Family accommodation: a diagnostic feature of obsessive-compulsive disorder?

KEYWORDS:

• Diagnosis
• OCD
• accommodation
• DSM
• child
• adult

1. Introduction

Obsessive-compulsive disorder (OCD) is an often debilitating psychiatric condition that affects approximately 1–4% of individuals [1]. A diagnosis of OCD per the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) requires the presence of obsessions, compulsions, or both (not attributable to another mental disorder, substance, or medical condition) with specifiers relating to degree of insight and history of a tic disorder [2]. To warrant a diagnosis, OCD symptoms must be time consuming (i.e. >1 h a day) and contribute to significant personal distress and/or impairment in key domains of functioning.

One significant feature of OCD that notably is not captured by the DSM is family accommodation (FA). FA refers to the changes that family members make to their own behavior to help a relative avoid or alleviate distress related to their symptoms. The term FA was first introduced in a study of adult OCD patients and their relatives [3]. Over time, research has shown that FA is also highly prevalent and problematic amongst families of pediatric patients with OCD and other anxiety disorders [4]. In the following sections, we describe FA of OCD and its impact on symptom maintenance and recovery, and ultimately make the case for its inclusion in OCD diagnostic criteria.

2. Family accommodation of OCD

FA is a broad term encompassing many heterogenous behaviors that occur in response to OCD presentations and symptoms. For example, in response to a relative’s contamination fears, family members may repeatedly assure them that no one has been in contact with germs or contaminants. In response to a relative’s obsessive doubting or scrupulosity, family members may listen to their repeated confessions, or promise they have not engaged in any wrongdoing. When OCD presents as aggressive or suicidal obsessions, family members may also provide excessive reassurance that the thoughts will not cause harm or lead to actual aggressive or suicidal behaviors. Such forms of FA involving repeated dialogue about the OCD can be time-consuming and emotionally stressful or draining for families.

Other forms of FA are even more striking, such as when contamination fears cause an individual to demand that family members excessively wash their own hands, purchase extra soap or cleaning supplies, check repeatedly for contaminants, or even bring them to repeated doctor’s appointments. Or, when an individual’s scrupulosity obsessions cause them to prohibit other family members from saying certain words or discussing certain subjects. A person with aggressive or suicidal obsessions may demand family members remove potentially harmful objects from the home, or handle these objects for them (e.g. while cutting food). And, when a person with OCD is overly preoccupied with symmetry or counting, family members may have to perform actions a specific number of times, or participate in compulsive ordering routines (e.g. arranging books on shelves). What is striking about these latter examples is the way in which FA can blur the boundary between individuals with OCD and non-afflicted family members. When family members’ hands are red and raw from excessive washing, or they are actively avoiding certain words or sharp objects, it is difficult to discern who has the disorder.

In some cases, high levels of FA enacted by family members are linked to forceful demands on the part of the person with OCD. Even children and adolescents may use force to impose accommodations on their relatives, and react in challenging ways when not accommodated. These reactions range from refusal to function, to increased anxiety and distress, to anger and verbal or physical aggression [5]. Faced with these possible outcomes, many families feel coerced to accommodate. Further, engaging in high levels of FA impacts more than family members’ behaviors. Research shows links to parent stress and anxiety, and to impairments in adaptive family functioning [6]. The pervasive effects of OCD on relatives’ behaviors, time, and emotions illustrates how this disorder can ultimately ‘take over’ an entire family system [5].

3. The impact of family accommodation on OCD symptom maintenance and recovery

FA has profound impacts on symptom maintenance and recovery. Several reviews and meta-analyses found that greater FA is associated with greater severity of OCD symptoms and related impairment [4,7]. A theorized mechanism by which this occurs is that FA facilitates avoidance of (and prevents exposure to) anxiety-provoking stimuli or situations. FA may convey a message implicitly validating irrational obsessive thoughts or the belief that the relative cannot cope with the distress those thoughts provoke. Further, individuals with OCD who are highly accommodated likely have fewer opportunities to practice self-regulation or coping skills.

