Social Support and Symptom Severity Among Patients With Obsessive-Compulsive Disorder or Panic Disorder With Agoraphobia: A Systematic Review
Literature Reviews
Social Support and Symptom Severity Among Patients With Obsessive-
Compulsive Disorder or Panic Disorder With Agoraphobia: A Systematic
Review
Véronique Palardy a, Ghassan El-Baalbaki* ab, Catherine Fredette a, Elias Rizkallah c,
Stéphane Guay de
[a] Department of Psychology, Université du Québec à Montréal, Montreal, Canada. [b] Faculty of Medicine, McGill University, Montreal,
Canada. [c] Department of Sociology, Université du Québec à Montréal, Montreal, Canada. [d] School of Criminology, Université de
Montréal, Montreal, Canada. [e] Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada.
Abstract
Panic disorder with or without agoraphobia (PD/A) and obsessive-compulsive disorder (OCD) are characterized by major behavioral
dysruptions that may affect patients’ social and marital functioning. The disorders’ impact on interpersonal relationships may also affect the
quality of support patients receive from their social network. The main goal of this systematic review is to determine the association
between social or marital support and symptom severity among adults with PD/A or OCD. A systematic search of databases was executed
and provided 35 eligible articles. Results from OCD studies indicated a negative association between marital adjustment and symptom
severity, and a positive association between accommodation from relatives and symptom severity. However, results were inconclusive for
negative forms of social support (e.g. criticism, hostility). Results from PD/A studies indicated a negative association between perceived
social support and symptom severity. Also, results from studies using an observational measure of marital adjustment indicated a negative
association between quality of support from the spouse and PD/A severity. However, results were inconclusive for perceived marital
adjustment and symptom severity. In conclusion, this systematic review generally suggests a major role of social and marital support in
PD/A and OCD symptomatology. However, given diversity of results and methods used in studies, more are needed to clarify the links
between support and symptom severity among patients with PD/A and OCD.
Keywords: obsessive-compulsive disorder, panic disorder, agoraphobia, social support, marital adjustment, accommodation, expressed
emotion
Europe's Journal of Psychology, 2018, Vol. 14(1), 254–286, doi:10.5964/ejop.v14i1.1252
Received: 2016-07-23. Accepted: 2017-08-11. Published (VoR): 2018-03-12.
Handling Editors: Vlad Glăveanu, Department of Psychology, Webster University Geneva, Geneva, Switzerland; Steven Hertler, Psychology
Department, College of New Rochelle, New Rochelle, NY, USA
*Corresponding author at: Department of Psychology, Université du Québec à Montréal, C.P. 8888 Succursale Centre-Ville, H3C 3P8, Montréal,
Canada. E-mail: el-baalbaki.ghassan@uqam.ca
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Anxiety disorders are the most common psychiatric disorders (Antony, 2011), with a 4.5% prevalence in the
world population (Vos et al., 2012). Panic disorder (PD) is characterised by recurrent panic attacks and
persistent concern about the attacks or their consequences (APA, 2013). A disorder commonly diagnosed with
panic disorder is agoraphobia (A), which is anxiety about being in places or situations in which escape might be
difficult or help might not be available in case of an attack, and often lead to complete or partial avoidance of
the anticipated situations (APA, 2013). Obsessive-compulsive disorder (OCD) is characterised by recurrent
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obsessions (persistent and intrusive thoughts, ideas, impulses or images) that cause anxiety, and compulsions
(repetitive behaviors or mental acts) that are performed in order to prevent or decrease obsessions-related
anxiety (APA, 2013). Although OCD is not categorized as an anxiety disorder in the latest version of the DSM
(DSM-5; APA, 2013), anxiety is still considered one of its major components. Moreover, the present review
covers the time period when OCD definition was based on the criteria from the third and fourth versions of the
DSM (APA, 1980; APA, 1994), which still classified OCD as an anxiety disorder.
OCD and PD/A share common aspects in addition to anxiety. Indeed, these disorders both include major
behavioral disruptions that can heavily affect patients’ social and marital functioning (Markowitz, Weissman,
Ouellette, Lish, & Klerman, 1989). Researchers investigating the impact of mental disorders discovered that it
was distressing not only for the patients but for the family as well (Maurin & Boyd, 1990), which is partly caused
by caregiving responsibilities toward the affected person (Maurin & Boyd, 1990). It can thus be expected that
the relatives’ burden will affect the support that they provide to the suffering person. The following will present
different concepts that are of importance when assessing social support in relation to OCD and PD/A.
Social Support
Social support is defined as the process through which help is provided or exchanged with others in an attempt
to facilitate one or more adaptational goals (Cohen, Gottlieb, & Underwood, 2000). Social support is a complex
and multifaceted construct that can be broken down into different types. Cohen (1992) distinguishes between
perceived social support, received social support, and social networks. Perceived and received social support
both concern the quality of social support, whereas the assessment of social networks provides a more
quantitative description of social support. More specifically, perceived social support refers to the respondent’s
perception that his or her relationships will provide resources such as emotional support and information, and
can be assessed with self-report questionnaires or interviews. Received social support refers to supportive
behaviors that a person does to help another face stressful life events. This type of support is observed or
assessed in a more objective way, for example by asking if a specific supportive action has been performed
(Helgeson, 1993). Also, this measure does not take into account the perception of the person receiving or
providing the supportive behaviors. Although social networks provide information about the existence, quantity,
and types of social relationships, they appear to be less associated with wellbeing than are perceived and
received social support (Cohen & Wills, 1985). Indeed, many studies have shown a negative association
between quality of social support and psychological distress (Brown, Andrews, Harris, Adler, & Bridge, 1986;
Cramer, 1991; Krause, Liang, & Yatomi, 1989; Panayiotou & Karekla, 2013).
In addition to the different types of support mentioned above, there are two dimensions in social support:
positive and negative (Ray, 1992). Positive social support concerns positive attitudes and behaviors from one
person toward another, for example self-disclosure and validation (Pizzamiglio, Julien, Parent, & Chartrand,
2001; Ray, 1992). Manifestations of negative social support include irritation, frustration, critical comments,
conflicts, misunderstanding and negative pressure from others (Ray, 1992).
Marital Adjustment
Support can be provided by different sources. Although friends and family can provide emotional or
instrumental support, the spouse or partner is generally considered as the principal source of support (Boeding
et al., 2013; Brown & Harris, 1978; Caplan, 1974; Cutrona & Russell, 1990; Jacobson, Holtzworth-Munroe, &
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Schmaling, 1989). When looking at support between spouses or partners, marital adjustment is of interest. It
refers to the quality of the marital relationship and is comprised of four components: troublesome dyadic
differences, interpersonal tensions and personal anxiety, dyadic satisfaction and cohesion, and consensus on
matters of importance to marital functioning (Spanier, 1976). It is of note that marital adjustment is a concept
wider than marital support. However, given that most marital adjustment questionnaires assess some aspects
of marital support (for example “do you confide in your partner”), it cannot be disregarded when looking at
marital support. Also, results from El-Baalbaki and colleagues (2011) have shown that a higher level of marital
adjustment was associated with more displays of support and validation during a problem solving interaction
between spouses. Since marital adjustment seems to be associated with an observational measure of marital
support, it is likely that these two concepts share common aspects.
Expressed Emotion
It is known that psychiatric disorders cause distress and dysfunction for people suffering from them. However,
these conditions can also affect patients’ relatives and friends, who may develop negative attitudes toward the
patient. Expressed Emotion refers to emotions a relative expresses about a psychiatric patient (Chambless,
Bryan, Aiken, Steketee, & Hooley, 2001). This concept includes three dimensions: hostility, criticism and
emotional over-involvement. Emotional over-involvement can be described as intrusiveness, excessively self-
sacrificing behavior, or exaggerated emotional response to the patient’s illness (El-Baalbaki et al., 2011).
