (0.31) | ||||
Single | 238 | 39.3 | 139 | 35.1 | |
Currently with a partner | 317 | 52.4 | 227 | 57.3 | |
Currently separated from partner | 50 | 8.3 | 30 | 7.6 | |
With offspring | 246 | 40.7 | 144 | 36.4 | χYates = 1.68 (0.20) |
Have a religion | 59 | 9.8 | 47 | 11.9 | χYates = 0.92 (0.34) |
Practice the religion | 334 | 55.2 | 213 | 53.8 | χYates = 0.00 (1.00) |
Not Working | 307 | 50.9 | 194 | 49.1 | χYates = 0.24 (0.62) |
Social Class (ABIPEME) | χPearson = 52.9 (<0.001) (0.23) | ||||
Class A | 59 | 9.7 | 106 | 26.7 | |
Class B | 246 | 40.5 | 139 | 35.1 | |
Class C | 237 | 39.2 | 112 | 28.2 | |
Class D | 47 | 7.7 | 26 | 6.6 | |
Class E | 12 | 1.9 | 10 | 1.4 | |
Self-declared skin color (nonwhite) | 119 | 19.7 | 50 | 12.6 | χYates = 7.97 (0.005) (0.22) |
Mean | SD | Mean | SD | Statistics Test (p) (Cohen’s d) | |
Current age (years) | 35.5 | 12.7 | 34.2 | 13.3 | tStudent = 1.47 (0.14) |
Number of years studied | 14.2 | 4.7 | 15.3 | 5.3 | tStudent = 3.37 (0.001) (0.22) |
Personal income (minimum wage) | 2.8 | 1.2 | 3.3 | 1.3 | tStudent = 5.34 (<0.001) (0.40) |
SLE Group (n = 605) | Non-SLE Group (n = 396) | Statistics Test (p) (φ Effect Size) | |||
---|---|---|---|---|---|
n | % | n | % | ||
Presence of DY-BOCS dimensions | |||||
Aggressive | 433 | 71.6 | 239 | 60.4 | χYates = 13.1 (<0.001) (0.14) |
Sexual/religious | 378 | 62.5 | 194 | 49 | χYates = 17.2 (<0.001) (0.17) |
Symmetry/ordering | 531 | 87.8 | 337 | 85.3 | χYates = 1.05 (0.31) |
Contamination/washing | 451 | 74.5 | 286 | 72.2 | χYates = 0.55 (0.46) |
Hoarding | 342 | 56.5 | 186 | 47 | χYates = 8.4 (0.004) (0.13) |
Miscellaneous | 538 | 88.9 | 335 | 84.6 | χYates = 3.64 (0.056) |
Sensory phenomena (any type) | 410 | 67.8 | 241 | 60.9 | χYates = 4.73 (0.03) (0.09) |
Body sensations | 259 | 42.8 | 112 | 28.3 | χYates = 21.0 (<0.001) (0.24) |
“Just right” sensations | 338 | 55.9 | 181 | 45.7 | χYates = 9.5 (0.002) (0.14) |
Incompleteness | 114 | 18.8 | 62 | 15.7 | χYates = 1.46 (0.23) |
Inner tension | 99 | 16.4 | 45 | 11.4 | χYates = 4.46 (0.035) (0.18) |
“Urge” sensations | 147 | 24.3 | 93 | 23.5 | χYates = 0.05 (0.83) |
Chronic tics (any type) | 192 | 31.7 | 92 | 23.2 | χYates = 8.1 (0.004) (0.17) |
Tourette’s syndrome | 62 | 10.2 | 26 | 6.6 | χYates = 3.6 (0.058) (0.20) |
Age at onset (categorical) | χPearson = 10.3 (0.006) (0.10) | ||||
Early (<11 years old) | 300 | 50.9 | 190 | 50.9 | |
Intermediate (11–18) | 191 | 32.4 | 146 | 39.1 | |
Late (≥18 years old) | 98 | 16.6 | 37 | 9 | |
OCS course | (n = 532) | (n = 359) | χPearson = 0.09 (0.96) | ||
Chronic/continuous | 38 | 7.2 | 24 | 6.7 | |
Episodic/oscillating | 263 | 49.4 | 180 | 50.1 | |
Progressively worsening | 231 | 43.4 | 155 | 43.2 | |
Familial OCD | 302 | 49.9 | 201 | 50.9 | χYates = 0.06 (0.81) |
Familial tics | 113 | 19.9 | 79 | 20.9 | χYates = 0.08 (0.78) |
Mean | SD | Mean | SD | ||
OCS duration (in years) | 22.7 | 13.2 | 22 | 13.2 | tStudent = 0.77 (0.44) |
Median | (Min–Max) | Median | (Min–Max) | Statistics | |
Test (p) | |||||
(Glass effect size) | |||||
Severity of DY-BOCS dimensions | |||||
Aggressive | 9 | (1–15) | 9 | (1–15) | UMW = 42,263.5 (0.38) |
Sexual/Religious | 9 | (1–15) | 8 | (1–15) | UMW = 25,901.5 (0.04) (0.78) |
Symmetry/ordering/arrangement | 10 | (1–15) | 9 | (1–15) | UMW = 73,878.5 (0.04) (0.38) |
