The Cognitive Models Of Ocd Psychology Essay

Published Date: 23 Mar 2015

The study is aimed to investigate the Quality of Life of Obsessive Compulsive Disorder patients in relation to Severity of the symptoms and Cognitive Appraisal. The study will explore the predictors of Quality of life of OCD patients from variables of Symptom Severity dimensions and Cognitive Appraisal. It is hypothesized that patients having OCD with more Symptom Severity, and Cognitive Appraisal of obsessions will have impaired Quality of life. Correlational research design and purposive sampling will be used. 60 patients with primary diagnosis of Obsessive Compulsive disorder, with age range of 18 years and above will be recruited. For assessment, Obsessive Compulsive Disorder Symptom Checklist (OCDSC), Stress Appraisal Measure (SAM), and WHOQOL-BREF will be used. Pearson Product Moment will be employed to find the relationship of Symptom Severity and Cognitive Appraisal with Physical health, Psychological health, Social and Environment related Quality of life. In addition, Multiple Regression Analysis will be used to explore the predictor of Quality of life of patients with Obsessive Compulsive disorder.

Introduction

The study investigates the Quality of Life (QoL) of Obsessive Compulsive Disorder (OCD) patients in terms of Symptom Severity and cognitive appraisal. The severity of symptomology and clinically manifested psychological distress exacerbates the functional impairment of OCD's patients. The functional impairment debilitates and gradually leads to poor treatment compliance as psychotherapy include the dysfunction area in treatment plan. The present study is intended to understand the relationship of the associated factors that will help facilitate the better understanding on etiological and therapeutic grounds.

Obsessive Compulsive Disorder

According to American Psychiatric Association (2000), Obsessive Compulsive Disorder OCD) is an anxiety disorder classified into Obsessions and Compulsions. Obsessions are intrusive, unwanted thoughts, id, images, or impulses that and individual experienced as senseless yet anxiety evoking. Compulsions are desires to engage in behavioral or mental acts according to specified "rules" or in reaction to obsessions (i.e., to lower down obsessional anxiety). However, individuals are unaware of the trigger and may perform stereotyped acts according to idiosyncratic rules (Wells, 1997).

Obsessions are persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate. The most common obsessions concern thought about contamination, doubting, aggressive or horrific impulses and sexual imagery (Wells, 1994; Wells & Morrison, 1994 as cited in Wells, 1997). A compulsion is a repetitive behavior that is overt or covert. Overt compulsions include hand washing, checking, ordering, or alignment of objects. Covert compulsions are mental acts such as praying, counting, or repeating words. The goal of these overt and covert compulsions is to reduce or prevent anxiety or distress (Wells, 1997).

Symptom Severity

Severe OCD is characterized by

Substantial frequency of obsessions and compulsions (from 4 hours a day to every minute of the patient's waking hours),

Substantial impairment from the OCD (usually in all domains of life including social, work, and family),

Poor insight into the symptoms (or how realistic the patient thinks their fears are), and/or

Substantial co morbidity which complicates the presentation of the symptoms (e.g., posttraumatic stress disorder or schizophrenia).

Severity of symptoms, as characterized by high frequency of symptoms or significant distress, is often measured through self-report measures such as the Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002). Obsessive-compulsive disorder symptoms include both obsessions and compulsions. Obsessions often have themes of fear of contamination or dirt, having things orderly and symmetrical, aggressive or horrific impulses and sexual images or thoughts. However, compulsions typically have themes of washing and cleaning, counting, checking, demanding reassurances, performing the same action repeatedly, and orderliness (Mayo Clinic Staff, 2012). Studies indicate that there are clinically meaningful differences among these symptom-based subtypes. It was reported that OCD patients with compulsive hoarding report higher levels of anxiety and depression, greater impairment in occupational, family, and social functioning and poorer response to pharmacological and cognitive-behavioral treatment (Abramowitz, Franklin, Schwartz, & Furr, 2003). Despite the documented detrimental effects of OCD on quality of life, evidence suggests that not all individuals with OCD are uniformly impaired. Masellis, Rector, and Richter (2003) found that severity of obsessions, but not compulsions, was related to lower overall quality of life. Similarly, Eisen et al., (2006) reported that severity of obsessions and comorbid depression predicted impairment across eight domains of Life Enjoyment and Satisfaction, whereas compulsion severity was related only to impaired work functioning. In contrast, Stengler-Wenzke, Kroll, Riedel-Heller, Matschinger, and Angermeyer (2007) found obsessions to be unrelated to Quality of life ratings, but that severity of compulsions was associated with reduced physical and psychological well-being, as well as impairment in social and family life and leisure activities.

Cognitive Appraisal

Grinker and Spiegel (1945, as cited in Sincero, 2012), explained appraisal as a process that requires mental activity involving judgment, discriminating and choice of activity based largely on the past experiences of and individual. According to Lazarus (1984), cognitive appraisal occurs in reaction to stress. One is the threatening tendency of the stress to the individual, and second is the evaluation of the resources that is required to minimize, tolerate or eradicate the stressor and the stress it produces. According to Lazarus, appraisal takes two forms, Primary Appraisal and Secondary Appraisal.