Criticism and hostility refer to critical comments and negative attitudes toward the patient about the disorder
and, as such, are manifestations of negative social support. Expressed Emotion is generally assessed during
an interview with the relative alone, the Camberwell Family Interview (CFI; Vaughn & Leff, 1976). It can also be
assessed with self-report measures, for example the Perceived Criticism Scale (PCS; Hooley & Teasdale,
1989) that assesses the relative’s level of criticism toward the patient, as perceived by the patient.
Accommodation
Family accommodation is a term used to describe the behavioral involvement of patients’ relatives in some
aspects of the disorder. An example would be the participation of a relative in the ritual of a patient suffering
from OCD. This concept is often used in studies of OCD relatives, since they appear to be more involved in
illness behaviors than relatives of patients with other mental disorders (Cooper, 1996). Studies have shown that
accommodation is performed by more than 88% of OCD relatives (Calvocoressi et al., 1995; Calvocoressi et
al., 1999; Stewart et al., 2008; Vikas, Avasthi, & Sharan, 2011) and that most of them accommodate on a daily
basis (Stewart et al., 2008). Although participation in patients’ rituals is a frequent form of accommodation,
relatives also accommodate by helping to avoid objects or places that exacerbate anxiety or by excessively
reassuring the patient about the obsessions (Calvocoressi et al., 1995).
Accommodation behaviors are generally aimed to support or help the person with OCD (Boeding et al., 2013)
and most relatives accommodate in order to decrease patients’ distress or anger (Calvocoressi et al., 1999). It
is thus considered as a positive and specific form of social support, because the supportive behaviors
specifically concern the symptoms of the disorder. However, accommodation might be associated with long-
term negative outcomes. Although it may decrease immediate patients’ distress, it could maintain OCD
symptoms by helping patients to avoid their anxiety, thus preventing them from becoming habituated to their
fear and confronting their irrational beliefs (Salkovskis, 1996).
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Accommodation is generally assessed with interviews or self-report questionnaires. The Family
Accommodation Scale (FAS; Calvocoressi et al., 1999) is the most used instrument to assess the level of family
accommodation and associated burden. It is a 12-item questionnaire administered by a clinician to relatives of
OCD patients. A self-rated version of the FAS was also recently developed (Pinto, Van Noppen, &
Calvocoressi, 2013).
Objectives and Hypotheses
The main objective of this systematic review is to assess whether social and marital support is associated with
severity of OCD and PD/A. It this hypothesized that positive social support will negatively correlate with severity
of the disorders, whereas negative social support will correlate positively with severity of the disorders.
Method
Selection of Articles
The search covered Pubmed, PsycNET Proquest, CINAHL, Embase, ISI, SCOPUS, Cochrane databases, from
January 1 1980 to June 30 2014, for articles concerning the association between social/marital support and
severity of OCD or PD/A symptoms before any treatment. It has been decided to select articles published since
1980 given that anxiety disorders were officially recognized for the first time in the third version of the DSM
(DSM-III; (APA, 1980), which was published in 1980. The generic query used was ("social support" OR
accommodation OR "Expressed Emotion" OR spousal OR marital OR couple) AND ("panic disorder*" OR
agoraphobia OR "obsessive-compulsive disorder*"). An independent search was also done in April 2016 to look
for articles released since June 2014. All databases mentioned above were covered and the same generic
query was used for the independent search.
Inclusion/Exclusion Criteria
Eligible articles included any article in any language published in final form, even if the abstract was not
available in English, and that assessed the association between social/marital support and severity of OCD or
PD/A symptoms. Included studies were published after December 30 1979 and conducted among adult
participants (18 years and over) with a primary diagnosis of OCD or PD/A. When possible, search limitations
were set in order to only include articles dating from 1980 with participants aged 18 years and over. When this
was not possible, manual selection was carried out. Any type of study was included, except case report studies.
Finally, included studies measured severity of OCD or PD/A symptoms as well as social/marital support with
self-reported questionnaires, observational instruments, or interviews by independent assessors.
Selection Procedure
Two independent reviewers screened the studies for eligibility. If the title, abstract or keywords of the article
contained clear indications that social or marital support was assessed, a full text review of the article was
conducted. Any disagreement on eligibility of articles between reviewers after full text review was resolved by
consensus after consultation with a third independent reviewer. Inter-rater reliability between the two
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independent correctors after full text review was 97% (171/177). For the remaining six articles, a consensus
was reached between the reviewers (three were included and three were excluded).
Results
The electronic database search provided 4011 articles, from which 2010 duplicates were removed. The other
2001 articles were screened by title, abstract and keywords, and this first selection led to the removal of 1826
articles. Two articles were impossible to retrieve (authors’ contacts could not be found; Cohen, 1986; Kitch,
1983), which led to 173 articles that went through a full text review. Among these articles, 148 were written in
English, six in Chinese, six in German, four in French, three in Italian, two in Portuguese, one in Japanese, one
in Korean, one in Turkish, and one in Dutch. Finally, 30 of these articles were included in the present review.
Results from the independent search led to the inclusion of three other articles, for a total sample of 33 articles.
Reasons for exclusion of the remaining 143 articles are described in Table 1. The article selection is described
in detail in Figure 1.
Figure 1. Article selection following each step.