Contamination/washing/cleaning | 10 | (1–15) | 9 | (1–15) | UMW = 49,696.5 (0.07) (0.58) |
Hoarding | 7 | (1–15) | 6 | (1–15) | UMW = 21,537.5 (0.006) (0.82) |
Miscellaneous | 10 | (1–15) | 9 | (1–15) | UMW = 75,618.5 (0.049) (0.37) |
DY-BOCS total score | 23 | (2–30) | 22 | (1–30) | UMW = 101,558 (<0.001) (0.15) |
Y-BOCS | |||||
Obsessions score | 13 | (1–20) | 13 | (3–20) | UMW = 109,860.0 (0.12) |
Compulsions score | 13 | (3–20) | 13 | (2–20) | UMW = 108,163.5 (0.048) (0.10) |
Y-BOCs total score | 26 | (7–40) | 25 | (7–40) | UMW = 108,143.5 (0.024) (0.10) |
Age at OCS onset | 10 | (3–50) | 10 | (3–54) | UMW = 104,221.0 (0.23) |
Gap of time without treatment | 15 | (0–56) | 14 | (0–58) | UMW = 102,008.5 (0.93) |
USP-SPS total score | 8 | (1–15) | 7 | (1–15) | UMW = 42,103.5 (0.25) |
BABS | 6 | (0–24) | 6 | (0–24) | UMW = 105,267.5 (0.12) |
SLE Group (n = 605) | Non-SLE Group (n = 396) | Statistics Test (p) (φ Effect Size) | |||
---|---|---|---|---|---|
n | % | n | % | ||
Any previous psychiatric treatment | 468 | 77.4 | 294 | 74.2 | χYates = 1.11 (0.29) |
SSRI | 431 | 71.2 | 277 | 69.9 | χYates = 0.14 (0.71) |
Clomipramine | 202 | 33.4 | 120 | 30.3 | χYates = 0.91 (0.34) |
Other antidepressants | 86 | 14.2 | 55 | 13.9 | χYates = 0.003 (0.96) |
Benzodiazepines | 243 | 40.2 | 135 | 34.1 | χYates = 3.50 (0.06) (0.10) |
Mood stabilizers | 63 | 10.4 | 44 | 11.1 | χYates = 0.06 (0.81) |
Lithium | 32 | 5.3 | 17 | 4.3 | χYates = 0.32 (0.57) |
Neuroleptics | 119 | 19.7 | 84 | 21.2 | χYates = 0.26 (0.61) |
Any previous psychotherapy | 389 | 64.3 | 254 | 64.1 | χYates = 0.00 (1.00) |
CBT (E/RP) | 93 | 23.9 | 63 | 24.8 | χYates = 0.03 (0.87) |
Psychiatric hospitalization | 33 | 5.5 | 35 | 8.8 | χYates = 3.81 (0.051) |
Suicidality | |||||
Suicidal ideation—lifetime | 232 | 39.7 | 116 | 30.9 | χYates = 7.26 (0.007) |
Suicidal ideation—current | 71 | 12.2 | 33 | 8.8 | χYates = 2.32 (0.13) |
Suicide attempt | 71 | 12.2 | 33 | 8.8 | χYates = 2.32 (0.13) |
Familial history of suicide | 101 | 17.3 | 55 | 14.7 | χYates = 0.94 (0.33) |
Median | (Min–Max) | Median | (Min–Max) | Statistics Test (p) (Glass effect size) | |
Beck Depression Inventory | 17 | (0–52) | 13 | (0–53) | UMW = 97,271.0 (<0.001) (0.19) |
Beck Anxiety Inventory | 16 | (0–52) | 12 | (0–53) | UMW = 97,590.0 (<0.001) (0.18) |
SLE (n = 605) | Non-SLE (n = 396) | Statistics Test (p) (φ Effect Size) | |||
---|---|---|---|---|---|
n | % | n | % | ||
ADHD | 95 | 15.7 | 42 | 10.6 | χYates = 4.84 (0.028) (0.19) |
Separation anxiety disorder | 37 | 6.1 | 12 | 3.0 | χYates = 4.28 (0.039) (0.29) |
Major depression | 220 | 36.4 | 112 | 28.3 | χYates = 6.69 (0.01) (0.14) |
Dysthymia | 78 | 12.9 | 34 | 8.6 | χYates = 4.05 (0.044) (0.19) |
Affective bipolar disorder | 16 | 2.6 | 7 | 1.8 | χYates = 0.48 (0.46) |
Alcohol use disorder | 31 | 5.1 | 14 | 3.5 | χYates = 1.06 (0.30) |
Panic + agoraphobia | 49 | 8.1 | 20 | 5.1 | χYates = 3.01 (0.08) |
Panic | 34 | 5.6 | 11 | 2.8 | χYates = 3.87 (0.049) (0.29) |
Agoraphobia | 29 | 4.8 | 17 | 4.3 | χYates = 0.05 (0.83) |
Social anxiety | 198 | 32.7 | 122 | 30.8 | χYates = 0.32 (0.57) |
Simple phobia | 190 | 31.4 | 118 | 29.8 | χYates = 0.22 (0.64) |
PTSD | 82 | 13.6 | 17 | 4.3 | χYates = 22.0 (<0.001) (0.47) |
Generalized anxiety disorder | 213 | 35.2 | 125 | 31.6 | χYates = 1.26 (0.26) |
Somatization disorder | 16 | 2.6 | 7 | 1.8 | χYates = 0.48 (0.49) |
