Child Psychiatry Hum Dev DOI 10.1007/s10578-015-0565-8
ORIGINAL ARTICLE
Obsessive–Compulsive Personality Traits in Youth with Obsessive–Compulsive Disorder Jennifer M. Park1 • Eric A. Storch2 • Anthony Pinto3,4 • Adam B. Lewin2
Ó Springer Science+Business Media New York 2015
Abstract While interest in the relationship between obsessive–compulsive disorder (OCD) and obsessive compulsive personality disorder has increased, there are currently no studies that have examined the presence of obsessive compulsive personality traits (OCPTs) in youth. The current study sought to determine the latent factors and psychometric properties of a modified version of the Childhood Retrospective Perfectionism Questionnaire (CHIRP) and examine the correlates of specific OCPTs (e.g., rigidity, perfectionism) in youth with OCD. Participants included 96 treatment-seeking youth diagnosed with primary OCD (and a parent). Parents and youth completed measures of OCPTs, OCD severity, depression, and disability. A confirmatory factor analysis of the modified CHIRP resulted in a two-factor model: perfectionism and preoccupation with details. The CHIRP and its subscales demonstrated acceptable internal consistency and preliminary evidence for convergent and divergent validity. Obsessive compulsive traits in youth were also found to be associated with the checking, symmetry and contamination symptom dimensions. Keywords Obsessive compulsive personality disorder Obsessive compulsive disorder Perfectionism Youth
& Jennifer M. Park [email protected] 1
Child CBT Program, Massachusetts General Hospital, 151 Merrimac Street, 3rd Floor, Boston, MA 02114, USA
2
Departments of Psychology, Pediatrics and Psychiatry & Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
3
Division of Psychiatry Research, Zucker Hillside Hospital, North Shore-LIJ Health System, Glen Oaks, NY, USA
4
Department of Psychiatry, Hofstra North Shore - LIJ School of Medicine, Hempstead, NY, USA
Introduction Obsessive compulsive disorder is a chronic neuropsychiatric disorder that has a prevalence rate of 1–2 % among children and adolescents [1]. Characterized by the presence of intrusive, anxiety-provoking thoughts (i.e., obsessions), and repetitive, ritualistic behaviors (i.e., compulsions), OCD in youth can be a distressing and disabling condition [2]. Obsessive compulsive personality disorder is characterized by a pervasive pattern of maladaptive behaviors, which cause distress and/or interference [3]. Individuals with OCPD often exhibit the need for mental and interpersonal control, over-conscientiousness, difficulty discarding items, inflexibility, orderliness, and perfectionism. Studies report significantly higher rates of OCPD amongst those with OCD (23–47 %), relative to healthy community controls (1–3 %) [4, 5]. Examination of the impact of OCPD on OCD symptoms in adults has yielded discrepant information regarding the relationship between OCPD and OCD, with some noting that the presence of OCPD was associated with greater OCD severity and disability, whereas others found that no association existed [4, 6, 7]. Still some studies have noted that even when OCPD was not associated with OCD severity, OCPD was significantly associated with increased psychosocial impairment [6]. Examination of the impact of comorbid OCPD on the treatment of OCD suggests OCPD may hinder treatment progress. Recent evidence suggests that adults with OCD and OCPD experience attenuated OCD treatment response and have a lower likelihood of OCD remission after 2 years [8, 9]. While the negative impact of comorbid OCD and OCPD in adults is clear, few studies have examined the presence of obsessive compulsive personality traits (OCPTs) in youth. Indeed, according to the DSM-5, OCPD cannot be diagnosed until after the age of 18 years [3];
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however, personality traits are often apparent during childhood and adolescence, and may impact the manifestation and clinical expression of psychiatric disorders [10]. Indeed, OCPT features, such as perfectionism and preoccupation with details/order, often manifest in children after obsessions and compulsions emerge, but before full criteria for OCD is met [11]. While the study of OCPTs in youth with OCD is limited, one study examined the overlap between OCPD and OCD in adults and identified three aspects of OCPD that is most frequently found in those with OCD: hoarding, perfectionism, and preoccupation with details [12]. A recent study of adults with OCPD (with and without comorbid OCD) retrospectively reported higher rates of perfectionism, inflexibility and drive for order during childhood relative to healthy controls [13]. Other retrospective reports of OCPTs in childhood have also predicted the development of other psychiatric disorders, particularly within eating disorder samples [14]. In a study comparing healthy controls with adult women with eating disorders (bulimia and anorexia nervosa), the presence of childhood OCPTs were found to significantly predict an eating disorder diagnosis in adulthood [14]. More interestingly, those who reported increased OCPTs in childhood (e.g., perfectionism, rigidity) had significantly higher rates of OCD and OCPD as adults. While these findings may suggest a link between OCPTs in childhood and OCD symptoms in adults, it is difficult to make this determination due to the dearth of study in this area. Hindering the study of OCPTs in youth with OCD is the lack of validated assessment tools that can evaluate the presence of OCPTs in this age group. The Childhood Retrospective Perfectionism Questionnaire (CHIRP) is a 20-item Retrospective Questionnaire, which measures the presence of OCPTs during childhood [15]. There are two versions of the CHIRP—self-report and informant report. Responses are binary (yes/no) and three subscales (perfectionism, inflexibility, and drive for order and symmetry) are provided. The CHIRP was initially developed and validated in a sample of 246 adults with a lifetime history of eating disorders. In the original measure, ‘‘childhood’’ was defined as being up to 12 years of age. The informant report was derived from parents, siblings, other relatives, and friends (all participants reported that they knew the proband throughout the whole of childhood). The self and informant report CHIRP demonstrated moderate to substantial test–retest reliability (r = 0.73; mean duration of re-test 5.99 months), inter-rater reliability (r = 0.60), and concurrent validity (r = 0.60). To assess the utility of the CHIRP for youth with OCD, the original measure was revised to be a parent-report measure of the presence of OCPTs in youth in the past 6 months. For example, items that originally read ‘‘Were you excessively careful to obey
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rules’’ were modified to read ‘‘Is your child excessively careful to obey rules?’’ No other modifications were made to the measure. Additionally, as this measure was utilized on an OCD sample, which is distinctly different from an eating disorder sample, the modified CHIRP focused on the OCPTs identified by Eisen et al. [12] to overlap most frequently with individuals with OCD (i.e., perfectionism, hoarding, and preoccupation with details). As the original CHIRP only had one item that referred to hoarding, the modified CHIRP was conceptualized to have two subscales rather than three. These two subscales were identified as perfectionism/inflexibility and preoccupation with details. Accordingly, in the present study we examined the psychometric properties of the modified CHIRP in a wellcharacterized sample of youth with OCD. We addressed the following questions: (1) Which OCPTs are frequently endorsed among youth with OCD? (2) What factors are derived from the CHIRP? (3) Does the CHIRP correlate with measures of perfectionism, inflexibility, and/or drive for order/symmetry? (4) Does the measure diverge from other measures of OCD? (5) Are OCPTs in youth associated with specific OCD symptoms dimensions?