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Table 1
Reasons for Exclusion of 143 Articles After Full Text Review
Association not assessed between social or marital support and PD/A or OCD severity at pretreatment (Number of excluded articles: 71)
(Abramowitz et al., 2013; Albert, Brunatto, Aguglia, et al., 2009; Almasi, Akuchekian, & Maracy, 2013; Arnow, Taylor, Agras, & Telch, 1985; Arrindell &
Emmelkamp, 1986; Barlow, Mavissakalian, & Hay, 1981; Barlow, O’Brien, & Last, 1984; Batinić, Trajković, Duisin, & Nikolic-Balkoski, 2009; Beekman et al.,
1998; Byrne, Carr, & Clark, 2004; Cerny, Barlow, Craske, & Himadi, 1987; Chambless, Blake, & Simmons, 2010; Chambless, Bryan, Aiken, Steketee, &
Hooley, 1999; Chambless & Steketee, 1999; Cheng, Jiang, & Du, 1998; Chernen & Friedman, 1993; Craske, Burton, & Barlow, 1989; Daiuto, 1996; De
Berardis et al., 2008; El-Baalbaki, Bélanger, Perreault, Fredman, & Baucom, 2010; Emmelkamp, 1980; Emmelkamp, de Haan, & Hoogduin, 1990;
Emmelkamp & de Lange, 1983; Emmelkamp et al., 1992; Emmelkamp & Gerlsma, 1994; Fauerbach, 1992; Ferrão et al., 2006; Fisher, 1983; Fisher &
Terence Wilson, 1985; Friedman, 1990; Fukada, 2010; Grunes, 1998; Hafner, 1984; Himadi, Cerny, & Barlow, 1986; Hou, Yen, Huang, Wang, & Yeh, 2010;
Huang, Li, Han, & Xiong, 2013; Jansson, Öst, & Jerremalm, 1987; Katerndahl, 2000; Katerndahl & Realini, 1997b; Keijsers, Hoogduin, & Schaap, 1994a,
1994b; Kleiner & Marshall, 1987; Koujalgi, Nayak, Patil, & Chate, 2014; Lebowitz, Panza, Su, & Bloch, 2012; Lelliott, Marks, Monteiro, Tsakiris, & Noshirvani,
1987; Löhr, Schewe, Baudach, & Hahlweg, 2003; Mannetter, 1989; Marchand et al., 1985; Marchand, Boisvert, Baudry, Berard, & Gaudette, 1984; McCarthy
& Shean, 1996; Nauta, Batelaan, & Van Balkom, 2012; Oatley & Hodgson, 1987; Omranifard, Akuchakian, Almasi, & Maraci, 2011; Pace, Thwaites, &
Freeston, 2011; Peter et al., 1998; Pyke & Roberts, 1987; Renshaw, 2003; Renshaw, Chambless, & Steketee, 2006; Simon, 1988; Smith, Friedman, & Nevid,
1999; Steketee, 1987, 1993; Steketee & Chambless, 2001; Svanborg, Bäärnhielm, Åberg Wistedt, & Lützen, 2008; Telfer, 1991; Thorpe, Freedman, & Lazar,
1985; Torres, Hoff, Padovani, & Ramos-Cerqueira, 2012; Turgeon, Marchand, & Dupuis, 1998; Van Minnen & Kampman, 2000; Yen et al., 2007; Young, 1997)
No valid measure of social support (Number of excluded articles: 9)
(Addis et al., 2004; Bond & Guastello, 2013; Franklin, 1989; Hafner, 1983, 1988; Shandley et al., 2008; Tynes, Salins, Skiba, & Winstead, 1992; Xia & Hai-Yin,
2004; Yan & Cui, 2003)
No valid measure of PD/A or OCD severity (Number of excluded articles: 29)
(Albert, Maina, Saracco, & Bogetto, 2006; Chambless et al., 2001; Chambless, Floyd, Rodebaugh, & Steketee, 2007; Green, Grace, Lindy, Gleser, & Leonard,
1990; Katerndahl & Realini, 1997a; Korostil & Feinstein, 2007; Lincoln et al., 2010; Ma, Zhao, & Luo, 2007; Marchesi et al., 2014; Markowitz et al., 1989;
Maulik, Eaton, & Bradshaw, 2010; McLeod, 1994; Murphy, Michelson, Marchione, Marchione, & Testa, 1998; Panayiotou & Karekla, 2013; Pankiewicz,
Majkowicz, & Krzykowski, 2012; Préville et al., 2010; Priest, 2013; Renshaw, Chambless, & Steketee, 2001; Renshaw, Chambless, Rodebaugh, & Steketee,
2000; Renshaw, Chambless, & Steketee, 2003; Simmons, Gordon, & Chambless, 2005; Staebler, Pollard, & Merkel, 1993; Steketee, Lam, Chambless,
Rodebaugh, & McCullouch, 2007; Takeuchi et al., 1997; Vázquez, Torres, Otero, & Díaz, 2011; Wang & Zhao, 2012; Whisman, 2007; Wood, Salguero, Cano-
Vindel, & Galea, 2013; Xu, Zhao, Li, & Lü, 2000; Zaider, Heimberg, & Iida, 2010)
Not an adult sample (Number of excluded articles: 2)
(Amir, Freshman, & Foa, 2000; Grunes, Neziroglu, & McKay, 2001)
No clinical PD/A or OCD (for the whole sample or part of the sample) (Number of excluded articles: 10)
(Amazonas, Arcoverde, Caldas, & da Silva, 2010; Bland & Hallam, 1981; Brown, Harris, & Eales, 1993; Gomes et al., 2010; Kenardy, Heron-Delaney,
Bellamy, Sterling, & Connelly, 2014; Kong, 2008; Landman-Peeters et al., 2005; Pinto, Van Noppen, & Calvocoressi, 2013; Powers, 1984; Sochos, 2014)
Comprehensive review (Number of excluded articles: 19)
(Bressi & Guggeri, 1996; Cobb, 1982; Côté & Gauthier, 1988; Craske & Zoellner, 1995; Fokias & Tyler, 1995; Friedman & Paradis, 2002; Goldfarb, Trudel,
Boyer, & Preville, 2007; Gore & Carter, 2001; Hand, 2000; Jackson & Wenzel, 2002; Jacobson, Holtzworth-Munroe, & Schmaling, 1989; Kleiner & Marshall,
1985; Marcaurelle, Bélanger, & Marchand, 2003; Marchand, Comeau, & Trudel, 1994; Mester, 1981; Rohrbaugh & Shean, 1988; Shean, 1990; Vandereycken,
1983; Wilson, 1984)
Case report (Number of excluded articles: 2)
(Hafner, 1982; Holmes, 1982)
Not a study (treatment guide) (Number of excluded articles: 1)
(Van Noppen & Steketee, 2003)
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Support and OCD Severity
The Association Between OCD Severity and Marital Adjustment
Two studies looked at the association between marital adjustment and OCD. In 2006, Abbey conducted a study
in order to examine romantic relationship functioning in individuals with OCD. The results indicated that
relationship satisfaction negatively correlated with the obsessing (r = -.26, p < .05) and positively correlated with
the neutralizing (r = .26, p < .05) subscales of the Obsessive-Compulsive Inventory, Revised (OCI-R). Self-
disclosure, which is an index of positive social support, negatively correlated with the obsessive subscale of the
OCI-R (r = -.30, p < .05). Moreover, the obsessive subscale also negatively correlated with the emotional
subscale (“my partner listens to me when I need someone to talk to”) of the Personal Assessment of Intimacy in
Relationship (PAIR; Schaefer & Olson, 1981; r = -.27, p < .05). No other significant associations between
measures of marital adjustment and OCD severity were found. Riggs, Hiss, and Foa (1992) also looked at the
link between marital distress and OCD symptom severity. The results indicated a significant negative
correlation between marital adjustment and avoidance of the situation related to the main obsession (r (50) =
-.28, p < .05), as rated by an independent assessor, but not between marital adjustment scores and ratings of
main obsessions (r (52) = -.04, p > .70) or rituals (r (52) = .06, p > .65). For a summary of these results, see
Table 2.
Table 2
Description of Studies Examining the Association Between Marital Adjustment and OCD
Author(s) Year Participants
Patients’
gender
Diagnostic
measure
Measure(s) of
severity
Measure(s) of
marital
adjustment Results
1 Abbey 2006 64 OCD patients 25 men,
39 women
OCI-R (cut-off
score of 4 on the
Obsessing
scale)
OCI-R PAIR, SDI, and
RAS
Relationship satisfaction (RAS) correlated with the
obsessing (-.26, p <.05) and neutralizing (.26, p < .05)
subscales of the OCI-R. Self-disclosure correlated with
the obsessing subscale of the OCI-R (-.30, p < .05). All
subscales of the PAIR correlated significantly with the
obsessive subscale of the OCI-R.
2 Riggs, Hiss, &
Foa
1992 54 OCD patients 20 men,
34 women
NS Assessor rating LWMAT Significant correlation between LWMAT and the assessor
rating of avoidance (r (50) = -.28, p < .05), but not
between LWMAT scores and ratings of main obsession (r
(52) = -.04, p > .70) or ritual (r (52) = .06, p > .65).
Note. OCI-R = Obsessive-Compulsive Inventory-Revised; PAIR = Personal Assessment of Intimacy in Relationships; RAS = Relationship
Assessment Scale; SDI = Self Disclosure Index.
The Association Between OCD Severity and Accommodation
Seventeen studies examined the association between accommodation and OCD. All but one study (Drury,
Ajmi, de la Cruz, Nordsletten, & Mataix-Cols, 2014) found a significant association between the level of
accommodation by the relatives and the severity of OCD. All of them (except for Drury et al., 2014) used the
Family Accommodation Scale (FAS) and the Yale-Brown obsessive-compulsive scale (Y-BOCS), which renders
them easily comparable. Given that some studies used the same sample (Albert et al., 2010; Albert, Brunatto,
Maina, & Bogetto, 2009; Van Noppen & Steketee, 2009; Van Noppen, 2003), results are combined in the
presentation of the data.