Primary appraisal has been distinguished into irrelevant, benign-positive and stressful. Irrelevant implies when experiences not stressful, it falls within the category of irrelevant (Lazarus & Folkman, 1984). The appraisal of relevancies is not themselves of great concern, but the cognitive processes by which these events are appraised. Benign-positive appraisal occurs if the outcome of encounter is constructed as positive and enhances well-being. These appraisals are characterized by positive emotions. Stress appraisal includes harm/loss, threat and challenge. In harm/loss, damage to the person is suspected. Threat concerns are the anticipated harms or lose. Challenge appraisal focus on the potential for gain or growth inherent in an encounter and they are characterized by pleasurable emotions such as eagerness, excitement, and exhilaration, whereas threat centers on the potential harms and is characterized by negative emotions such as fear, anxiety, and anger (Lazarus & Folkman, 1984).

The aim of secondary appraisal is to provide information about the individuals coping options in a situation. It has three components including problem focused coping, emotion focused coping and future expectancy. When an individual is deciding whether a situation is a threat or challenge, or he must do something to manage the situation, secondary appraisal becomes significant in order to figure out what might and can be done. Secondary appraisal activity is crucial feature of stressful encounter (Lazarus & Folkman, 1984). When an individual is faced with adverse situation, something needs to be done to control it and avoid any subsequent consequences. Secondary appraisal follows primary appraisal of a situation. This necessarily includes evaluation of the situation and suitable reaction. The person than evaluate what can be done to cope with a particular situation. The reaction to the situation is decided by carefully analyzing what is at stake and what can be done to reduce negative consequences (Lazarus & Folkman, 1984).

Cognitive Models of OCD

According to O'Leary (2005), the number of cognitive models describing OCD phenomenon. These illustrate the rate of dysfunctions in general cognitive processing or dysfunction in cognitive appraisal and beliefs.

Salkovskis Model (1985; Wells, 1997) based on cognitive and behavioral concepts in the formulation of obsessional problems. It theorized that the importance of appraisal of intrusion as the major source of distress, rather than the content of the intrusion itself. The appraisal of the significance of intrusions is determined by underlying beliefs. Once negative appraisals of responsibility occur, the second process of initiation of neutralizing responses which may be internal or external begins. When a person neutralized the intrusive thought he attempts to reduce responsibility and discomfort. Thus, the recurrences of intrusions become more likely because responses to them result in such cognitions acquiring greater salience. Studies have found significant correlations between responsibility and obsessive-compulsive behaviors in both clinical (e.g., OCCWG, 2001) and nonclinical participants (Freeston, Ladouceur, Thibodeau, & Gagnon, 1992; as cited in O'Leary, 2005).

According to Rachman (1998; as cited in O'Leary, 2005), the catastrophic misinterpretation about the importance of unwanted thoughts made by a person increases the range and seriousness of potentially threatening stimuli. In this way numbers of neutral stimuli that were insignificant are interpreted as threatening. This transfer of the neutral stimuli and situation to potentially threatening ones increases the range of threats and therefore increases the opportunities for the provocation of obsessions. This happens with both internal as well as external cues. In internal cues, the person deduces a threat from the fact of feeling anxious. Moreover, when the patient feel anxious he interpret it as if he is losing control of self and thus there is an increased likelihood that he will act upon the unwanted impulse. Hence, the catastrophic misinterpretation of one's anxiety can interact to increase the misinterpretation of the intrusion. Neutralizing prevents exposure to any disconfirming evidence regarding the personal significance of the intrusive thoughts. This cycle remains until the catastrophic misinterpretation is changed or reduced and the internal or external stimuli are no longer interpreted as threatening.

Quality of life

The World Health Organization (1994) defines Quality of Life as an individual's perception of his/her position in life in the context of the culture and value systems in which he/she lives, and in relation to his/her goals, expectations, standards and concerns. It is a broad-ranging concept, compromising of the person's physical health, psychological state, social relationships, and their relationship to salient features of their environment (Hollar, 2012, p.74). Obsessive compulsive disorder may significantly affect self-care, social relationships, occupational functioning, family and marital relationships, child-rearing capacities, and use of recreations or spare time (American Psychological Association, 2007). Bobes (2001) revealed that patients with obsessive-compulsive illness had definite impairment in all domains of quality of life other than physical functioning. Similar findings emerged from the studies of Moritz (2005) and Eisen (2006), also showed that as compared to general population, OCD patients have poor health related quality of life in all domains except physical health. Few studies, however, have examined whether OCD symptom dimensions are differentially associated with impairment in functioning and Quality of life. Only one study to date has evaluated the impact of different dimensions of OCD symptoms on Quality of life. Fontenelle et al., (2010) found that whereas depression severity predicted impairment across eight domains of functioning assessed by SF-36, only hoarding and washing, but not other OCD symptom domains, predicted impairment in other areas of functioning social functioning and limitations due to physical health problems, respectively.

OCD sufferers generally recognize their obsessions and compulsions as irrational, and may become further distressed by this realization. Cummins (2000) suggest that it is difficult to define Quality of Life because it can be characterized in both objective and subjective terms (as cited in Barofsky, 2012). According to Spranger & Schwartz (1999), Quality of life is a multidimensional and dynamic concept: perspective can change with the onset of major illness. With the onset of illness, individuals relevant cognitive or affective processes (e.g. in their health or lives) include making comparisons of one's situation, with others who are better or worse off. People may adjust to deteriorating circumstances because they want to feel as good as possible about themselves (Ayers, et al. 2007).

