Four-Factor Structure of Obsessive-Compulsive Disorder Symptoms in Children, Adolescents, and Adults

doi:10.1097/CHI.0b013e318172ef1e

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 47, Issue 7, July 2008, Pages 763-772

https://doi.org/10.1097/CHI.0b013e318172ef1e Get rights and content

Abstract

Objective

To determine whether the four-factor category-based obsessive-compulsive disorder (OCD) symptom structure from a previous confirmatory factor analysis (CFA) may be appropriately used in child, adolescent, and adult groups. Symptom dimensions are increasingly used as quantitative traits in genetic, neuroimaging, and treatment studies of OCD across all ages. Identification of a category-based OCD symptom dimension structure that is validated for use across child, adolescent, and adult age groups is necessary to guide ongoing translational research.

Method

Four OCD samples comprising 356 individuals were divided into child, adolescent, and adult groups. The fit of the only CFA-defined four-factor model was compared across these independent age group samples. Multiple-group CFA using maximum likelihood estimation assessed adequacy of fit comparing unconstrained and measurement weight-constrained models. The fit of previous exploratory factor analysis-defined three- and five-factor models on adults was also examined using CFA.

Results

A four-factor solution provided adequate but imperfect fit across age groups, with comparable indices to the only previous OCD CFA: factor 1 (aggressive/sexual/religious/somatic/checking); factor 2 (symmetry/ordering/counting/repeating); factor 3 (contamination/cleaning), and factor 4 (hoarding). Models in which factor loadings were constrained and unconstrained across the three age groups yielded comparable model fit. Factors were highly correlated and were not mutually exclusive. The four-factor solution provided an improved fit to both three- and five-factor solutions using CFA across the three age groups.

Conclusions

A four-factor, CFA-defined, category-based model of OCD symptom dimensions is adequate for use in children, adolescents, and adult age groups. The factor structure of this multiple age group sample has limitations and is imperfect, but current findings support the comparability of the defined latent OCD dimensions across age groups. Further work is needed to optimize a comprehensive symptom dimension model reflecting clinical heterogeneity for use in emergent translational studies. J. Am. Acad. Child Adolesc. Psychiatry, 2008; 47(7):763–772.

Section snippets

Participants

Participants were evaluated independently at one of the following outpatient clinics: the Harvard Pediatric OCD Clinic at McLean Hospital, Belmont, MA; the Service de psychopathologie de l'enfant et de l'adolescent (Child and Adolescent Psychopathology Clinic), Robert Debré Hospital, Paris; the TS/OCD clinic at the Yale Child Study Center, New Haven, CT; and the Adult OCD clinics at Yale University and Brown University. All of the subjects had a definitive diagnosis of OCD according to DSM-IV

Descriptive Analyses

Lifetime mean symptom sums and lifetime frequencies of any symptom for each nonmiscellaneous Y-BOCS and CYBOCS checklist category for each age group, and related age group differences are listed in Table 1. Within all of the age groups, the presence of any aggressive obsessions and any checking compulsions had the highest lifetime frequencies compared with other symptom categories. Similarly, the presence of any sexual obsessions and any hoarding compulsions had the lowest lifetime frequencies

CFAs

Fit of the Unconstrained Four-Factor Model in the Three Age Groups. The hypothesized four-factor structure tested in this study included the following dimensions—factor 1: sexual/aggressive/religious/somatic/checking; factor 2: symmetry/ordering/repeating/counting; factor 3: contamination/cleaning; and factor 4: hoarding obsessions/compulsions.

The initial step in the present multiple-group CFA procedure (test of the unconstrained model) set out to determine whether the hypothesis that the

Discussion

This study indicates that the four-factor category-based OCD symptom dimension structure defined in the only previous symptom CFA provides an adequate fit for the data in independent child, adolescent, and adult age groups (with equal factor loadings across age groups). Fit indices across the three groups are similar to those reported for the Summerfeldt et al.⁷ independent adult sample. As such, the first CFA study on adult OCD has now been replicated in an independent multiple age group