Method Participants Participants were 96 treatment-seeking youth (56 % female) and their parents recruited from the regular clinical flow at an OCD specialty clinic at a public university in the Southeastern US. Recruitment was part of a larger study examining neuropsychological functioning among youth with OCD prior to treatment (see Lewin et al. [16]). An initial assessment was part of screening evaluation for inclusion in a study examining neuropsychological functioning in youth with OCD. Youth were between the ages of 7–17 years old (M = 11.77, SD = 2.93) and had a principal diagnosis of OCD. Exclusion criteria included the presence of autism, psychosis, bipolar disorder, physical condition (e.g., seizure disorder, visual impairment, traumatic brain injury), or mental retardation. Medication status was not exclusionary if medications were stable (i.e., no medication changes within 8 weeks). Mean duration of illness was 3.47 (3.05) years. Forty-three (45 %) received OCD psychotherapy in the past. Rates for comorbid diagnoses were the following: generalized anxiety disorder (GAD; 22 %), social phobia (2 %), separation anxiety (6 %), panic disorder (2 %), tic disorders (30 %), depressive disorders (20 %), ADHD (17 %), disruptive behavior disorder (8 %), trichotillomania (3 %), eating disorder (1 %). The racial composition of the sample was 91 % Caucasian (n = 87), 1 % Asian (n = 1), and 2 % Other/
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Mixed (n = 2). Three percent identified as Hispanic/Latino (n = 3). Procedures All study procedures were approved by the local institutional review board. Consent from parents and assent from youth were ascertained prior to administration of study procedures. Diagnoses were determined based on clinical interviews conducted by experienced doctoral level clinicians and confirmed via consensus review with two expert clinicians (utilizing all available information—Interviews, Parent Reports, Questionnaires) as well as semi-structured interviews (Anxiety Disorder Interview Schedule—Parent and Child Versions) administered by trained research assistants. Following the interview a trained clinician administered the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS; [17]) with both parent and child to confirm OCD diagnoses. Final ratings on the CY-BOCS were determined from an integration of parent and child responses and clinical judgment. Rater training for the ADIS and CY-BOCS included instructional training, observations of three ratings, and three ratings while observed. Parents and youth completed a demographic form along with a set of Questionnaires pertaining to the youth’s behavioral, mood, and anxiety symptoms. All study procedures were completed prior to initiating treatment. Measures Anxiety Disorder Interview Schedule: Child and Parent Versions (ADIS C/P) [18] The ADIS-C/P is a semi-structured clinician rated interview. It provides differential diagnosis for anxiety and mood disorders based on the DSM-IV-TR criteria. OCD diagnoses derived from the ADIS were all in agreement with a clinical interview completed by an independent doctoral-level clinician. Childhood Retrospective Perfectionism Questionnaire (CHIRP) [15] Description regarding the CHIRP and the modifications made to the measure for the present sample is described above. Children’s Yale–Brown Obsessive–Compulsive Scale (CYBOCS) [17] The CYBOCS is a clinician-rated interview that consists of both a ten item severity scale and checklist of obsessive–
compulsive symptoms. The CYBOCS is the considered the gold-standard to assess OCD, severity and impairment in youth [19]. Scores for obsessions, compulsions and composite total severity scores are provided. Binary outcomes for obsessive compulsive symptom dimensions were assessed via the CYBOCS-SC [20]. The presence of a symptom dimensions was determined by the presence of any clinical symptom within that dimension. The CYBOCS has demonstrated sound psychometric properties, including good reliability and validity [17, 21]. Internal consistency for the CYBOCS was good in the present sample (a = 0.85). A random 13 % of the sample were reviewed for inter-rater reliability, and reliability was deemed high (ICC = 0.96) [16]. Obsessive Compulsive Inventory: Child Version (OCI-CV) [22] The OCI-CV is a 21-item youth self-report measure that assesses specific obsessive compulsive symptom types. The items ask the youth to rate the frequency of these symptoms in the last month, from 0 (never) to 2 (often). The OCI-CV provides a composite score as well as scores for the following factorially derived subscales: hoarding, neutralizing, obsessions, washing, ordering, doubting, and checking. The OCI-CV total score and subscale scores have demonstrated strong internal consistency, test–retest reliability, and treatment sensitivity [22, 23]. Internal consistency for the OCI-CV was excellent for the present sample (a = 0.92). Child Sheehan Disability Scale: Parent (CSDS-P) [24] The CSDS-P allows parents to rate the degree of impairment a youth’s OCD symptoms have on the parent’s work, social life, and family home life as well as the parent’s perception on the degree to which the youth’s OCD symptoms have impaired his/her social, academic and family domains. The CSDS-P has demonstrated good reliability and validity [24]. In the present sample, the CSDS-P had good internal consistency (a = 0.87). The Multidimensional Anxiety Scale for Children (MASC) [25] The MASC is a youth self-report measure, which assesses general, social, and separation anxiety in youths. The MASC has 39 items on a four point Likert scale, which ranges from 0 (never true about me) to 3 (often true about me) scale and provides a total composite score. The MASC provides several subscales, including perfectionism, social anxiety, and performance fears. The measure has demonstrated good psychometric properties, including good
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internal consistency, test–retest reliability, and convergent and divergent validity [25, 26]. The MASC demonstrated excellent internal consistency in the present sample as well (a = 0.92). The Perfectionism subscale of the MASC has also been utilized in previous studies to examine perfectionism in children and adolescents [27, 28]. Children’s Depression Inventory–Short Form (CDI-SF) [29] The CDI-SF is a ten-item youth self-report measure that assesses the presence of depressive symptoms in the past 2 weeks. The internal consistency of the CDI-SF in the present sample was good (a = 0.85). Analytic Plan Two-factor CFA models were examined to evaluate the factor structures of the CHIRP. While larger sample sizes are considered optimal, previous research indicates that CFAs can be well employed with smaller sample sizes, particularly when a simple model (e.g., few factors, no indirect effects) is tested [30]. The CFA model was constructed using Mplus version 7 [31]. The model hypothesized the presence of two theoretically based factors: perfectionism/inflexibility and preoccupation with details (see Fig. 1). As the data is categorical, the robust weighted least squares (WLSMV) estimator was used for parameter estimation. The comparative fit index (CFI) and root mean square error of approximation (RMSEA) were utilized to determine model fit [32, 33]. The following scores suggest good fit: CFI [ 0.9 [32]; RMSEA \ 0.08 [34]. Modification indices were also examined to determine model fit, where values above 10 were indicative of parameter estimations that should be modified [35]. Factor loadings B 0.40 were considered poor, while scores [0.40 were considered acceptable. Item reliability was examined via corrected item-total correlations, where items with a correlated value \0.30 are considered poor items [36]. Poor items were considered for removal from the measure, depending on corrected itemtotal correlation and theoretical relevance [35]. Cronbach’s alpha was used to assess the internal consistency of the CHIRP and their factor scores. Alphas of 0.60 were defined as ‘‘questionable’’, 0.70 as ‘‘acceptable’’, and 0.80 as ‘‘good’’ [37]. Pearson’s product moment correlation coefficients were computed to examine divergent validity and convergent validity as well as associations between CHIRP and measures of OCD symptom presentation and severity, parent-reported OCD-related impairment, and youth-reported anxiety and depressive symptoms. Finally, the relationship between OCPT and OCD symptom dimensions were evaluated utilizing logistic regressions.
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Results Model Fit The minimum fit function Chi square of the two factor 20-item CFA model was significant (v2 (196) = 231.40, p = 0.001), reflecting inadequate fit; however, the Chi square estimation is biased towards sample size, where larger sample sizes and models with more variables are more likely to result in a significant Chi square. The CFI (0.87) reflected poor fit; however, the RMSEA (0.06) reflected adequate fit. Modification indices did not suggest any parameter modifications were necessary to improve model fit. An examination of the factor loadings indicated that the following four items were a poor fit for the CFA model (see Fig. 1): 4a. If you had pets, did your child take looking after their pets to extremes; 6a. Could your child be described as someone who was inflexible?; 6c. Could your child cope with changing plans at short notice?; and 6d. Did you child like to have written plans or have intricate details about events or activities spelled out so they know what was going to happen? The second CFA model removed these four items, as well as item 4b (Does your child have any other hobby, which is taken to extreme or where they place supreme effort to the exclusion of other activities), due to the item’s poor itemtotal correlation (see Fig. 2). The minimum fit function Chi square of the re-specified CFA model was significant (v2 (89) = 123.21, p = 0.01); however, the v2 value decreased, while the p value increased, suggesting that the re-specified model was a better fit than the original model. The CFI (0.93) also improved in the new model, while the RMSEA (0.06) remained the same. Based off the above, the re-specified CFA model was considered to have acceptable model fit. Confirmatory Factor Analysis See Fig. 2 for final 15-item CFA model. Items 6c and 6e loaded poorly onto the perfectionism/inflexibility factor; however, the two items were not removed due to the theoretical relevance of the items. All other items had adequate factor loadings for each factor. Item Analysis and Internal Consistency Corrected item-total correlations are presented in Table 1. Items 4a, 4b, 6a, 6c, 6d, and 6e demonstrated low itemtotal correlations (\0.30), while all other items were adequate (see Table 1). The items that were flagged as poor items corresponded with items that also had poor factor loadings in the original CFA. These items, excluding item 6e (which was kept in the measure for theoretical relevance), were omitted from the final 15-item CHIRP.
Child Psychiatry Hum Dev Fig. 1 Two-factor CFA model of the 20-item CHIRP
The frequency of endorsements of individual items for the 15-item CHIRP is presented in Table 2. Items reflecting inflexibility (i.e., difficulty with periods of transition, child can be described as stubborn) were most frequently endorsed. Average score for the 15-item CHIRP total was 4.99 (SD = 2.99). Cronbach’s alpha was acceptable for the 15-item CHIRP total (a = 0.76). Acceptable internal consistency was also demonstrated for the perfectionism/ inflexibility (a = 0.71) and preoccupation with details (a = 0.71) factors. Correlations Among Study Measures As seen in Table 3, the 15-item CHIRP was both moderately and significantly correlated with the OCI-CV total, as
well as the OCI-CV subscales of washing, ordering, and doubting. The CHIRP was also significantly correlated with child reported depressive symptoms (CDI), child reported internalizing symptoms (MASC total), as well as child-reported perfectionism symptoms (MASC perfectionism). However, the CHIRP was not significantly correlated with obsessive–compulsive symptom severity (CYBOCS), or parent reported disability (SDS-P). The CHIRP perfectionism/inflexibility subscale was significantly associated with the child-reported washing symptoms (OCI-CV) and child reported perfectionism (MASC Perfectionism), but was not associated with OCICV subscales of doubting, obsessions, ordering, hoarding or neutralizing, as well as MASC subscales of social anxiety or performance fears (see Table 3). The CHIRP
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Child Psychiatry Hum Dev Fig. 2 Two-factor CFA model of the modified 15-item CHIRP
preoccupation with details subscale was significantly associated with the OCI-CV subscales of doubting, washing, and ordering, but was not associated with obsessions, hoarding and neutralizing subscales The preoccupation with details subscale was also not associated with the MASC subscales of perfectionism, social anxiety, and performance fears.
checking, symmetry, and contamination dimensions (see Table 4). In other words, those with increased OCPTs were 1.26 times more likely to have checking symptoms, 1.21 times more likely to have symmetry symptoms, and 1.23 times more likely to have contamination symptoms. The CHIRP did not significantly predict the hoarding or sexual/ religious dimensions.
Associations with Symptom Dimensions
Discussion Five logistic regressions were employed to examine the association between OCPTs (based on the 15-item CHIRP) and OCD symptoms dimensions (as determined by the CYBOCS-SC). A composite score of the 15-item CHIRP was utilized as the independent variable. These analyses suggested that the 15-item CHIRP significantly predicted the probability of having OCD symptoms that were within the
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Despite the increased interest in understanding and evaluating comorbid OCPD and OCD, there are currently no measures that assess for OCPTs in youth with OCD. From the results of this study, the modified 15-item CHIRP has demonstrated adequate psychometric properties and would be an acceptable measure to evaluate the presence of
Child Psychiatry Hum Dev Table 1 Item reliability for 20-item CHIRP Item
Mean if item removed
Variance if item removed
Corrected item-total correlation
Cronbach’s alpha if item deleted
1a
6.20
11.55
0.490
0.71
1b
6.10
11.81
0.379
0.72
1c
6.28
12.02
0.378
0.72
1d
6.21
11.96
0.362
0.72
2a
6.26
12.10
0.336
0.73
2b
6.29
11.81
0.459
0.72
2c
6.35
12.18
0.374
0.72
2d
6.23
11.83
0.414
0.72
3a
6.42
12.43
0.360
0.73
3b
6.28
12.16
0.330
0.73
3c 4a
6.28 6.51
12.06 13.15
0.362 0.171
0.72 0.74
4b
6.36
12.52
0.258
0.73
5a
6.09
11.94
0.337
0.73
5b
6.24
12.09
0.333
0.73
6a
5.99
12.34
0.218
0.74
6b
5.88
12.13
0.300
0.73
6c
6.08
13.56
-0.120
0.76
6d
6.09
12.63
0.136
0.74
6e
6.01
12.18
0.265
0.73
Table 2 Frequency of endorsement on the 15-item CHIRP Item
Yes (%)
1a. At school does your child put more effort into their school work because of attention to detail or perfectionism, than their friends/classmates?
32
1b. In your opinion does your child spend more time on homework than others?
41
1c. Is your child’s work always exceptionally neat? (e.g., do they redo a piece of work if it had errors in it even if there was just one mistake?
26
1d. Does your child always strive for the best mark at school or get upset if they are not always top of the class?
31
With regard to self-care and appearance, is your child excessively concerned with: 2a. Making sure their appearance is just right (e.g., their hair parting is straight or symmetrical, etc., without bumps, etc.?) 2b. Making sure their clothes are coordinated (e.g., colour and style)
26 25
2c. Order and symmetry with their appearance (e.g., hair/hems/cuffs)
25
2d. Does your child spend excessive time and effort on matters of personal hygiene (e.g., cleaning their teeth, washing their hands, etc.)?
19
3a. Does your child spend an excessive amount of time making their room tidy and organised?
10
3b. Do they like to make sure that everything was ‘‘just so’’ and in its proper place?
26
3c. Is your child excessively concerned about order and symmetry (e.g., lining things up)?
25
5a. Is your child excessively careful to obey rules and not put a foot wrong?
42
5b. Is your child excessively careful and cautious (e.g., with a tendency to hoard money, sweets, toys, etc.)
28
6b. Does your child find periods of transition more difficult than their peers, e.g., difficult to adjust to changes in school, home or the family?
63
6e. Could your child be described as stubborn (determined)? For example, if they made up their mind to do something, would they carry it through no matter what?