According to Salkovskis (1985) the difference between the obsessive compulsive disorder patient who experience prominent distress and disturbance lies in the meaning they make out of their obsessions. However, normal individual tends to view these intrusions as meaningless and benign whereas OCD patient make catastrophic interpretation out to these cognitive intrusions. These maladaptive interpretations discriminates the OCD patients. Cognitive models of OCD implied that a thought will be distressing and repetitive depending on the meaning assigned to it, not because of the content of obsessional thoughts (Teachman, 2005). The Obsessive Compulsive Cognitions Working Group (OCCWG) has shown that symptom severity correlates with appraisals of intrusive thoughts among individuals with OCD. In comparison with individuals who do not have OCD, those with OCD appraise unwanted intrusive thoughts as more important to control and as conveying more responsibility for preventing harm related to the thought (OCCWG, 2001). Purdon and Clark (1994) suggested that high scores on measures of OCD suggest that the individual is more likely to believe that intrusive and unwanted thought will occur in real life and will experience more guilt in reaction to those thoughts. Appraisals that one could act on the intrusive thought as well as appraisals about control, responsibility and the significance of the thought for one's personality also correlate with the OCD symptoms (as cited in Corcoran and Woody, 2007). Thus, models of Obsessive compulsive disorder showed that cognitive appraisal of unwanted intrusive thoughts will produce significant distress in patients having OCD that in turn will affect quality of life.

There is evidence suggesting a relationship between Cognitive Appraisal and Psychological and Physical well-being (Coyne, Aldwin & Lazarus, 1981; Harris, Heller & Braddock, 1988; Jerusalem, 1993; Nezu, 1986). There is a general Conesus among research that an individual appraisal of the significance of the situation in terms of personal well-being will be a major determinant of affect (Carver et al., 1989; Harris et al., 1988; Lazarus & Folkman, 1987; Lazarus, 1991; Smith & Ellsworth, 1985). The way a person evaluates the significance of an event for him/her produces different emotional reaction, making some people more vulnerable to adverse effect than other (Kessler et al., 1983; as cited in Kausar, 1994). Perceived control experienced by an individual has an effect on outcome (Partridge & Johnston, 1989). Increased levels of perceived personal control are associated with more favorable psychological adjustment (Folkman, 1984) and perceived lack of control on the other hand predicts psychological symptoms (Prime-Emberry, 1972; as cited in Kausar, 1994). How an individual appraises and copes with the stress is important to his/her well-being (Antonovsky, 1979; Lazarus 1981). According to Lazarus and Folkman (1984), a fit between cognitive appraisal and coping strategies is postulated to produce a better outcome. Johnson and Kenkel (1991) concluded that appraisals of threat (Appraisal of self, holding self back) and use of coping strategies of detachment and seeking social support were associated with emotional distress. Moreover, Felsten (1991) suggested that appraisals of challenges and expectations of successful coping should be associated with lower distress and better well-being. Rassin et al. (2001; as cited in Yorulmaz, 2007) suggested that unwanted and intrusive thoughts are experienced by everyone and the difference between normal and abnormal lies in the appraisal process, frequency and distress. Therefore, the examination symptom severity and cognitive appraisal as the predictors of quality of life of OCD patients may facilitate the understanding if the distress and impairment faced by them.

In OCD, primary appraisal occurs in conjunction with the intrusive thoughts associated with obsessions, and secondary appraisal leads to faulty coping (compulsions and avoidance). According to Carr (1971), patients with OCD typically overestimate the likelihood of an unfavorable outcome in the context of primary appraisal (during obsessions) (as cited in Stein, Hollander, & Rothbaum, 2009) and they perform compulsive behaviors in order to reduce perceived threat. In term of cognitive domains, studies of patients with OCD have found an exaggerated sense of responsibility, overestimation of threat, perfectionism, over importance of thoughts, need for control and intolerance of ambiguity (Rachman, 1993; Salkovskis, 1985; as cited in Sten, Hollander, & Rothbaum, 2009). Individuals with OCD report markedly reduced Quality of life and general well-being, diminished occupational attainment, impaired family functioning, and higher rates of suicidal thought attempts. According to Koran et al. (1996), severity of OCD is inversely correlated with social functioning (as cited in Simpson, Neria, Fernandaz & Schneier, 2010). According to Teachman (2007), subjective cognitive complaints exacerbate the effects of obsessional beliefs, and promote maladaptive responses to intrusive thoughts thus increasing the severity of the OCD symptoms.

In present study, it is intended to explore mediating role of Cognitive Appraisal on Quality of Life perceived by Obsessive Compulsive Disorder patients with Symptom Severity and Cognitive Appraisal of the disorder are expected to impair the patient's functioning.

Literature Review

This section includes the review of the studies that investigated the studied variables that are Symptom Severity, Cognitive Appraisal and Quality of life.

Kumar, Sharma, Kandavel & Reddy (2012) examined the contribution of cognitive appraisals to the quality of life (QoL) in patients with obsessive compulsive disorder. In Cross sectional study, it was hypothesized that cognitive appraisals of obsession contribute to poor quality of life in OCD patients. Sample size was 31 consecutive patients from Behavioral Medicine Unit of the NIMHANS and 30 Normal controls. Exclusion criteria were patients having severe co morbid psychiatric, physical and neurological disorder. The assessment was done by using mini Internal Neuropsychiatry Interview (MINI), the YBOCS severity scale, Clinical Global Impression-severity, the Depression Anxiety and Stress Scale-21, the Interpretation of Intrusive Inventory-31 and WHOQOL-BREF. Data was analyzed using independent t-test and chi-square test. Relationship between the domains of cognitive appraisal and the QoL after controlling for the duration of symptoms was analyzed by using Partial correlation. The results indicated that all the domains of cognitive appraisal have strong negative relationship with psychological domain of QoL. Thought control and inflated personal responsibility also correlated negatively with the total QoL. Cognitive appraisal specifically contributes to poorer QoL in OCD so modification of beliefs and appraisal may be essential for better QoL. Main limitations were small size, patients were recruited from Behavioral Medicine Unit of major psychiatric hospital, and findings may not be easily generalized. Sample was predominantly male so it's important to examine gender difference in cognitive appraisal and its relationship to QoL.

Fontelle et al., (2010) in a study compared patients with OCD and normal on severity of different OCD dimensions and levels of QoL of patients with OCD. Further, it was also investigated the socio demographic variables and co occurring depressions and anxiety symptoms have significant contribution in impairment of QoL of OCD patient. They hypothesized that universal pattern of impairment in the physical, mental, and social aspects of quality of life of patient will be associated with more significant hoarding symptoms. The patients with the diagnosis of OCD were included; age between 18-80 years and without any other neurological, endocrinological or systematic disorder. The measures used were Saving inventory revised (SI-R), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Obsessive Compulsive Inventory- Revised (OCI-R), Medical Outcome Study 36-item short form health survey (SF-36). Chi-square and independent student t-test was used for the comparison of categorical and continuous variables respectively. The patient who met the inclusion criteria was 135 out of which 65 were patients, and 70 were controls. The result supported the hypothesize only partially, the decline in particular aspects of patients QoL was significantly associated with hoarding and washing symptoms for but co occurring symptoms, the most prominent determinant of the impairment of QoL of subject with OCD were depressive and anxious ones. The study had limitations that sample was taken from specialized institutions, second control group was of nonclinical individuals, rating on depression scale and QoL Instrument may be dependent on state and change during continuity of OCD, they applied generic tool for measuring QoL in OCD.

Teachman (2007) studied subjective concerns about cognitive decline partially mediate this relationship between obsessional beliefs and OCD symptoms across young and older adult age group in a large community sample. The sample size was 335 including males and females. Obsessive-Compulsive Inventory-Revised, Obsessional Beliefs Questionnaire and Memory Functioning Questionnaire were used. This study attempted to evaluate the modification of cognitive model proposed by Rachman and Salkovskis. The results provide support to cognitive models of obsessions and suggest that obsessional beliefs that have been validated in younger adult samples are also important for older adults. It was shown that the relationship among subjective cognitive concerns, obsessional beliefs and OCD symptoms was consisted but older patients showed greater subjective cognitive concerns,

Grant et al. (2006) carried out a study to find out the differences of OCD patients with primary OCD and sexual obsessions and OCD patients without sexual obsession on number of clinical variables. They included co morbidity, symptom severity, insight, quality of life, and social and occupational functioning under the clinical domains. 293 subjects, meting criteria for OCD, aged 19 years or older were included and interviewed. Clinical interview for DSM-IV Axis-I disorder, Yale-Brown Obsessive Compulsive Scale (YBOCS) to assess OCD symptom severity, Subject Clinical Global Improvement scale was used to evaluate the response towards medication. Rating on the degree to which previous treatments have proved to be effective was taken on 7 point scale. Brown assessment of Beliefs Scale (BABS) was used to evaluate the insight and current Depressive symptom and QOL by were assessed by using 17-item Hamilton Rating scale for Depression and Quality of life Enjoyment and Satisfaction Questionnaire respectively. The findings supported the hypothesize that earlier age of OCD, presiding entry in treatment, increased rate of aggressive and religious obsession onset was related to having OCD with sexual obsessions, and also with increaser depressive symptoms, longer duration of treatment, and higher rates of impulse control disorder.

Teachman, Woody and Magee (2006) attempted to evaluate cognitive theories of obsessions and they experimentally manipulated appraisals of the importance of intrusive thoughts. The design contained both experimental and quasi-experimental elements. Implicit Association Test was used to examine the influence of instructions about the importance versus meaninglessness of unwanted thoughts on reaction time. Obsessive-Compulsive Inventory-Revised, Beck Depression Inventory, Interpretation of Intrusions Inventory III, Obsessional Beliefs Questionnaire-Short Form, State Self-Esteem Scale, and Personal Significance Scale were the part of study. Results indicated that the manipulation shifted implicit appraisals of unwanted thoughts in the expected direction, but not self-evaluation of morality or dangerousness. Interestingly, explicit self-esteem and beliefs about the significance of unwanted thoughts were associated wit the measure of OCD beliefs, whereas implicit self-evaluations of dangerousness were better predicted by the interaction of pre-existing OCD beliefs with the manipulation.

Libby et al., (2004) studied Cognitive Appraisals in young people with Obsessive Compulsive Disorder. The study had two aims to investigate whether the same pattern of cognitive appraisal found in studies with adults will be observed in the younger population. A secondary aim of the study was to establish the relationship between cognitive appraisal and the extent these predict obsessive-compulsive symptoms. Three groups of young people aged between 11 and 18 years old were recruited for the study. First group were of patients with OCD, second was patient with anxiety disorder and third one was non clinical group. Leyton Obsessional Inventory-Child Version, Responsibility Attitude Scale, thought-Action Fusion Scale, and Multidimensional Perfectionism Scale was used n the study. The young people with OCD had significantly higher scores on inflated responsibility, thought-action fusion, and one aspect of perfectionism, concern over mistakes, than the other groups. In addition, inflated responsibility independently predicted OCD symptom severity. The results generally supported the cognitive appraisals held by adults with OCD to young people with the disorder.

Saxena et al., (2010) conducted a research to compare compulsive hoarding and non compulsive hoarding OCD patients across variety of QoL domains. They hypothesized that hoarders would be older and have lower FAF scores than non hoarding OCD patients. Secondly, hoarding patients would be less satisfied with their living situations, given their amount of clutter, and hoarders would have greater victimization/ safety concerns and finally hoarders would have greater financial problems and receive more social service assistance than non-hoarding OCD patients. To study this171 adult patients were selected (84 males, 87 females) with age aged 18-72. They were diagnosed OCD and treated openly between 1998 and 2005. Out of these patient 34 met criteria of having compulsive hoarding syndrome. 137 patients didn't report any hoarding symptoms. Patient presented with a wide range of co morbid diagnosis. Those with active psychosis, mania, dementia, mental retardation or other cognitive impairment were excluded. Standardized rating scales were used to assess symptom severity and level of functioning. YBOCS was used to measure OCD symptom severity. Severity of depressive and anxiety symptoms were measured by 28 item Hamilton Depression rating scale (HDRS-28) and Hamilton Anxiety Scale (Ham-A) respectively. QoL was assessed with Lehman Quality of Life Interview Short. Obtained scores for QoL between 2 groups were compared using Analysis of Variance procedures. ANCOVA were performed with covariates and also for secondary analysis on individual items. Results showed that compulsive hoarders were significantly older that non hoarding OCD patients. QoL scores on victimization and safety factors differed significant between 2 groups. Hoarder felt less safe in streets and less satisfied with protection. Both groups had significant occupational impairment, unemployment and disability. Discrepancy in sample size between 2 patient groups and intensive patient setting were the limitations of study.

Eisen et al., (2006) conducted a study to assess multiple aspects of QoL in individuals with OCD. It was hypothesized that all aspects of QoL would be affected, and that severity of OCD symptoms and depressive symptoms would be associated with impairment in QoL. 5 years prospective naturalistic study was conducted on 197 participants with an age 18 years or older, primary OCD. An exclusion criterion was having an organic mental disorder. YBOCS, Brown assessment of Belief scale, Modified Hamilton rating scale for Depression, Quality of Life Enjoyment and Satisfaction Questionnaire, Social Occupational Functioning assessment scale, Medical outcome survey 36-item short form Health Pearson product moment correlation coefficient was conducted to assess relationship between clinical features of OCD and QoL. Results showed that YBOCS score of 20 appeared to be an inflection point where QoL becomes significantly more impaired, suggesting that functioning and QoL, may be preserved in individuals with OCD until threshold of severity is crossed. Limitations of the study were participants seeking treatment and therefore finding may not apply to those individuals who do not seek treatment. Moreover, subjects were evaluated only once. It was suggested that the role of treatment in improving QoL in OCD should be further investigated along with a need to assess which aspect of QoL and psychological functioning.

Guraraj et al., (2008) conducted research in which they hypothesized that patients suffering from severe OCD may have comparable level of global functioning, family burden and QoL and disability with patient suffering from schizophrenia. 70 subjects from National Institute of Mental Health and Neuroscience gave informed consent. Inclusion criteria were (a) a primary diagnosis of DSM IV OCD/schizophrenia (b) continuous illness for the previous 2 year (c) Clinical Global Impression Severity (CGI-S) score of > 4 (d) availability of a primary care giver involved in patient care for 2 years Mini-international Neuropsychiatry Interview was conducted to confirm the diagnosis. Global Assessment of Functioning (GAF), World Health Organization (WHO-Quality of life (QOL)(BREF Version), WHO Disability Assessment Schedule-II (WHO-DAS-II). Family Burden Schedule (FBS) were used to assess global functioning, quality of life and disability. ANCOVA was employed with age of onset and duration of illness as covariate for comparison of family burden, QoL and disability between 2 groups. Pearson correlation between socio demographic/ clinical variable, family accommodation and functioning with family burden were performed. The results demonstrated that severe OCD is associated with significant impairment in functioning and severe family burden and disability. QoL was poor and severe OCD and schizophrenia are often associated with comparable disability, family burden and poor QoL.

Huppert et al., (2009) compared the QoL of OCD patients with functioning of matched healthy controls. They hypothesized that OCD patients in remission would report similar QoL and functioning matched healthy controls (HCs), while individuals with OCD would report poorer QoL and functional impairment. Additional prediction was that OCD patients and comorbid psychiatric disorder would report the worst QoL and functional impairment. Finally, Individuals with a history of OCD (current or past) increased severity of OCD would be related to decrease in QoL and increased functional impairment, even when controlling for depression. 66 comprised the current sample. 36 HCs were included. They were matched on age, sex and ethnicity. Structured clinical interview DSM-IV, Yale Brown Obsessive Compulsive Scale, the Hamilton Rating scale for Depression and Hamilton Rating Scale for Anxiety were used. Subjects also completed Quality of Life Enjoyment and Satisfaction Questionnaire. Social Scale-Self Report, Medical Outcome Study 36 items short form Health Survey and Sheehan Disability Scale was also administered. Four groups were formed on the basis of SCID and Y-BOCS responses (1)healthy controls with no history of psychiatric disorders (2) patient in remission not meeting OCD criteria (3) patient who met current SCID criteria for OCD only and (4) patient who met SCID criteria for OCD and another current Axis 1 psychiatric disorder (hereafter comorbid OCD). ANCOVA, Pearson, partial co relations and co relational analysis were conducted. The results showed that individuals with OCD without co morbidity both have significantly worse QoL and functioning than healthy controls. Level of functioning and QoL in individuals in remission tended to fall between that of healthy control and individuals with OCD only. In terms of severity of OCD and functional impairment, individuals with comorbid OCD were in moderate to severe range individual with OCD only were in mild to moderate range and OCD remission were in very mild range. QOL and Functional impairment was related to severity of OCD.

Yorulmaz (2007), suggested a comprehensive cognitive model for OCD symptoms. It was aimed to adapt three instruments to examine the interrelationships among the vulnerability factors and OCD symptoms in different cultures. Canadian sample consisted of 360 participants and Turkish sample consiste of 306 participants.The sample of the present study was composed of two different groups, namely nonclinical university student samples from Canada and Turkey. The instrument set of the current study was composed of the Demographic Information Form and nine self-report instruments namely Eysenck Personality Questionnaire-Revised & Abbreviated (EPQR-A), Religiousness Screening Questionnaire (RSQ), Rosenberg Self Esteem Scale (RSES), Interpretation of Intrusions Inventory (III), Obsessive- Compulsive Beliefs Questionnaire (OBQ), Thought-Action Fusion Scale (TAFS), Thought Control Strategies Questionnaire (TSQ), White Bear Suppression Inventory (WBSI), Responsibility Attitude Scale (RAS), Padua Inventory-Washington State University Revision (PI-WSUR). Pearson correlation coefficients were used for statistical analysis. The analysis revealed some cross-cultural similarities and differences in these factors and OCD symptoms. Neuroticism, age, introversion, OCD beliefs on responsibility/threat estimation, perfectionism/certainty and thought-action fusion in likelihood dimension were found to be associated with the OCD symptoms in both Turkish and Canadian samples. The relationship between non-specific, appraisal and control factors, and OCD symptoms were also significant in both samples. However, religiousness was only significant factor in OCD symptoms and contributed to several belief and control factors toward these symptoms, only for Turkish subjects. Besides, Turkish students seemed to utilize worry more for OCD symptoms; whereas, Canadian participants used self-punishment.

Prabhuet al., (2012) studied Symptom dimension in OCD and their association with Clinical characteristic and comorbid disorders. Dimensional-Yale-Brown Obsessive Compulsive Scale, WHO quality of life BREF and Global Assessment of Functioning scale was administered on 161 patients who met DSM-IV criteria for OCD. Finding indicated that aggression; sexual/religious dimensions were related with the onset of OCD symptoms. Sex, family size, severity of symptoms, insight, impaired functioning and physical quality of life was connected to fear of contamination.

Kim et al., carried out a research study in 2011 on depression mediate the relationship between obsessive-compulsive symptoms and eating disorder symptoms in an inpatients sample. The study estimated the role of depression in inpatients of eating disorder that explains the connection between eating disorder and OCD symptoms. 491 patients were included in study from eating disorder clinic with the primary diagnosis of eating disorder. Three measures were used: Eating Disorder Inventory-3, Yale-Brown Obsessive Compulsive Scale and Beck Depression Inventory -II. Structural Analyses Modeling was used to find out the interconnection between eating disorder, Obsessive Compulsive Disorder and depression symptoms. Results indicated that depression mediates the coalition between eating disorder symptoms and OCD symptoms.

Thus the literature review shows Cognitive Appraisal, severity of OCD symptoms and Quality of Life are interrelated. It is evident that the patient with OCD symptom will have poorer Quality of life and this will be further affected by the presence of any psychiatric co morbidity. Individual with OCD have anticipation of feared situations and they also experiences feelings of guilt, low self esteem, tiredness, and difficulty in making decisions. In such cases it may be difficult to separate Depression, anxiety and OCD. The patient in response to disturbing obsessions will develop symptoms of depression as well. Moreover depression may often result from the on-going distress caused by the problems at work and at home that are often associated with symptoms of OCD.

Indigenous Researches

An indigenous study was carried out by Saleem and Mahmood (2010) on social, cultural and clinical presentation of symptoms of obsessive compulsive disorder. This study involves three stages. During first stage semi structured interviews were carried out with twenty patients with firm diagnosis to elicit the presenting symptoms. For validation, frequency with which those symptoms occur and their relative importance was rated on four point scale by experience Clinical Psychologist. The results of this stage showed that Clinical psychologist regarded compulsion to be of more diagnostic importance than compulsions in OCD as well as they considered compulsion more common than obsession in OCD. In the final stage, a list comprising 36 symptoms along with measures of anxiety, depression and other OCD symptoms checklist from a subscale of Symptom checklist-R was given to 83 patients with OCD and 67 patients that were non OCD. The results showed that compulsions were reported to be similar to those already shown by other studies while social, cultural and religious background influence the content of obsessions. Moreover, the term Napak was another term used for dirt, impurity and germs.