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Many studies found a significant positive correlation between accommodation and total scores on the measure
of obsessive-compulsive disorder severity (Boeding et al., 2013; Calvocoressi et al., 1999; Cherian, Pandian,
Bada Math, Kandavel, & Reddy, 2013; Cherian, Pandian, Bada Math, Kandavel, & Janardhan Reddy, 2014;
Ferrão & Florão, 2010; Gomes et al., 2014; Ramos-Cerqueira, Torres, Torresan, Negreiros, & Vitorino, 2008;
Stewart et al., 2008; Vikas et al., 2011; Wu, Pinto, et al., 2016), meaning that the more accommodation
provided by the relatives, the more severe the OCD symptoms.
Some authors also found significant association between specific areas of accommodation and symptoms of
OCD. Indeed, Vikas and colleagues (2011) found that participation in rituals was correlated with the level of
obsessions (r = .52, p < .01) and compulsions (r = .54, p < .01). Some results demonstrated that the level of
accommodation was associated with contamination/cleaning compulsions (r = .18, p = .03, Albert et al., 2010; r
= .26, p = .007, Stewart et al., 2008). Also, Albert and colleagues (Albert, Brunatto, Maina, & Bogetto, (2009;
Albert et al., 2010) found that accommodation total scores were significantly correlated with obsessions (r
= .21, p = .013) but not compulsions (r and p are not available in the original article). However, results from
Beoding’s study (2013) indicated a significant positive correlation between accommodation and severity of
compulsions (r = .39, p < .05) but not with severity of obsessions (r = .26, p > .05), which contradicts results
obtained by Albert and colleagues (2010).
Other authors also found that accommodation by the family could predict the severity of OCD symptomatology.
Indeed, Van Noppen and Steketee (2003, 2009) reported that the level of accommodation, as rated by patients,
predicted OCD severity in regression analyses (b = 0.47, p < .01, partial correlation = .42, R2change = .16, p
> .01). Accommodation was also predictive of OCD severity when rated by relatives (b = 0.50, p < .01, partial
correlation = .46, R2change = .20, p > .01). Accommodation alone as rated by patients and relatives explained
16 and 20%, respectively, of the symptom severity (F (1,44) = 9.19, p < .01; F (1.44) = 11.7, p = .001). They
also found that among many factors (e.g. relatives’ attributions, emotional over-involvement, and criticism),
accommodation was the strongest predictor of OCD severity, explaining 42% of the variance (direct causal
effects .42, p < .05). On the other hand, other authors found that OCD symptomatology could predict
accommodation behaviors among the relatives. For example, Stewart and colleagues (2008) reported
significant correlations between OCD severity and cleaning/contamination symptoms (r = .26, p = .007). When
entered in a stepwise regression analysis, these factors remained significant. Similarly, Albert and colleagues
(2010) also entered the significant factors in a regression analysis and reported that a higher FAS total score
was predicted by the contamination/cleaning symptom dimension score (β = 0.22, t = 2.87, p = .005).
The only study that found negative results is the one by Drury and colleagues (2014). They conducted a study
on hoarders and their relatives in order to assess the impact of hoarding on functioning as well as burden for
the relatives. They used a different measure, the Family Impact Scale for Hoarding disorder (FISH), in order to
assess both the level of family accommodation displayed by the relatives and the associated burden. The
results indicate that hoarding severity did not predict FISH scores (b = 0.20, t = 1.33, p = .190).
Finally, two recent meta-analyses investigated the association between family accommodation and OCD
severity. In Strauss, Hale, and Stobie (2015), results from 14 studies (seven with adults and seven on pediatric
OCD) showed a statistically significant medium effect size (r = .35, 95% CI [.23, .47]), so that family
accommodation accounts for approximately 12% of the variance in OCD symptom severity. In Wu, McGuire, et
al. (2016), 41 studies on accommodation and OCD severity were included. Among those studies, 15 were on
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adults with OCD. Results showed a medium positive effect (r = .42, 95% CI [.36, .47], z = 13.00, p < .001),
which indicates that higher OCD severity is associated with increased family accommodation. Also, there was
no significant difference by categorical age groups (Q(1)btwn = 1.36, p = .24) and no significant effect when
examining participant mean age (β = -0.002, SE = .003, z = -0.82, p = .41). This suggests that the association
between family accommodation and OCD severity is similar whether participants are adults or children. For a
summary of these results, see Table 3.
Table 3
Description of Studies Examining the Association Between Accommodation and OCD
Author(s) Year Participants
Patients’
gender
Diagnostic
measure
Measure(s) of
severity
Measure(s) of
accommodation Results
1 Albert, Brunatto,
Maina, & Bogetto
2009,
2010
97 OCD
patients and
141 relatives
49 men,
48 women
SCID-I Y-BOCS FAS FAS and Y-BOCS total scores were positively
correlated. FAS total score was significantly correlated
with Y-BOCS obsession subscale.
2 Boeding 2013 20 OCD
patients and
their partner
1 man,
19 women
MINI Y-BOCS FAS FAS and Y-BOCS total scores were positively correlated
(.39, p < .05). FAS total score was significantly
correlated with Y-BOCS compulsion subscale (.39, p
< .05).
3 Calvocoressi et al. 1999 36 OCD
patients and
36 relatives
19 men,
17 women
Evaluation by a
psychiatrist
Y-BOCS FAS FAS and Y-BOCS total scores were positively correlated
(r = .49, p < .003, n = 34).
4 Cherian, Pandian,
Badamath, Kandavel,
&
Reddy
2013 100 OCD
patients and
their primary
caregiver
57 men,
43 women
NS Y-BOCS FAS FAS and Y-BOCS total scores were positively
correlated.
5 Cherian, Pandian,
Badamath, Kandavel,
& Reddy
2014 94 OCD
patients and
their primary
caregiver
52 men,
42 women
MINI CGI and Y-
BOCS
FAS Y-BOCS total scores (r = .30, p < .01) and CGI (r = .34,
p < .001) were correlated with FAS total scores.
6 Drury, Ajmi, de la
Cruz, Nordsletten, &
Mataix-Cols
2014 41 OCD
patients
(hoarding
disorder) and
60 relatives
with hoarding
9 men,
32 women
SIHD HRS-SR FISH OCD severity did not predict FISH scores (b = 0.20, t =
1.33, p = .19)
7 Ferrão & Florão 2010 47 OCD
patients and
47 relatives
22 men,
25 women
SCID-I Y-BOCS FAS FAS and Y-BOCS total score (.71, p < .001, n = 45)
8 Gomes et al. 2014 114 OCD
patients and
114 relatives
43 men,
71 women
SCID-I CGI, OCI-R,
and Y-BOCS
FAS-IR Positive correlations (spearman) between FA and Y-
BOCS obsessions (r = .28, p = .002), compulsions (r
= .26, p = .005) and total scores (r = .30, p = .001).
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Author(s) Year Participants
Patients’
gender
Diagnostic
measure
Measure(s) of
severity
Measure(s) of
accommodation Results
Positive correlation between FA and CGI (r = .34, p
< .001).
9 Ramos-Cerqueira,
Torres, Torresan,
Negreiros, & Vitorino
2008 50 OCD
patients and
50 caregivers
22 men,
28 women
NS Y-BOCS FAS Positive correlation between Y-BOCS and FAS total
scores (r = .26, p < .001).
10 Stewart et al. 2008 110 OCD
patients and
110 relatives
58 men,
52 women
Assessment by
both a
psychiatrist and
a behavior
therapist
Y-BOCS FAS Y-BOCS and FAS total scores were positively correlated
(r = .35, p = .0003). FAS was associated with cleaning/
contamination compulsions (r = .26, p = .007)
11 Strauss, Hale, &
Stobie (meta-analysis)
2015 14 included
studies (7 on
adult OCD)
849 OCD
patients and
849 relatives
38% to 57%
female
DSM-IV criteria,
Y-BOCS (score
16+), DCR-10
Y-BOCS FAS The medium effect size was significant (r = .35; 95%
CI: .23 to .47). Family accommodation accounts for
approximately 12% of the variance in OCD symptom
severity.
12 Van Noppen &
Steketee
2003,
2009
50 OCD
patients and
50 relatives
23 men,
27 women
SCID-I Y-BOCS FAS FA made the largest contribution in the model,
explaining 42% of the variance in OCD severity (direct
causal effects .42, p < .05).
13 Viskas, Avasthi, &
Sharan
2011 32 OCD
patients and
32 relatives
NS (Majority
of patients
were male)
DCR-10 Y-BOCS FAS Participation in rituals was positively correlated with Y-
BOCS obsession (r = .52, p < .01), compulsion (r = .54,
p < .01) and total score (.55, p < .01). Total FA was
positively correlated with all subscales of the Y-BOCS
(obsession: r = .49, p < .01; compulsion: r = .50, p < .01;
total: r = .51, p < .01).
14 Wu et al. 2016 61 OCD
patients and
54 relatives
(18 were
spouses)
27 men,
34 women
Clinical
consensus
between
researcher and
psychologist
Y-BOCS, CGI FAS-PV FA, as perceived by patients, correlated positively with
Y-BOCS (r = .37, p < .01) and CGI (r = .53, p < .001).
15 Wu et al. (meta-
analysis)
2016 41 included
studies (15 on
adult OCD)
2509 OCD
patients
50% female NS NS NS The random effects meta-analysis identified a medium
positive effect, (r = .42, 95% CI [.36, .47], z = 13.00, p
< .001).
Note. CGI = Clinical Global Impression; DCR = ICD-10 Diagnostic Criteria for Research; FA = Family Accommodation; FAS = Family
Accommodation Scale; FAS-IR = Family Accommodation Scale-Interviewer Rated; FAS-PV = Family Accommodation Scale-Patient
Version; FISH = Family Impact Scale for Hoarding Disorder; HRS-SR = Hoarding Rating Scale-Self Report; MINI = Mini-International
Neuropsychiatric Interview; OCI-R = Obsessive Compulsive Inventory- Revised ; SCID-I = Structured Clinical Interview for DSM-IV Axis I
disorders; SIHD = Structured Interview for Hoarding Disorders; Y-BOCS = Yale-Brown Obsessive Compulsive Scale.
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The Association Between OCD Severity and Expressed Emotion
Three studies were interested in the association between OCD severity and Expressed Emotion, with one of
them demonstrating a significant association. Indeed, Cherian and colleagues’ (2014) results indicate that
perceived criticism was associated with OCD severity as measured by the Y-BOCS (r = .24, p < .01) and the
Clinical Global Impression (CGI; r = .27, p < .01). Finally, Van Noppen and Steketee (2003, 2009) found no
significant association between Expressed Emotions variables (criticism, hostility, emotional over-involvement)
and OCD severity, when rated by patients or relatives. When accommodation of the family was entered in the
model, criticism lost its significance (Van Noppen & Steketee, 2003, 2009). See Table 4 for a summary of the
results.
Table 4
Description of Studies Examining the Association Between Expressed Emotion and OCD
Author(s) Year Participants
Patients’
gender
Diagnostic
measure
Measure(s) of
severity
Measure(s) of
Expressed
Emotion Results
1 Cherian,
Pandian,
Badamath,
Kandavel, &
Reddy
2014 94 OCD patients
and their primary
caregiver
52 men,
42 women
MINI CGI and Y-
BOCS
FEICS (patient
rated)
Perceived criticism (FEICS) was associated with Y-
BOCS total score (r = .24, p < .01) and CGI (r = .27, p
< .01).
2 Van Noppen &
Steketee
2003
2009
50 OCD patients
and 50 relatives
23 men,
27 women
SCID-I Y-BOCS IRQ, LEE, PCM,
PRS, and RRQ
No significant association between EE variables
(criticism, hostility) and OCD severity, when EE was
rated by patients or relatives.
Note. BAT = Behavioural Avoidance Test; CFI = Camberwell Family Interview; CGI = Clinical Global Impression; FEICS = Family Emotional
Involvement and Criticism Scale; IRQ = Influential Relationships Questionnaire; LEE = Level of Expressed Emotion Scale; MINI = Mini-
International Neuropsychiatric Interview; PCM = Perceived Criticism Measure; PRS = Patient Rejection Scale; RRQ = Relative’s Reaction
Questionnaire; SCID-I = Structured Clinical Interview for DSM-IV Axis I disorders; SCID-P = Structured Clinical Interview for DSM-III-R –
Patient version; TSR = Target Symptom Ratings
Support and PD/A Severity
The Association Between PD/A Severity and Social Support
Three studies looked at the link between PD/A and social support, with two of them demonstrating that the level
of support is associated with the severity of PD/A symptoms. Huang and colleagues (2010) developed a
structural equation model in order to investigate the effects of social support on panic and agoraphobic
symptoms as well as suicidal ideation. They found that social support influenced panic symptoms (negative
association, -.47), which then influenced agoraphobic symptoms (χ 28 = 3.53; AGFI = 0.95; p = .897). Smith
(1998) found a significant negative correlation between the size of support (number of friends) and the
frequency of panic attacks (r (66) = -.25, p = .04) in a sample of African Americans. Although social support
appraisal did not predict agoraphobia in a regression analysis, the authors did find a significant negative
correlation between the two variables (r = -.27, p < .05). However, they did not find a link between social
support appraisal and severity of panic symptoms.
Renneberg, Chambless, Fydrich, and Goldstein (2002) conducted a study in order to investigate affect balance
in dyads of patients and their relatives and its association with outcome following cognitive behavioral therapy.
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Given that the relatives were nine parents and 26 spouses, this study was included under both social and
marital support (see paragraph below). In order to assess the level of affectivity in their sample, the authors
used an observational measure, which assesses both verbal and non-verbal behaviors in an interaction
between partners. Based on these observations, they separated the group between affect-balanced and affect-
unbalanced dyads. The authors found that the two groups did not differ on pre-treatment scores of measures of
agoraphobia and panic (t-tests p > .17 for all measures), which means that the quality of the interaction during
a problem-solving task between partners was not associated with symptoms severity. Refer to Table 5 for a
summary of these results.
Table 5
Description of Studies Examining the Association Between Social Support and PD/A
Author(s) Year Participants
Patients’
gender
Diagnostic
measure
Measure(s) of
severity
Measure(s) of
social support Results
1 Huang, Yen, &
Lung
2010 60 PDA patients 30 men,
30 women
MINI PASC SSS Social support was a direct protector of panic symptoms
(-.47), but not agoraphobic symptoms
2 Renneberg,
Chambless,
Fydrich, &
Goldstein
2002 35 PDA patients
and 35
significant others
(26 spouses, 9
parents)
12 men,
23 women
SCID-I MIA KPI Groups of affect-balanced versus affect-unbalanced
dyads did not differ at pretreatment on measures of
agoraphobia and panic (t-tests, all ps > .17)
3 Smith 1998 81 PDA patients 7 men,
74 women
ADIS-IV BSQ, FQ, and
MIA
SSAS and SSRS Significant correlation between size of support – friends
and frequency of panic/month (r (66) = -.25, p = .04).
Note. ADIS-IV = Anxiety Disorder Interview for DSM-IV; BSQ = Body Sensations Questionnaire; FQ = Fear Questionnaire; KPI =
Kategoriensystem für Parnerschaftliche Interaktion (interaction coding system); MIA = Mobility Inventory for Agoraphobia; MINI = Mini-
International Neuropsychiatric Interview; PASC = Panic and Agoraphobic Symptoms Checklist; SCID-I = Structured Clinical Interview for
DSM-III-R; SSS = Social Support Scale; SSAS = Social Support Appraisals Scale; SSRS = Social Support Resources Scale.
The Association Between PD/A Severity and Marital Adjustment
Eleven studies evaluated the link between marital adjustment and the severity of either panic disorder and\or
agoraphobia. Authors reported mixed results. Since authors did not all use the same measure of marital
adjustment, results will be presented by the type of measure utilized in order to compare similar articles. It is
thus possible that one study gets described in several places due to its use of multiple questionnaires.
Self-report measures — Three studies used the Maudsley Marital Questionnaire (MMQ) or its modified
version (MMMQ) as a measure of marital adjustment. More specifically, the MMQ assesses three domains:
marital adjustment, sexual adjustment and general life with the partner (e.g. domestic task, social activity).
None of the studies found a significant correlation between marital adjustment and panic or agoraphobia
symptoms. Indeed, Arrindell, Emmelkamp, and Sanderman (1986) found no significant correlation between the
MMQ marital scale and severity, as assessed by the Fear Questionnaire (FQ) and an observation of phobic
anxiety and avoidance by both the therapist and an independent observer (Watson & Marks, 1971; p > .02 for
all measures (Bonferroni adjustment)). Cobb, Mathews, Childs Clarke, and Blowers (1984) evaluated whether
integrating the spouse as a co-therapist would enhance the outcome of a behavioural therapy for agoraphobia.
The authors found that there was no association between initial severity of marital problems, as assessed by
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the MMMQ, and the severity of agoraphobia. However, no statistics were presented for this result. Monteiro,
Marks, and Ramm (1985) also used the MMMQ and found that at pre-treatment, there was no significant
difference in agoraphobic symptoms, as assessed by the FQ, between participants qualified as being in a
“good” versus a “less good” marriage (p > .05). Although not explicitly reported by the authors of the original
study, the authors of the present review based their results on graphs presented in the original study.
Chambless (1985) used the Marital Dissatisfaction Questionnaire (MDQ), which is a five-item questionnaire that
assesses the discrepancy between the respondent’s perception of his/her actual and ideal spouse. The author
did not find any significant correlations between the level of marital dissatisfaction and severity of agoraphobia
(r = .10, p > .05) or frequency of panic attacks (r = -.10, p > .05).
Marcaurelle, Bélanger, Marchand, Katerelos, and Mainguy (2005) were interested to see the effects of marital
conflicts and adjustment on severity of PDA. They used the Dyadic Adjustment Scale (DAS), which is a
measure that assesses four areas of marital adjustment: cohesion, consensus, satisfaction and affection. Their
results demonstrate that patients with PDA who demonstrated lower levels of marital adjustment had more
frequent catastrophic thoughts (r = -.048, p < .0001) as well as stronger fear of bodily sensations (r = -.33; p
< .007) and fear of consequences of anxiety (r = -.46, p < .002). No significant correlation was found between
PDA total clinical severity and marital adjustment. El-Baalbaki and colleagues (2011) were also interested in
marital interactions as a predictor of panic and agoraphobia symptom severity. Comparable to the results of
Marcaurelle and colleagues (2005) described above, they found significant negative correlations between DAS
and catastrophic thoughts (r = -.46, p < .01), fear of bodily sensations (r = -.31, p < .05), and fear of
consequences of anxiety (r = -.49, p < .01). However, Peter, Hand, and Wilke (1993) found no association
between agoraphobic severity, as measured by the FQ, and DAS scores.
In their study, Lange and Van Dyck (1992) utilized the Interactional Problem Solving Inventory (IPSI), which is a
self-report questionnaire that measures the extent to which partners are satisfied with their problem-solving
abilities. They did not find any significant correlation between relationship quality and agoraphobic severity
before treatment, except for the avoidance of busy streets subscale of the FAS-IR (r = -.29, p < .10). However,
the significance level was set at .10 and there is no mention of whether or not the test was one-tailed or two-
tailed.
Finally, Tukel (1995) divided his 45 participants with PDA into three subgroups, those of housewives, working
women, and working men. Participants were assessed on severity of PDA (FQ) and quality of marital
relationship (MMQ). Results indicated a significant positive correlation between severity of PDA and quality of
marital relationship for housewives (r = .61, p = .04). No significant correlations were found for the other
subgroups (r = .15, p > .05 for working women; r = .10, p > .05 for working men).
Observational measures — Two studies included an observational measure of the interaction between
patients and their relatives. Chambless and colleagues (2002) were interested in the marital interaction
between couples in which one partner has PDA and a control group. They used the Kategoriensystem für
Parnerschaftliche Interaktion (KPI), which is a system used to code a problem-solving interaction between two
partners. During analysis of the interaction, each meaningful unit of speech is assigned a verbal and non-verbal
code (e.g. positive, negative, or neutral). The authors found that panic frequency was not significantly related to
any self-reported marital variables. However, they demonstrated that husbands whose wives were more
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avoidant engaged in a higher rate of negative verbal behavior (r = .44, p < .006) and were more critical (r = .35,
p < .031) during the problem-solving interaction. The Renneberg and colleagues’ study (2002), described in a
section above, also used the KPI. They did not find a significant difference between marital adjustment and
severity of panic or agoraphobic symptoms.
El-Baalbaki and colleagues (2011) used a different observational measure, the Global Couple Interaction
Coding System (GCIS). It also evaluates partners during a problem-solving situation but it evaluates each
partner on five components of their verbal and non-verbal marital interaction. The five components are divided
into three negative dimensions: (a) avoidance of and withdrawal from the discussion, (b) dominance,
asymmetry in the control of the conversation, and (c) hostility, criticism, and conflict; and two positive
dimensions: (a) support and validation, which reflect active listening and warmth, and (b) problem-solving skills.
Behaviors are rated according to four levels of severity (absent, mild, moderate, excessive). The authors found
many significant correlations between aspects of the interaction and symptoms of panic and agoraphobia.
Indeed, spouse’s criticism and hostility were positively correlated with fears of bodily sensations (r = .31, p
< .05) and catastrophic thoughts (r = .39, p < .01). Spouse’s dominance was also positively correlated with
these two variables (r = .29, p < .05 and r = .38, p < .01, respectively). Spouse’s support-valid action was
negatively correlated with PDA clinical severity (r = -.26, p < .05), catastrophic thoughts (r = -.31, p < .05), and
agoraphobic avoidance (when accompanied; r = -.31, p < .05). Spouse’s problem-solving skills and clarification/
negotiation were negatively associated with agoraphobic avoidance (when accompanied; r = -.26, p < .05).
Lastly, quality of solutions by the spouse was negatively associated with fear of bodily sensations (r = -.25, p
< .05). For further information, refer to Table 6.
Table 6
Description of Studies Examining the Association Between Marital Adjustment and PD/A
Author(s) Year Participants
Patients’
gender
Diagnostic
measure
Measure(s) of
severity
Measure(s) of
marital
adjustment Results
1 Arrindell,
Emmelkamp&
Sanderman
1986 23 PDA patients
and their partner
23 women Clinical interview FQ, Phobic
Anxiety and
Phobic
Avoidance
ratings by
therapist and
independent
observer
Clinical interview
by an independent
assessor, and
MMQ
No significant correlation between any measure of PDA
severity and measures of marital quality (all ps > .02).
2 Chambless 1985 378 PDA
patients
64 men,
314 women
Diagnostic
interview
MI MDQ No statistical correlation between MDQ and severity of
agoraphobia (r = .10, p > .05, n = 74) or frequency of
panic attacks (t = -.10, p > .05, n =108)
3 Chambless et
al.
2002 22 PDA patients
and their partner
22 women SCID-I MIA KPI Husbands whose wives were more avoidant engaged in
a higher rate of negative verbal behavior (r = .44, p
= .006) and were more critical (r = .35, p = .031). Panic
frequency was not significantly related to any marital
variable.
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Author(s) Year Participants
Patients’
gender
Diagnostic
measure
Measure(s) of
severity
Measure(s) of
marital
adjustment Results
4 Cobb,
Mathews,
Childs-Clarke,
& Blowers
1984 19 agoraphobic
patients and
their partner
4 men,
15 women
Diagnostic
interview
FQ MMMQ No assciation between the initial severity of marital
problems and the severity of agoraphobia.
5 El-Baalbaki et
al.
2011 65 PDA patients
and their partner
19 men,
46 women
ADIS-IV-L ACQ, ADIS-
CSR, ASI, BSQ,
MIA
DAS and GCIS PDA severity correlated negatively with positive
behaviors and positively with negative behaviors during
the problem-solving interaction. Marital adjustment, as
reported by PDA patients, was correlated with BSQ (r =
-.31, p < .05), ACQ (r = -.46, p < .01), and ASI (r = -.49,
p < .01) scores.
6 Lange & Van
Dyck
1992 25 PDA patients NS NS FAS-IR and FQ IPSI No significant correlation between agoraphobic severity
and problem solving.
7 Marcaurelle,
Bélanger,
Marchand,
Katerelos, &
Mainguy
2005 67 PDA patients 23 men,
44 women
ADIS-IV-L ADIS-CSR, ASI,
BSQ, MIA
DAS Marital adjustment was associated with ACQ (r = -.48, p
< .0001), BSQ (r = -.33; p < .007) and ASI (r = -.46, p
< .002) scores.
8 Monteiro,
Marks, Ramm
1985 27 agoraphobic
patients
4 men,
23 women
NS FQ MMMQ Subjects with good and less good marriages did not
differ at pretreatment on agoraphobic severity.
9 Peter, Hand, &
Wilke
1993 25 agoraphobic
patients and
their partner
3 men,
22 women
Evaluation by a
psychiatrist,
according to
DSM-III criteria
FQ DAS No association between severity of agoraphobia and
marital adjustment.
10 Renneberg
Chambless,
Fydrich, &
Goldstein
2002 35 PDA patients
and 35
significant others
(26 spouses, 9
parents)
12 men,
23 women
SCID-I MIA and panic
frequency/week
KPI Groups of affect-balanced versus affect-unbalanced
dyads did not differ at pretreatment on measures of
agoraphobia and panic (t-tests, all ps > .17).
11 Tukel 1995 45 PDA patients 15 men,
30 women
DSM-III criteria FQ MMQ Quality of relationship was positively correlated with
PDA severity for housewives (r = .61, p = .04). No other
significant correlation.
Note. ACQ = Agoraphobic Cognitions Questionnaire; ADIS-IV-L = Anxiety Disorders Interview Schedule, Lifetime Version; ADIS-CSR =
Anxiety Disorders Interview Schedule- Clinician Severity Rating; ASI = Anxiety Sensitivity Inventory; BSQ = Body Sensations
Questionnaire; DAS = Dyadic Adjustment Scale; FAS = Fear and Avoidance Scales- Interviewer Rated; FMSS = Five-Minute Speech
Sample; FSS = Fear Survey Schedule; FQ = Fear Questionnaire; GCIS = Global Couple Interaction Coding System; IPSI = Interactional
Problem Solving Inventory; KPI = Kategoriensystem für Partnerschaftliche Interaktion (interaction coding system); LWMAT = Lock and
Wallace Marital Adjustment Test; MI = Mobility Inventory; MIA = Mobility Inventory for Agoraphobia; MDQ = Marital Dissatisfaction
Questionnaire; MMQ = Maudsley Marital Questionnaire; MMMQ = Modified Maudsley Marital Questionnaire; MQ = Marital Questionnaire;
NS = Not specified; PCS = Perceived Criticism Scale; SCID-I = Structured Clinical Interview for DSM-III-R disorders.
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The Association Between PD/A Severity and Expressed Emotion
Two studies assessed the level of Expressed Emotion in relation to the severity of agoraphobia. Peter and
colleagues (1993) reported significant associations between the severity of agoraphobia and the critics and
emotional warmth subscales of the CFI (critics: r = .55, p < .01; emotional warmth: r = -.56, p < .01). In Rodde
and Florin's (2002) study, 46 participants with PD/A and their partner were included. However, only results for
32 couples were reported (14 couples dropped out). Expressed Emotion status was assessed with the Five-
Minute Speech Sample (FMSS), a five-minute monologue during which the partner is asked to talk about the
patient and their relationship. There were no significant associations between Expressed Emotion status and
fear of bodily sensations (BSQ). For a summary, see Table 7.
Table 7
Description of Studies Examining the Association Between Expressed Emotion and PD/A
Author(s) Year Participants
Patients’
gender
Diagnostic
measure
Measure(s) of
severity
Measure(s) of
Expressed
Emotion Results
1 Peter, Hand, &
Wilke
1993 25 agoraphobic
patients and
their partner
3 men,
22 women
Evaluation by a
psychiatrist,
according to
DSM-III criteria
FQ CFI Severity was positively associated with criticism (r = .55,
p < .01) and negatively with emotional warmth (r = -.56,
p < .01) as perceived by the patient.
2 Rodde & Florin 2002 32 PD/A patients
and their partner
12 men,
20 women
DSM-III criteria BSQ FMSS No significant association (statistics not provided by
authors from original study).
Note. BSQ = Body Sensations Questionnaire; CFI = Camberwell Family Interview; FQ = Fear Questionnaire
Discussion
OCD Studies
Suffering from OCD can create major changes in the dynamics of an intimate relationship and the family.
Results presented above generally demonstrate that the level of support influence the severity of OCD. Indeed,
all but one study assessing family accommodation found significant results, indicating that the more
accommodation behaviors performed by the relatives, the more severe the OCD symptoms. Both meta-
analyses also found a positive association between family accommodation and OCD severity. However, half of
the sample of studies in the Strauss et al. (2015) meta-analysis were studies on pediatric OCD. Given that the
authors did not examine the effect of age, it cannot be concluded that results would have been the same for
adult patients only.
Although family members wish to alleviate the burden on the patients by modifying their habits and participating
in the rituals, their behaviors seem to maintain and contribute to the severity of the disorder by favouring
avoidance by the patients. It is also interesting to note that the authors of this study consider accommodation
as a specific measure of social support because it is considered as support that is directly linked to the
symptoms of OCD. A systematic review by Fredette and colleagues (2016) also found that PTSD specific
measures of social support tended to be more associated with the outcome of cognitive behavioral therapy than
global measures of support. Results relating to Expressed Emotion and OCD severity are mixed. Cherian and
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colleagues (2014) found that the level of criticism influenced OCD severity so that victims with relatives who are
more critical of them seem to experience more severe symptoms. Van Noppen and Steketee (2009) tested a
model combining accommodation and measures of Expressed Emotion. Criticism was indeed correlated to the
severity of OCD. However, measures of Expressed Emotion did not predict severity when accommodation was
considered. This latter result supports the other studies, which found a robust link between accommodation and
OCD severity. Finally, marital adjustment also seems to be associated with OCD severity, so that a better
quality of relationship between partners is correlated with less severe symptoms. These results are based on
two studies.
PD/A Studies
Studies analyzing the association between social or marital support and the severity of PD/A present mixed
results. Researches using measures of social support seem to indicate that people with good support, either in
terms of their perception of the quality of their support or the size of their network, present less severe
symptoms. Concerning marital adjustment, results are mixed and the methods used were diverse. Nine studies
used self-reported measures, from which two found that better marital adjustment was negatively correlated
with symptoms of panic and agoraphobia. Interestingly, these two studies used the same questionnaire, the
DAS, and found strikingly similar results. Another study found a difference between satisfied and unsatisfied
dyads on measures of symptom severity. However, significance was not assessed. Surprisingly, one study
(Tukel, 1995) also found that marital adjustment between housewives with PDA and their spouses was
positively correlated with severity of disorder. There were no significant correlations between marital adjustment
and PDA severity among working men and women. These results may be understood using the assortative
mating hypothesis, which suggests that partners choose each other on the basis of perceived attributes
(Hafner, 1977). For example, a woman with agoraphobia who has dependent traits may choose a partner with
more dominant traits. Both partners would thus benefit from a dynamic where the husband endorses more
responsibilities and takes care of his agoraphobic wife. Given that improvement in agoraphobic symptoms
would lead to more autonomy from the wife and break this dynamic, it may also lead to a decline in marital
satisfaction for both partners. Thus, it is possible that housewives and their husbands are more likely to have
these attributes that allow them to benefit from an agoraphobic dynamic, in comparison to working men and
women.
However, when patients are not distinguished according to their working status, most results seem to indicate
that level of marital adjustment, as assessed by self-reported questionnaires, is not associated with the severity
of panic and agoraphobic symptoms. Given that marital adjustment is a concept that is larger than marital
support, it would be interesting to create more specific measures of marital support in order to eliminate factors
that are not directly in link with support (e.g. sexuality).
Three studies also assessed marital adjustment with observational measures, two of which found significant
results. These results indicated that negative social support (e.g. criticism and dominance) is associated with
more severe symptoms while positive support (e.g. proposing positive solutions) is associated with less severe
symptoms. However, one other study (Renneberg et al., 2002) found no significant differences between
balanced-affected and unbalanced-affected dyads on measures of panic and agoraphobia severity. In order to
understand the latter result, we performed statistical analyses to determine the effect sizes and statistical
power, using descriptive data from Table 2 in the original article. Effect sizes were calculated between the
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balanced- and unbalanced-affected dyads on measures of agoraphobia and panic frequency. A medium effect
size (Cohen’s d = .48) was found for panic frequency. However, statistical power was low (27%), hence one
cannot conclude that results between the two groups on measures of panic frequency are equivalent. More
studies would thus be needed to have a clearer picture.
Finally, two studies analyzed the link between Expressed Emotion and severity of PD/A. In the first study (Peter
et al., 1993), it was found that criticism was negatively associated with the symptomatology of PD/A. Also,
positive aspects of support were assessed with the CFI, and it was found that emotional warmth was
associated with less severe symptoms. Given that Expressed Emotion assesses relatives’ attitudes and
behaviors toward the patient’s illness, it is considered a specific measure of social support. As reported for the
results concerning OCD, the specific way people deal with their partner’s symptoms seems to be correlated
with the severity of the symptomatology. In the second study (Rodde & Florin, 2002), no significant association
was found between Expressed Emotion and the severity of PD/A. However, no statistics were presented, which
makes it difficult to draw conclusions.
Conclusion
Results presented in this systematic review generally indicate that social and marital support is associated with
the severity of OCD and PD/A, which supports our hypotheses. Indeed, negative social support seems to be
associated with more severe symptoms whereas positive social support might be beneficial for people suffering
from OCD or PD/A. These results stress the importance of relatives in helping people recover from their illness.
Living with someone suffering from a mental illness can be difficult for the relatives, as they might not know how
to support or react to the patient’s behaviors. Thus, solutions such as integrating the relatives in the therapy as
well as providing them with tools (e.g. psychoeducation, personalized therapy for the relatives) on how to deal
with the symptoms of the disorder might be beneficial to both the patient and the relatives. However, more
studies would be needed to assess the level of support, using both observational and self-report measures of
social support, as well as more specific measures as they seem to be more strongly correlated with the severity
of OCD and PD/A. Moreover, studies that assess and compare both the negative and positive forms of social
support would be interesting, since negative social support has been found to be more strongly correlated with
symptom severity in a study of post-traumatic stress disorder (Zoellner, Foa, & Brigidi, 1999).
To conclude, this systematic review has some limitations. Indeed, the wide spectrum of questionnaires used by
different researchers rendered it difficult to compare studies adequately. Moreover, the authors of the present
study did not always have full access to the description of the questionnaires, which at times made it necessary
to infer their content (e.g. MDQ). Moreover, the authors decided to cover a broad spectrum of concepts relating
to social support (e.g. accommodation and marital adjustment) in order to render this systematic review as
exhaustive as possible. Readers need to keep this in mind when interpreting the results. In order to
compensate for this, the authors tried to only present results pertaining to social support when it was possible.
For example, only FAS total scores and results of the participation in the rituals subscale were used, since
other subscales concerning the impact of accommodation on relatives were not manifestations of social support
as it was defined in this review. Also, results concerning emotional over-involvement were left out, since it is not
included in our definition of social support. Finally, some studies had limited statistics, which makes the
interpretation of their results difficult.
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Funding
The authors have no funding to report.
Competing Interests
The authors have declared that no competing interests exist.
Acknowledgments
We thank Ike Bedikyan, Linda Kwakkenbos and Yue Zhao for their precious help with articles written in Turkish, German
and Chinese, respectively.
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A bout the Au thor s
Véronique Palardy is a Ph.D Candidate in psychology. Her principal interests are anxiety disorders and personality disor-
ders.
Ghassan El-Baalbaki is a professor at Université du Québec à Montréal. He also is an adjunct professor at McGill Univer-
sity, and is clinical psychologist. His various interests include anxiety and mood disorders, personality disorders, health psy-
chology, and marital relationships.
Catherine Fredette is a Ph.D Candidate in psychology. Her research interests are primarily anxiety disorders and post-trau-
matic stress disorder.
Elias Rizkallah is a professor at Université du Québec à Montréal. His study interests are social and cultural representa-
tions as well as social sciences methodology.
Stéphane Guay is a professor at Université de Montréal. He is also director of Fernand-Séguin research center (Institut
Université en Santé Mentale de Montréal). His research is focused on post-traumatic stress disorder, anxiety disorders and
relationships.
Social Support and OCD/PDA Severity: A Systematic Review 286
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2018, Vol. 14(1), 254–286
doi:10.5964/ejop.v14i1.1252
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Social Support and OCD/PDA Severity: A Systematic Review
(Introduction)
Social Support
Marital Adjustment
Expressed Emotion
Accommodation
Objectives and Hypotheses
Method
Selection of Articles
Inclusion/Exclusion Criteria
Selection Procedure
Results
Support and OCD Severity
Support and PD/A Severity
Discussion
OCD Studies
PD/A Studies
Conclusion
(Additional Information)
Funding
Competing Interests
Acknowledgments
References
About the Authors