These mechanisms have direct bearing on the front-line, evidence-based OCD treatment, cognitive-behavior therapy (CBT) with exposure and response prevention (E/RP). Indeed, research shows that lower FA predicts better E/RP treatment outcomes for youth with OCD [8], and that reduced FA mediates treatment response [9]. The detrimental impact of FA on OCD treatment extends beyond psychotherapy; similar findings are also shown for pharmacological treatment [8]. As a result, OCD treatments are increasingly emphasizing and targeting FA [10]. There is growing indication that OCD remission rates are superior for treatments that target FA than for those that do not (e.g. 58% versus 27% remission rates for family-focused versus standard OCD treatment) [9].

4. Expert opinion

FA is not part of the diagnostic criteria for OCD, but its prevalence, impact, and treatment implications suggest a revision to address this may be indicated. Indeed, up to 99% of family members of individuals with OCD report participating in at least one type of FA, often on a daily basis [11]. Other diagnostic features of OCD, such as low insight in pediatric patients, are reported at much lower rates (e.g. 9.7%) and fail to consistently show associations with OCD severity or impairment [12].

Adding FA to the diagnostic criteria may carry positive benefits for OCD assessment, treatment, and research. Regarding assessment, OCD can be challenging to diagnose and many cases are missed, leading to a cascade of other detrimental consequences (e.g. suicidality) [13,14]. Data indicating it takes an average of 8 years from OCD onset to treatment, with longer latency conferring worse prognosis, underscore the need for better evaluation and diagnostic procedures [15,16]. Including FA in the diagnostic criteria would mean that a family member describing the need to accommodate would be a recognizable mental health symptom that could lead to further clinical investigation and diagnosis. This could be especially helpful in childhood and adolescence, when OCD diagnosis can be especially complex. For example, a key diagnostic criterion in the DSM—that compulsions are intended to neutralize anxiety/obsessions—includes the caveat that ‘young children may not be able to articulate the aims of these behaviors or mental acts.’ The DSM also stipulates that the obsessions or compulsions be time-consuming (i.e. taking an hour or more a day), but children struggle to correctly estimate time periods [17], and even adults have difficulty estimating time spent on mental activities. Considering the time that relatives spend accommodating the obsessive-compulsive symptoms could help to clarify how time-consuming the problem actually is. This would be a feasible goal in a variety of mental health settings, as FA can be validly, reliably, and easily assessed with a number of measures and informants [3].

Another benefit of adding FA to the diagnostic criteria relates to treatment implications. About 60% of patients do not achieve remission following front-line OCD treatments, which do not include a focus on FA [18]. As noted, addressing FA in treatment has shown great potential to improve youth OCD outcomes. Several approaches incorporate parent work focused on FA into CBT or E/RP approaches [9]. Stand-alone parent interventions that target reducing FA, such as SPACE (Supportive Parenting for Anxious Childhood Emotions), also show evidence of efficacy [10]. Including FA in the OCD diagnostic criteria can help advance recognition for involving relatives in treatment, including with regards to billing and compensation. For instance, ‘family therapy without patient present’ is not reimbursed by Medicaid in some states or for certain providers, or reimbursed at lower rates than other therapy modalities, posing challenges for clinicians that may prevent families from obtaining the services they need [19].

Finally, adding FA to the diagnostic criteria can positively impact research. If the presence of FA is a diagnostic criterion, it will be assessed and recorded in almost all clinical research settings, leading to even better data. Research on FA has proliferated in the past 10 years, but many areas of inquiry remain, such as cross-cultural differences and similarities, and predictors and moderators of FA. Enhanced understanding of these aspects of FA through more and better data will help refine treatment approaches and ultimately benefit patients and their families.

FA of OCD is ubiquitous, contributes to family distress and dysfunction, maintains symptoms, and interferes with therapy gains. Addressing FA may be an essential component of treatment in many if not all cases of OCD. Incorporating FA into the diagnostic criteria for OCD may carry important benefits for assessment, treatment, and research. Finally, while FA was first studied in OCD, it has been found to be highly prevalent across anxiety disorders. OCD may once again lead the way with regards to inclusion in the DSM, setting the stage for similar changes across anxiety and its disorders.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded.