ReviewA meta-analytic review of the relationship between family accommodation and OCD symptom severity
Introduction
Obsessive compulsive disorder (OCD) is characterized by obsessive thoughts and compulsive behaviors (American Psychiatric Association, 2013). Obsessions are persistent thoughts, impulses, or images that are experienced as distressing. Compulsions occur in response to obsessions with the aim of reducing distress. These may consist of repetitive behaviors (for example washing or checking) or mental acts (such as counting or praying). Obsessive compulsive disorder has been associated with significant impairments in social functioning and quality of life (Eisen et al., 2006) and high comorbidity rates with other psychiatric disorders (Torres et al., 2006).
Whilst behavioral and cognitive therapies are the psychological interventions for OCD with the strongest evidence base (National Institute of Health and Care Excellence, 2005; Olatunji, Davis, Powers, & Smits, 2013), including for children and young people (Geller et al., 2012, Freeman et al., 2014), outcomes are disappointing, with about 50% of people not meeting recovery criteria after therapy (Fisher & Wells, 2005). One reason for these disappointing outcomes may be that family members can accommodate OCD by performing compulsive rituals for the person, such as checking and cleaning, providing reassurance and through modifying routines (Stobie, 2009, Storch et al., 2007a). It is now well established that family members accommodate OCD (Calvocoressi et al., 1995, Merlo et al., 2009, Renshaw et al., 2005; Stewart et al., 2008), with evidence to suggest that almost 90% of family members accommodate symptoms to some extent (see Calvocoressi et al., 1995, Pinto et al., 2013).
Accommodation of OCD symptoms is likely to directly impede the mechanisms targeted by behavioral and cognitive therapies and is therefore hypothesized to hinder positive therapy outcomes. According to Emotional Processing Theory (Foa & Kozak, 1986), a behavioral theory of OCD, accommodation would prevent habituation from occurring and from an inhibitory learning perspective (Craske et al., 2008, Craske et al., 2012; Craske et al., 2014), accommodation would both reduce opportunities to develop and strengthen a competing non-fear structure about the feared object or situation and would lessen opportunities to learn to tolerate distress. From a cognitive perspective, accommodation would limit opportunities to gather evidence that challenges beliefs about obsessive thoughts (see Storch et al., 2007a), including the belief that thoughts are important and should be controlled, a belief more strongly associated with OCD than with other anxiety disorders (Obsessive Compulsive Cognitions Working Group [OCCWG], 2005). That is, if a family member engages in a ritual they are implicitly reinforcing the belief that the intrusive thought is important and should be responded to.
In line with this, empirical research has found that family accommodation is associated with OCD symptom severity in both adults and children with OCD (Calvocoressi et al., 1999, Merlo et al., 2009), that family accommodation predicts poorer treatment outcome (Amir, Freshman, & Foa, 2000; Merlo et al., 2009), although not all studies have found a link (Peris et al., 2008), and that changes in family accommodation temporally precede symptom improvement in young people with OCD (Piacentini et al., 2011). This is of important clinical relevance. If family accommodation plays a role in exacerbating OCD symptom severity then research trials evaluating family accommodation interventions should be prioritized. The hope would be that family accommodation interventions would improve therapy outcomes, resulting in a greater number of people benefitting from behavioral and cognitive therapies.
Despite the clinical importance of this area a meta-analysis examining the relationship between family accommodation and OCD symptom severity has not been published to our knowledge. This is an important gap in the literature as a meta-analysis would establish if, across studies, there is indeed a significant association between family accommodation and OCD symptom severity and it would identify the size of any effect. A meta-analysis would also show whether effect sizes across studies are homogeneous. This would suggest whether or not the effect size between family accommodation and symptom severity is similar or different for different groups (e.g. adults and children with OCD) which may indicate that family accommodation plays a different role in symptom severity in different populations. Finally, it is possible that publication bias exists in this area of research, with the potential for non-publication of non-significant findings biasing findings. In order to address this gap in the literature this paper presents a meta-analysis of the association between family accommodation and OCD symptom severity alongside an assessment of possible publication bias.
Section snippets
Literature search strategy
A systematic search of the literature was conducted using six databases (PsycINFO, Web of Knowledge, Scopus, MEDLINE, ProQuest Dissertations and Theses and CINAHL). Titles were searched using the terms, [family, relative, parent* or carer] in combination with [accommodat* or involvement] and [obsess*, intrus* or OCD]. It included papers indexed by these electronic databases published before April 2014 and relevant papers in the reference lists of retrieved articles were also searched.
Selection of studies
Inclusion
Summary of the studies included in the analysis
The final papers selected for review consisted of 14 studies exploring family accommodation and OCD symptom severity (see Fig. 1). Table 1 provides a summary of the included studies.
Summary of findings
This paper presents a meta-analysis of the association between levels of family accommodation of OCD symptoms and OCD symptom severity. Family accommodation was significantly associated with OCD symptom severity with a medium effect size (r = .35). Homogeneity was non-significant, showing that effect sizes across the studies were not significantly different from each other. This suggests that the strength of the relationship between family accommodation and OCD symptom severity is similar across
Acknowledgement
There were no sources of funding for this study.
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2021, Journal of Obsessive-Compulsive and Related DisordersCitation Excerpt :Therefore, higher levels of OCD severity may be associated with higher accommodation from parents of children with OCD because, for example, dependent children may require more help with the practical rituals (i.e., obtaining cleaning products) and parents may feel intuitively, responsible for alleviating their child's distress. However, such research is predominately based on associations found in cross-sectional studies and, therefore, cannot claim to show directionality, or causality, between OCD severity and accommodation (Strauss et al., 2015). However, it is likely that there are qualitative differences in the relationship and interactions within the parent-child dyad when compared to the relationships family members (including parents) may have with an adult with OCD.
Psychometric properties of the Chinese version of the family accommodation scale for obsessive-compulsive disorder interviewer-rated
2021, Comprehensive PsychiatryCitation Excerpt :Regarding convergent validity, similar to the hypothesis and previous studies, the FAS-IR scores were positively correlated with the Y-BOCS, CGIS, SDS, and FAD-12 scores and negatively associated with the GAF ratings. The results reconfirmed that high levels of FA are associated with increased severity of OCD, including the majority of previous studies and two meta-analysis studies [64,65], which confirmed that FA was moderately related to symptom severity. Many relatives engaged in FA behaviors may be behaving in a seemingly innocuous manner and aim to alleviate anxiety and distress of patients; however, it is unfortunate that the symptoms are shaped, maintained and reinforced and subsequently impaired different life domains in the long run.