Obsessive– Compulsive Disorder 453
ber of adult OCD patients have their first onset in late childhood or adolescence, most
children with obsessional symptoms do not progress to OCD in adulthood (Rachman,
Shafran, & Riskind, 2006). Thus presence of obsessional symptoms, at least in child-
hood, may not play a strong etiological role in OCD. As discussed in the next section, a
number of specific cognitive factors have been postulated for elevated vulnerability for
OCD.
Course and Consequence
Although it is very difficult to determine the natural course of OCD because of treat-
ment effects, it would appear from various long-term follow-up studies that OCD tends
to take a chronic course, with waxing and waning of symptoms over a lifetime, often
in response to fluctuations in life stress. In a long-term Swedish study that spanned
almost 50 years, Skoog and Skoog (1999) found that only 20% of the sample exhibited
complete symptom recovery. Steketee and Barlow (2002) concluded that the majority of
patients continue to meet diagnostic criteria for OCD or retain significant obsessional
symptoms. In fact OCD may have one of the lowest spontaneous remission rates of the
anxiety disorders (Foa & Kozak, 1996). OCD, then, is a chronic unremitting anxiety
disorder with early onset and a symptom presentation that waxes and wanes in severity
over the course of a lifetime.
Given this characterization, it is not surprising that the disorder has a significant
negative impact on occupational and social functioning as well as educational attain-
ment, although the personal cost and suffering of OCD is probably equivalent to that
of other anxiety disorders (Antony, Downie, & Swinson, 1998; Karno, Golding, Soren-
son, & Burnam, 1988). Nevertheless, OCD can have a significant negative impact on
family members, marital functioning, and parent–child relationships. Family members
are often implicated in patients’ rituals either by accommodating to their demands (i.e.,
engage in excessive washing and cleaning or provision of reassurance) or totally oppos-
ing their obsessional concerns (Calvocoressi et al., 1995; de Silva, 2003). Either coping
strategy can lead to an increase in distress and depression for both the OCD sufferer
and family members as well as severe disruption of family functioning and relationships
(Amir, Freshman, & Foa, 2000; de Silva, 2003). Much of the negative effects of OCD
on family life depend on the severity of the illness and the individual’s current living
arrangements.
Clinician Guideline 11.3
Cognitive assessment and treatment should consider the impact of the OCD on family mem-
bers and the significant role they may play in maintaining the client’s symptomatology.Comorbidity
Like the other anxiety disorders, OCD has a high rate of diagnostic comorbidity. Half
to three- quarters of OCD patients have at least one other current disorder (see Antony,
Downie, et al., 1998) and fewer than 15% have a sole diagnosis of OCD over a lifetime
(Brown, Campbell, et al., 2001). Major depression is one of the most common comorbid