Pain disorder | 20 | 3.3 | 7 | 1.8 | χYates = 1.61 (0.20) |
Hypochondria | 18 | 3.0 | 14 | 3.5 | χYates = 0.89 (0.64) |
Body dysmorphic disorder | 72 | 11.9 | 39 | 9.8 | χYates = 2.25 (0.28) |
Any eating disorder | 51 | 8.4 | 27 | 6.8 | χYates = 0.66 (0.42) |
Grooming behavior disorder | 128 | 21.8 | 76 | 19.2 | χYates = 0.46 (0.50) |
Intermittent explosive disorder | 39 | 6.5 | 20 | 5.1 | χYates = 0.57 (0.45) |
Compulsive buying disorder | 52 | 8.6 | 23 | 5.9 | χYates = 2.21 (0.14) |
Compulsive sexual behavior | 15 | 2.5 | 6 | 1.6 | χYates = 0.64 (0.42) |
Internet addiction | 15 | 2.5 | 8 | 2.0 | χYates = 2.07 (0.36) |
Model 1—Table-by-Table Analysis (forward Conditional Method) | Cross-Validation Analysis | ||||
---|---|---|---|---|---|
Variable that remained in the model | p | OR (95% CI) | Training Subset (70%) | Testing Subset (30%) | Conclusion |
Table 1—sociodemographic variables | rP(p) | rP(p) | |||
Self-declared skin color (nonwhite) | 0.033 | 1.51 (1.18–2.42) | 0.176 (<0.001) | 0.095 (0.104) | Overfitted |
Table 2—OCD intrinsic factors | |||||
Presence of sensory phenomena | <0.001 | 1.47 (1.04–1.76) | 0.193 (<0.001) | 0.208 (<0.001) | Not overfitted |
Severity of sexual/religious DY-BOCS dimension | <0.001 | 1.06 | |||
Severity of hoarding DY-BOCS dimension | 0.001 | 1.06 | |||
Table 3—OCD extrinsic factors | |||||
BDI (depression severity) | <0.001 | 1.03 | 0.131 (0.001) | 0.168 (0.003) | Not overfitted |
Table 4—psychiatric comorbidities | |||||
ADHD | 0.042 | 1.18 (1.07–2.31) | 0.147 (<0.001) | 0.149 (0.01) | Not overfitted |
Separation anxiety | 0.037 | 1.31 (1.07–4.05) | |||
PTSD | <0.001 | 1.42 (1.04–4.99) | |||
Model 2—analysis of all variables together (enter method) | |||||
Variable that remained in the model | p | OR (CI 95%) | Training Subset (70%) | Testing Subset (30%) | Conclusion |
rP(p) | rP(p) | ||||
Early onset | 0.003 | 1.03 (1.01–1.05) | 0.208 (<0.001) | 0.214 (<0.001) | Not overfitted |
Severity of hoarding DY-BOCS dimension | 0.005 | 1.05 (1.02–1.09) | |||
Severity of sexual/religious DY-BOCS dimension | 0.006 | 1.04 (1.01–1.07) | |||
Psychiatric hospitalization | 0.015 | 1.95 (1.14–3.35) | |||
Beck Depression Inventory score | 0.04 | 1.01 (1.00–1.03) | |||
PTSD | <0.001 | 2.93 (1.62–5.29) | |||
Presence of sensory phenomena | <0.001 | 1.87 (1.39–2.52) |
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Kracker Imthon, A.; Antônio Caldart, C.; do Rosário, M.C.; Fontenelle, L.F.; Constantino Miguel, E.; Arzeno Ferrão, Y. Stressful Life Events and the Clinical Expression of Obsessive–Compulsive Disorder (OCD): An Exploratory Study. J. Clin. Med. 2020, 9, 3371. https://doi.org/10.3390/jcm9103371
Kracker Imthon A, Antônio Caldart C, do Rosário MC, Fontenelle LF, Constantino Miguel E, Arzeno Ferrão Y. Stressful Life Events and the Clinical Expression of Obsessive–Compulsive Disorder (OCD): An Exploratory Study. Journal of Clinical Medicine. 2020; 9(10):3371. https://doi.org/10.3390/jcm9103371
Chicago/Turabian StyleKracker Imthon, André, César Antônio Caldart, Maria Conceição do Rosário, Leonardo F. Fontenelle, Euripedes Constantino Miguel, and Ygor Arzeno Ferrão. 2020. "Stressful Life Events and the Clinical Expression of Obsessive–Compulsive Disorder (OCD): An Exploratory Study" Journal of Clinical Medicine 9, no. 10: 3371. https://doi.org/10.3390/jcm9103371