52
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Child Psychiatry Hum Dev Table 3 Associations between study measures
CHIRP 15-item total
CHIRP perfectionism
CHIRP self-care
CY-BOCS total
0.128
0.164
0.032
OCI total
0.382**
0.238*
0.381**
OCI doubting
0.279**
0.150
0.304**
OCI obsessions
0.145
0.138
0.07
OCI washing
0.352**
0.226*
0.343**
OCI ordering
0.324**
0.146
0.385**
OCI hoarding
0.071
0.022
0.096
OCI neutralizing
0.163
0.123
0.138
MASC total
0.235*
0.243*
0.238*
MASC perfectionism
0.231*
0.234*
0.129
MASC social anxiety
0.062
0.071
0.027
MASC performance fears
0.023
0.026
0.009
CDI
0.229*
0.123
0.250*
SDS-P
0.095
0.136
0.010
CHIRP Childhood Retrospective Perfectionism Questionnaire, OCI Obsessive Compulsive Inventory, MASC The Multidimensional Anxiety Scale for Children, CDI Child Depression Inventory, SDS-P— Sheehan Disability Scale—Parent * p \ 0.05; ** p \ 0.01 Table 4 Logistic regression of CHIRP predicting likelihood of symptom dimensions Symptom dimension
B
SE
df
Odds ratio
95 % CI
Checking
0.23
0.09
1
1.26*
1.04–1.51
Symmetry/order
0.19
0.10
1
1.21*
1.01–1.47
Sexual/religious
0.08
0.07
1
1.08
0.95–1.23
Hoarding
0.07
0.07
1
1.07
0.93–1.23
Contamination
0.21
0.08
1
1.23*
1.05–1.45
* p \ 0.05
OCPTs in youth with OCD. The CFA indicated that the majority of CHIRP items had strong factor loadings on the perfectionism/inflexibility and preoccupation with details factors. The two items that had poor loadings (6b and 6e) were kept within the model based on theoretical relevance as previous factor analyses of OCPD diagnostic criteria have identified rigidity and inflexibility as core features of OCPD [38, 39]. The CHIRP total and the two subscales demonstrated acceptable internal consistency. The significant associations between the CHIRP Perfectionism/Inflexibility subscale and the MASC Perfectionism subscale as well as the significant associations between the CHIRP preoccupation with details subscale and the OCI-CV Doubting and Ordering subscales are suggestive of convergent validity. The two subscales did not converge with the OCI-CV Obsessions and Neutralizing subscales, or the MASC Social Anxiety and Performance subscales, demonstrating divergent validity. The 15-item CHIRP was not associated with OCD severity or parent-reported OCD-related impairment;
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however, this is in line with findings from previous research with adults with comorbid OCPD and OCD [6, 40]. These findings may be attributed to the developmental age of the sample as personality traits are fluid during childhood and adolescence and, therefore, may be more susceptible to change. OCPTs may also contribute to greater psychosocial impairment rather than functional impairment, particularly as parents may accommodate youth to ensure that functional impairment is minimized. Parents may also maintain (or reinforce) specific aspects of the youth’s OCPTs (e.g., perfectionist tendencies, rigidity to routines); therefore, parents may not perceive these behaviors to be problematic or excessive. Youth with increased OCPTs were also found to have a greater likelihood of having OCD symptoms in particular symptom dimensions, specifically symptoms related to checking, contamination or symmetry. Similarly, studies with adults have noted that OCPD is associated with greater contamination, symmetry, and doubting symptoms [4, 7, 13]. While these results are compelling, longitudinal studies are necessary to evaluate the trajectory of childhood OCPTs into adulthood and determine whether OCPTs may serve as a marker for OCD youth who are at risk of developing OCPD. From our current sample, other than tic disorder, GAD was the most prevalent comorbid diagnosis. As perfectionism is common in GAD, there is a possibility that the perfectionism features captured by the CHIRP may be reflective of GAD rather than OCPD. However, studies of GAD have found that rather than perfectionism or need for control, intolerance of uncertainty is the main feature that
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is involved in the development and maintenance of GAD related worries [41]. In OCD and OCPD, however, perfectionism is a core feature of these disorders and manifests differently between OCD and OCPD. Perfectionism in OCD is strongly associated with doubt. The need to do something in precisely the right way drives an OCD individual to engage in rituals until a ‘‘just right’’ feeling is achieved. When perfect certainty is not achieved, those with OCD experience intense feelings of doubt, which may manifest into checking and repeating rituals [42, 43]. In OCPD, perfectionism is associated with ‘‘self-imposed high standards of performance’’ [3], rather than motivated by feelings of doubt/anxiety that arises when perfection is not achieved. The perfectionism items in the CHIRP specifically targeted the type of perfectionism associated with OCPD. Items included questions such as ‘‘Did your child always strive for the best mark in school?’’ and ‘‘Did you put more effort into your schoolwork because of attention to detail or perfectionism?’’ The present study had several limitations. First, while the sample size was considered adequate, the CFA model may have benefited from a larger sample. Second, there was no comparison group that could be utilized to evaluate the possible differences in OCPT symptoms within the OCD group. Third, as the CHIRP is a binary measure that only allows for yes/no answers, the measure may not have captured the continuum at which OCPTs may manifest in youth, thereby constraining the responses with floor and ceiling effects. Fourth, as only parent report responses on the CHIRP were taken into account, child reports may result in different outcomes; however, studies have noted that parent reports may be more accurate than child reports [21]. Fifth, the reliability of the original CHIRP was not strong and only one validation study was conducted for this measure. Still, the modified CHIRP demonstrated improved psychometric properties compared to the original CHIRP. Finally, all participants were part of treatment-seeking families, whereas non-treatment seeking families may experience a higher prevalence of OCPTs. Within these limitations, this was the first study to examine the psychometric properties of the CHIRP in youth with OCD, as well as the first to investigate the presence of OCPTs in this population. Additionally, as previous studies have only examined OCPTs in childhood retrospectively, this is also the first study to examine OCPTs in childhood in present time. Several directions for future investigation are highlighted. First, studies should work towards replication and further validation of the measure in a larger sample size as well as in non-OCD samples. While associations between the two factors and subscales on the MASC suggested convergent and divergent validity, this should be further examined by utilizing clear convergent measures (specific measures of perfectionism/inflexibility and preoccupation to details)
Study in non-OCD samples will help determine if the rate of OCPTs in OCD samples is developmentally normative for this age group or pathological. Second, studies should evaluate the role of family accommodation in OCD youth with OCPTs, as well as the rate of behavioral difficulties (e.g., oppositional behaviors) and psychosocial impairment. Finally, the impact of OCPTs on treatment outcome in youth with OCD should also be examined.
Summary While OCPTs in adulthood are often associated with a number of psychiatric conditions (e.g., OCD, anorexia), there is evidence that suggests that these traits may manifest during childhood. Unfortunately, research in OCPTs in childhood is hindered by the lack of psychometrically valid measures. In this study we found that a modified 15-item CHIRP may be an appropriate measure of childhood OCPTs. While OCPTs were not associated with OCD severity or impairment, there were associations found between OCPTs and various symptoms dimensions, including contamination, symmetry and doubting symptoms. Consideration of the presence of OCPTs can provide important information in regards to prognosis, treatment development, and treatment success among youth with OCD.
References 1. Zohar AH (1999) The epidemiology of obsessive–compulsive disorder in children and adolescents. Child Adolesc Psychiatr Clin N Am 8:445–460 2. Piacentini J, Bergman RL, Keller M, McCracken J (2003) Functional impairment in children and adolescents with obsessive–compulsive disorder. J Child Adolesc Psychopharmacol 13(Suppl 1):S61–S69 3. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatry Publishing, Arlington 4. Garyfallos G, Katsigiannopoulos K, Adamopoulou A, Papazisis G, Karastergious A, Bozikas V (2010) Comorbidity of obsessive– compulsive disorder with obsessive–compulsive personality disorder: Does it imply a specific subtype of obsessive–compulsive disorder? Psychiatry Res 177:156–160 5. Pinto A, Eisen JL, Mancebo MC, Rasmussen SA (2008) Obsessive–compulsive personality disorder obsessive compulsive personality disorder. In: Abramowitz JS, McKay D, Taylor S (eds) Obsessive–compulsive disorder: subtypes and spectrum conditions. Elsevier, New York 6. Coles ME, Pinto A, Mancebo MC, Rasmussen SA, Eisen JL (2008) OCD with comorbid OCPD: A subtype of OCD? J Psychiatry Res 42:289–296 7. Lochner C, Serebro P, van der Merwe L et al (2011) Comorbid obsessive–compulsive personality disorder in obsessive–compulsive disorder (OCD): a marker of severity. Prog Neuropsychopharmacol Biol Psychiatry 35:1087–1092
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Child Psychiatry Hum Dev 8. Pinto A (2009). Understanding obsessive compulsive personality disorder and its impact on obsessive compulive disorder. 16th Annual Obsessive Compulsive Foundation Conference. Minneapolis 9. Pinto A, Liebowitz MR, Foa EB, Simpson HB (2011) Obsessive compulsive personality disorder as a predictor of exposure and ritual prevention outcome for obsessive compulsive disorder. Behav Res Ther 49:453–458 10. Duggan C, Milton J, Egan V, McCarthy L, Palmer B, Lee A (2003) Theories of general personality and mental disorder. Br J Psychiatry Suppl 44:S19–S23 11. Coles ME, Hart AS, Schofield CA (2012) Initial data characterizing the progression from obsessions and compulsions to fullblown obsessive compulsive disorder. Cogn Ther Res 36:685–693 12. Eisen JL, Coles ME, Shea MT, Pagano ME et al (2006) Clarifying the convergence between obsessive compulsive personality disorder criteria and obsessive compulsive disorder. J Personal Disord 3:294–305 13. Pinto A, Greene AL, Storch EA, Simpson H (2015) Prevalence of childhood-obsessive compulsive personality traits in adults with obsessive compulsive disorder versus obsessive compulsive personality disorder. J Obsessive Compuls Relat Disord 4:25–29 14. Anderluh MB, Tchanturia K, Rabe-Hesketh S, Treasure J (2003) Childhood obsessive compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype. Am J Psychiatry 160:242–247 15. Southgate L, Tchanturia K, Collier D, Treasure J (2008) The development of the childhood retrospective perfectionism questionnaire (CHIRP) in an eating disorder sample. Eur Eat Disord Rev 16:451–462 16. Lewin AB, Larson MJ, Park JM, McGuire JH, Murphy TK, Storch EA (2014) Neuropsychological functioning in youth with obsessive compulsive disorder: an examination of executive function and memory impairment. Psychiatry Res 216:108–115 17. Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI, King RA, Goodman WK et al (1997) Children’s Yale–Brown obsessive compulsive scale: reliability and validity. J Am Acad Child Adolesc Psychiatry 36:844–852 18. Silverman WK, Albano AM (1996) The anxiety disorders interview schedule for DSM-IV child and parent versions. Oxford University Press, London 19. Lewin AB, Piacentini J (2010) Evidence-based assessment of child obsessive compulsive disorder: recommendations for clinical practice and treatment research. Child Youth Care Forum 39:73–89 20. Park JM, Burke N, Lewin AB (2015) Obsessive compulsive disorder symptom dimensions: etiology, phenomenology, and clinical implications. In obsessive–compulsive disorder: etiology phenomenology and treatment, C.W. Lack (ed.) Onus Books, UK 21. Storch EA, Murphy TK, Adkins JW, Lewin AB, Geffken GR, Johns NB et al (2006) The children’s Yale–Brown obsessive– compulsive scale: psychometric properties of child- and parentreport formats. J Anxiety Disord 20:1055–1070 22. Foa EB, Coles M, Huppert JD, Pasupuleti RV, Franklin ME, March J (2010) Development and validation of a child version of the obsessive compulsive inventory. Behav Ther 41:121–132 23. Jones AM, De Nadai AS, Arnold EB, McGuire JF, Lewin AB, Murphy TK et al (2013) Psychometric properties of the obsessive compulsive inventory: child version in children and adolescents with obsessive–compulsive disorder. Child Psychiatry Hum Dev 44:137–151