Another study was conducted by Amin and Mahmood (2010) with an objective to explore relationship between Obsessive Compulsive symptoms of OCD and problems faced by the students. 208 (119 males and 89 females) graduating students age ranged 18 to 24 were included as the sample of the study through purposive sampling. Measures used were Obsessive Compulsive Symptom Checklist (OSCS) and Student Problem Checklist (SPCL). Result showed significant correlation between the two measures. 11.06% of students scored similar to the patient population on OSCS.

Another study was conducted by Chaudhry and Rahman (2002), investigated the demographic characteristics of Obsessive Compulsive Disorder and its co morbidity with depression with schizophrenia. The findings of this study suggest that depression was more associated with OCD than schizophrenia.

A study was conducted by Jabeen and Kausar (2008) on prevalence, symptomatology, phenomenology and etiology of Obsessive Compulsive Disorder in Punjab. This study had several objective including studying the prevalence of OCD, development of obsessive compulsive symptom checklist and finally to examine the expression of symptoms and phenomenology of OCD. To estimate the prevalence of OCD, three years records of psychiatry units of main teaching hospitals of Punjab province was taken. Depression was the most commonly occurring disorder in female and OCD being the 5th most occurring among anxiety disorders. Indigenous symptom checklist was developed in different phases. Principal Component Analyses indicated in 5 types of symptoms for obsessions and for compulsions. Reliability for this scale was found to be satisfactory. To meet the third objective that is to determine the manifestation and phenomenology of OCD in Pakistan. OCD symptom checklist was administered on 200 OCD patients. MANOVA and paired sample t-test was used as a statistical procedures. The results of this study were also discussed in socio and religious context.

Sadia and Sitwat (2006) conducted a study on role of family functioning in Development of Obsessive Compulsive Disorder. The qualitative study was carried out with an aim of investigating the role of perceived family functioning in the development of OCD. They also compare the family functioning between clinical and non-clinical participants and to contrast the healthy and unhealthy styles of family functioning that triggers the development of OCD. Phenomenological approach was used with Constructivist paradigm with 5 OCD patients and 5 healthy individuals age ranged 18 years. Purposive sampling was used and then symptom checklist-R was administered to screen out OCA or any other psychological disorder. In pilot study, in-depth interviews were conducted with was than transcribed in native language. Contrasting themes and common themes were established and were explained with respect to the literature and theory.

In 2010, Ghafoor and Mohsin conducted a study on relationship of religiosity, guilt, and self esteem in individuals having Obsessive Compulsive Disorder (OCD). Correlational research design was used and purposive sampling was used to include 200 (100 males and 200 females) OCD patients. 5 measures were administered including Clark-Beck Obsessive Compulsive Inventory, Religious Activity Scale, Rosenberg Self-esteem Scale and Guilt Assessment scale for Obsessive Compulsive Disorder. Descriptive analyses, correlational analysis and multiple regression analysis was used as statistical procedure. Findings resulted in a positive interaction between guilt score and OCD scores. Guilt regarding washing compulsions, checking compulsions and interpersonal conflicts were more prominent determinants of OCD.

Reviews of indigenous studies have investigated the variables of family functioning, comorbidities, religiosity and self esteem in studies done on Obsessive Compulsive disorder. There is a need to investigate Quality of life in relation to severity of symptoms and appraisal of illness stress. It was observed that limited research was conducted on Cognitive Appraisal and Symptom Severity as correlates of Quality of life in various areas of life. One indigenous study was conducted by Rasul and Farooqi (2009) that investigate whether there are gender differences in perceived quality of life of patient suffering from Obsessive Compulsive Disorders. Findings indicate impaired Quality of life with significant gender difference. Most of the studies did not consider some factors that have closer relevance for quality of life including length of illness, illness subtypes, number of symptoms, insight, etc. Along with them there is a lack of specific quality of life instruments for OCD used in these researches (Ritsner and Awad, 2007). In the light of these researches, there is a need to explore the dimensions of manifested Symptoms severity and cognitive appraisal in relation quality of life of patients of OCD.

Social and Clinical Significance

OCD is a debilitating mental disorder that greatly influences the individual life. It has an impact on the functionality of a patient that is in turn determined by the symptom severity and appraisal of the disorder cognitively. The study will provide the sufficient evidence of the contributing relation of symptoms severity and cognitive appraisal in exacerbating the functional impairment in patient's physical and psychological health, social relationships and environmental interaction. Literature showed that obsessive compulsive disorder is concurrent with disability, increased health care services, and economic problems. Therefore, it is important that certain types of cognitive appraisal in OCD affect the QOL. Moreover, the study will provide increase awareness unveiling the role of appraisal in the maintenance of the illness. Studying the role of belief and appraisal of obsession will help the professional to plan desired therapeutic treatment particular to the patient of OCD.

Objectives of the study

So the objectives of the present study are as follows:

To find out the relationship of Symptom Severity of OCD patients with Cognitive appraisal of OCD.