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The scales produce an obsession severity score (0–20), a compulsion severity score (0–20), and a total severity score (0–40). The CY-BOCS has demonstrated good reliability and validity in previous work (Stewart et al., 2008; Storch et al., 2004). The severity scales in the current study also demonstrated good internal consistency (α = .78).
The role of disgust in anxiety and related disorders has been extensively studied in adults, however its role in childhood psychopathology is in need of further investigation. The adult literature has suggested that two distinct sub-constructs within “disgust proneness” may differentially predict anxiety-related disorders. Namely, disgust propensity (DP) has been defined as the likelihood an individual will experience a disgust reaction, and disgust sensitivity (DS) as the degree to which an individual is distressed by their experience of disgust. The current study aimed to validate the Disgust Propensity and Sensitivity Scale-Revised (DPSS-R) in a sample of youth receiving intensive services for OCD and anxiety, examine the relationship between disgust sub-constructs and obsessional content in a sample of youth with OCD, and examine the relationship between disgust change and symptom severity at discharge. A confirmatory factor analysis supported a two-factor structure of the DPSS-R. DP was found to be uniquely predictive of contamination obsessions, and DS was found to be uniquely predictive of moral obsessions. Lastly, change in DP, but not DS, predicted overall change in OCD symptom severity. The present study provides a valid measure of DS and DP in youth with anxiety and related disorders, and suggests that subconstructs of disgust may serve as distinct risk factors for obsessional content in youth with OCD. Future research should examine the predictive validity of DP and DS longitudinally, as well as examine effective ways to more effectively target DP with exposure therapy.
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Citation Excerpt :
Nonetheless, there were a few important presentational differences between child and adult OCD patients that emerged even when the total number of presentations was controlled for. First, religious obsessions comprised a larger portion of total obsessions for children, consistent with findings from several past studies (Geller et al., 2001; Mancebo et al., 2008) and contradicting others (e.g., Farrell et al., 2006; Hanna, 1995; Stewart et al., 2008). This suggests that children with OCD may be particularly sensitive to obsessions involving religious themes, perhaps because they are still embedded in a family context in which their religion is essentially chosen, which in turn increases pressure to uphold ritualistic practices or moral obligations (Peris & Rozenman, 2016).
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Reviewed and accepted by Deputy Editor John Walkup, M.D.

Grant support was provided by the Obsessive-Compulsive Foundation (S.E.S., M.C.R., D.AG.); McIngvale Foundation (S.E.S., D.L.P., D.A.G.); Harvard Scholar in Medicine Award (S.E.S.); CIHR Postgraduate Fellowship (S.E.S.); University of Ottawa International Fellowship (S.E.S.); Tourette Syndrome Association (M.C.R.); NIMH-K08-MH01481 (D.A.G.); NINDS-R01-NS16648 (D.L.P.) and MH49351 (J.F.L.). The authors thank Erin Hendrickson and Casey Walsh for their assistance with manuscript preparation and the reviewers for their valuable feedback.

This article is the subject of an editorial by Drs. Marc Riddle and Marco Grados in this issue.

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Four-Factor Structure of Obsessive-Compulsive Disorder Symptoms in Children, Adolescents, and Adults

Abstract

Objective

Method

Results

Conclusions

Section snippets

Participants

Descriptive Analyses

CFAs

Discussion

Schizophr Res

Biol Psychiatry

Behav Res Ther

Psychiatry Res

Psychiatry Res

Psychiatry Res

Biol Psychiatry

J Affect Disord

J Am Acad Child Adolesc Psychiatry

Behav Res Ther

Biol Psychiatry

J Am Acad Child Adolesc Psychiatry

Behav Res Ther

Behav Res Ther

Behav Res Ther

A family study of early-onset obsessive-compulsive disorder

Am J Med Genet B Neuropsychiatr Genet

Familiality of symptom dimensions in depression

Arch Gen Psychiatry

Obsessive-compulsive disorder phenotypes: implications for genetic studies

Mol Psychiatry

Recent findings in the genetics of OCD

J Clin Psychiatry

Symptoms of obsessive-compulsive disorder

Am J Psychiatry

Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders

J Clin Psychiatry

Exploratory factor analysis of obsessive-compulsive patients and association with 5-HTTLPR polymorphism

Am J Med Genet B Neuropsychiatr Genet

Symptom dimensions in obsessive-compulsive disorder: toward quantitative phenotypes

Am J Med Genet