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24. Whiteside SP (2009) Adapting the Sheehan disability scale to assess child and parent impairment related to childhood anxiety disorders. J Clin Child Adolesc Psychol 38:721–730 25. March JS, Parker JD, Sullivan K, Stallings P, Conners CK (1997) The multidimensional anxiety scale for children (masc): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry 36:554–565 26. March JS, Sullivan K, Parker J (1999) Test–retest reliability of the multidimensional anxiety scale for children. J Anxiety Disord 13:349–358 27. Grills-Taquechel AE, Ollendick TH, Fisak B (2008) Reexamination of the MASC factor structure and discriminant ability in a mixed clinical outpatient sample. Depress Anxiety 25:942–950 28. Lundahl A, West T, Martin EK, Campbell C, Vanderbeek J, Hansen DJ (2011) Relationship of obsessive–compulsive behaviors of primary caregivers with a history of sexual abuse and perfectionism in their sexually abused children. McNair Sch J 29. Kovacs M (1992) The Children’s Depression Inventory Manual. Multi-Health Systems, Ontario 30. Iacobucci D (2010) Structural equations modeling: fit indices, sample size, and advanced topics. J Consum Psychol 20:90–98 31. Muthen LK, Muthen BO (2007) Mplus user’s guide, 6th edn. Muthen & Muthen, Los Angeles 32. Bollen KA, Long JS (1993) Testing structural equation models. Sage, Newbury Park 33. Bentler PM (1990) Comparative fit indexes in structural models. Psychol Bull 107:238–246 34. Browne MW, Cudeck R (1993) Alternative ways of assessing model fit. In: Bollen KA, Long JS (eds) Testing structural models. Sage, Newbury Park 35. Kline RB (2010) Principles and practice of structural equation modeling, 3rd edn. Guilford Press, New York city 36. Field A (2005) Discovering statistics using SPSS, 2nd edn. Sage, London 37. Nunnally JC, Berstein H (1994) Psychometric theory, 3rd edn. McGraw-Hill, New York 38. Ansell EB, Pinto A, Crosby RD, Becker DF et al (2010) The prevalence and structure of obsessive compulsive personality disorder in Hispanic psychiatric outpatients. J Behav Ther Exp Psychiatry 41:275–281 39. Grilo CM, Sanislow CA, Gunderson JG, Pagano ME et al (2004) Two-year stability and change of schizotypal borderline, avoidance and obsessive compulsive personality disorders. J Consult Clin Psychol 72:767–775 40. Albert U, Maina G, Forner F, Bogetto F (2004) DSM-IV obsessive–compulsive personality disorder: prevalence in patients with anxiety disorders and in healthy comparison subjects. Compr Psychiatry 45:325–332 41. Buhr K, Dugas, MJ (2001). Intolerance of uncertainty and its relationship to worry. Poster session presented at the annual convention of the association for advancement of behavior therapy, Philadelphia, PA 42. Frost RO, Steketee G (1997) Perfectionism in obsessive compulsive disorder patients. Behav Res Ther 35:291–296 43. Frost RO, Marten P, Lahart CM, Roseblate R (1990) The dimensions of perfectionism. Cogn Ther Res 14:449–468
ORIGINAL ARTICLE
Obsessive–Compulsive Personality Traits in Youth with Obsessive–Compulsive Disorder Jennifer M. Park1 • Eric A. Storch2 • Anthony Pinto3,4 • Adam B. Lewin2
Ó Springer Science+Business Media New York 2015
Abstract While interest in the relationship between obsessive–compulsive disorder (OCD) and obsessive compulsive personality disorder has increased, there are currently no studies that have examined the presence of obsessive compulsive personality traits (OCPTs) in youth. The current study sought to determine the latent factors and psychometric properties of a modified version of the Childhood Retrospective Perfectionism Questionnaire (CHIRP) and examine the correlates of specific OCPTs (e.g., rigidity, perfectionism) in youth with OCD. Participants included 96 treatment-seeking youth diagnosed with primary OCD (and a parent). Parents and youth completed measures of OCPTs, OCD severity, depression, and disability. A confirmatory factor analysis of the modified CHIRP resulted in a two-factor model: perfectionism and preoccupation with details. The CHIRP and its subscales demonstrated acceptable internal consistency and preliminary evidence for convergent and divergent validity. Obsessive compulsive traits in youth were also found to be associated with the checking, symmetry and contamination symptom dimensions. Keywords Obsessive compulsive personality disorder Obsessive compulsive disorder Perfectionism Youth
& Jennifer M. Park [email protected] 1
Child CBT Program, Massachusetts General Hospital, 151 Merrimac Street, 3rd Floor, Boston, MA 02114, USA
2
Departments of Psychology, Pediatrics and Psychiatry & Behavioral Neurosciences, University of South Florida, Tampa, FL, USA
3
Division of Psychiatry Research, Zucker Hillside Hospital, North Shore-LIJ Health System, Glen Oaks, NY, USA
4
Department of Psychiatry, Hofstra North Shore - LIJ School of Medicine, Hempstead, NY, USA