To investigate the relationship between Symptom severity of OCD and Physical, Psychological health, Social and Environmental related Quality of life of OCD patients.

To explore the relation of Cognitive Appraisal of OCD with physical, psychological health, Social and Environmental related Quality of life.

To explore the predicting relation between Symptom severity, Cognitive Appraisal and Quality of life.

Hypotheses

Patients having OCD with more Symptom Severity will have an impaired Cognitive Appraisal of obsessions and compulsions.

Patients having OCD with more Symptom Severity will have an impaired Quality of life.

Patients with negative Cognitive Appraisal will have an impaired Quality of life:

Sub Hypotheses

Higher the stress appraisal, lower will be the Quality of life.

Higher the threat appraisal, lower will be the Quality of life.

Higher the challenge appraisal, lower will be the Quality of life.

Higher the centrality appraisal, lower will be the Quality of life.

Higher the control by self appraisal, lower will be the Quality of life.

Higher the control by others appraisal, lower will be the Quality of life.

Higher the uncontrollability appraisal, lower will be the Quality of life.

Symptom severity and negative Cognitive Appraisal are likely to predict Quality of life of patients with OCD.

Method

Research Design

Correlational research design will be used in the present study.

Sampling

Purposive Sampling strategies will be used. Sample for study will consist of 90 patients with the diagnosis of Obsessive Compulsive Disorder, which is determined from G Power.

Inclusion Criteria

Inclusion criteria will be diagnosed patients of OCD with an age range of 18-55 years. Sample size will be 100 including both men and women with a primary diagnosis of OCD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2000), and are seeking treatment.

Exclusion Criteria

Patients who had severe co- morbid psychiatric and neurological disorders (i.e., psychosis, bipolar affective disorder, mental retardation) will be excluded from the study.

Operational Definitions

Symptom Severity is operationally defined as a scores measured on Obsessive Compulsive Disorder Symptom Checklist. Higher the score more is the severity of symptoms.

Cognitive Appraisal is operationally defined as a scores measured on Stress Appraisal Measure. Higher the score more is the negative appraisal of the symptoms.

Quality of life is operationally defined as a scores measured on World Health Organization Quality of Life- BREF. Lower scores means impaired Quality of Life.

Measures

Obsessive Compulsive Disorder Symptom Checklist (OCDSC)

Obsessive Compulsive Disorder Symptoms Checklist will be used to assess and evaluate the symptoms and phenomenology of OCD (Jabeen & Kausar, 2008). This scale consists of 102 items and items are scored on 5 point likert scale. It has 5 subscales including Obsessions, Compulsions, Thoughts/Fears and Apprehension leading to compulsive act, experience during compulsive acts and Perceived Consequences of the Compulsive act not performed. Obsessions and compulsions were shown to include 5 symptoms each. Reliability (internal consistency) for most of the scales is satisfactory (Jabeen & Kausar, 2008) (See Appendix A).

Stress Appraisal Measure (SAM)

Stress Appraisal Measures (SAM; Peacock & Wong, 1990) consists of 38 items and was originally designed to assess the cognitive appraisal of anticipatory stressors. It comprises of 7 subscales, which assess both primary and secondary appraisal as well as overall stressfulness, which are scored on 5 points likert scale (from not at all to extremely. The seven scales included are: stress, threat, challenge, centrality, control by self, control by other and uncontrollability. The overall stressfulessness of an encounter is assessed with stress scale 'treat' appraisal scale measures the extent to which a person feels threatened due to the expected negative outcome of a situation. In present study, translated Urdu version will be used which has already been translated by Kausar (2001) (See Appendix B).

World Health Organization Quality of Life (WHOQOL-BREF)

The WHOQOL-BREF, urdu version (The WHOQOL Group, 1998) will be used to assess the quality of life of OCD patients, It is a cross-culturally valid measure of QOL with good to excellent reliability and validity (Skevington, Lotfy & O'Connell, 2004). The brief scale consists of 26 items, five-point rating likert scale, and lower scores means poorer QOL. It provides measurement on four domains of QOL: physical (pain, energy, sleep, mobility etc.), psychological (positive and negative feelings, self-esteem etc.), social (relationships, social support, & sex) and environment (safety and security, finance, home environment, leisure etc.). In present research study, translated Urdu version will be used (See Appendix C).

Statistical Analyses

Pearson Product Moment Correlation Coefficient will be employed to find the relation between Symptoms Severity, Cognitive Appraisal and domains of Quality of life. Multiple Regression Analysis will be used to explore the predictor of Quality of life of patients with Obsessive Compulsive disorder.

Procedure

Initially in the study, permission for using the relevant tools will be taken from particular authors. After that, heads of different hospitals and institutions will be contacted and permission will be taken for data collection. The participant will be given brief introduction about the objective of the study and consent will be taken. The participants will be ensured about the confidentiality of the provided information and that it will use for academic purposes only. After that they will be given questionnaire to fill in the presence of researcher.

Ethical Considerations

The participants will be explained about the purpose and objective of the research study before hand. Informed consent will be taken and confidentiality will be ensured. Only those individuals will be included in the research that is willing to participate voluntarily.

Written permission will be taken from the organizations, institutes or hospitals in which study will be embarked upon.

Measure included in the research study will be used after taking formal written permission from the relevant authors.