Introduction Obsessive compulsive disorder is a chronic neuropsychiatric disorder that has a prevalence rate of 1–2 % among children and adolescents [1]. Characterized by the presence of intrusive, anxiety-provoking thoughts (i.e., obsessions), and repetitive, ritualistic behaviors (i.e., compulsions), OCD in youth can be a distressing and disabling condition [2]. Obsessive compulsive personality disorder is characterized by a pervasive pattern of maladaptive behaviors, which cause distress and/or interference [3]. Individuals with OCPD often exhibit the need for mental and interpersonal control, over-conscientiousness, difficulty discarding items, inflexibility, orderliness, and perfectionism. Studies report significantly higher rates of OCPD amongst those with OCD (23–47 %), relative to healthy community controls (1–3 %) [4, 5]. Examination of the impact of OCPD on OCD symptoms in adults has yielded discrepant information regarding the relationship between OCPD and OCD, with some noting that the presence of OCPD was associated with greater OCD severity and disability, whereas others found that no association existed [4, 6, 7]. Still some studies have noted that even when OCPD was not associated with OCD severity, OCPD was significantly associated with increased psychosocial impairment [6]. Examination of the impact of comorbid OCPD on the treatment of OCD suggests OCPD may hinder treatment progress. Recent evidence suggests that adults with OCD and OCPD experience attenuated OCD treatment response and have a lower likelihood of OCD remission after 2 years [8, 9]. While the negative impact of comorbid OCD and OCPD in adults is clear, few studies have examined the presence of obsessive compulsive personality traits (OCPTs) in youth. Indeed, according to the DSM-5, OCPD cannot be diagnosed until after the age of 18 years [3];
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however, personality traits are often apparent during childhood and adolescence, and may impact the manifestation and clinical expression of psychiatric disorders [10]. Indeed, OCPT features, such as perfectionism and preoccupation with details/order, often manifest in children after obsessions and compulsions emerge, but before full criteria for OCD is met [11]. While the study of OCPTs in youth with OCD is limited, one study examined the overlap between OCPD and OCD in adults and identified three aspects of OCPD that is most frequently found in those with OCD: hoarding, perfectionism, and preoccupation with details [12]. A recent study of adults with OCPD (with and without comorbid OCD) retrospectively reported higher rates of perfectionism, inflexibility and drive for order during childhood relative to healthy controls [13]. Other retrospective reports of OCPTs in childhood have also predicted the development of other psychiatric disorders, particularly within eating disorder samples [14]. In a study comparing healthy controls with adult women with eating disorders (bulimia and anorexia nervosa), the presence of childhood OCPTs were found to significantly predict an eating disorder diagnosis in adulthood [14]. More interestingly, those who reported increased OCPTs in childhood (e.g., perfectionism, rigidity) had significantly higher rates of OCD and OCPD as adults. While these findings may suggest a link between OCPTs in childhood and OCD symptoms in adults, it is difficult to make this determination due to the dearth of study in this area. Hindering the study of OCPTs in youth with OCD is the lack of validated assessment tools that can evaluate the presence of OCPTs in this age group. The Childhood Retrospective Perfectionism Questionnaire (CHIRP) is a 20-item Retrospective Questionnaire, which measures the presence of OCPTs during childhood [15]. There are two versions of the CHIRP—self-report and informant report. Responses are binary (yes/no) and three subscales (perfectionism, inflexibility, and drive for order and symmetry) are provided. The CHIRP was initially developed and validated in a sample of 246 adults with a lifetime history of eating disorders. In the original measure, ‘‘childhood’’ was defined as being up to 12 years of age. The informant report was derived from parents, siblings, other relatives, and friends (all participants reported that they knew the proband throughout the whole of childhood). The self and informant report CHIRP demonstrated moderate to substantial test–retest reliability (r = 0.73; mean duration of re-test 5.99 months), inter-rater reliability (r = 0.60), and concurrent validity (r = 0.60). To assess the utility of the CHIRP for youth with OCD, the original measure was revised to be a parent-report measure of the presence of OCPTs in youth in the past 6 months. For example, items that originally read ‘‘Were you excessively careful to obey
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rules’’ were modified to read ‘‘Is your child excessively careful to obey rules?’’ No other modifications were made to the measure. Additionally, as this measure was utilized on an OCD sample, which is distinctly different from an eating disorder sample, the modified CHIRP focused on the OCPTs identified by Eisen et al. [12] to overlap most frequently with individuals with OCD (i.e., perfectionism, hoarding, and preoccupation with details). As the original CHIRP only had one item that referred to hoarding, the modified CHIRP was conceptualized to have two subscales rather than three. These two subscales were identified as perfectionism/inflexibility and preoccupation with details. Accordingly, in the present study we examined the psychometric properties of the modified CHIRP in a wellcharacterized sample of youth with OCD. We addressed the following questions: (1) Which OCPTs are frequently endorsed among youth with OCD? (2) What factors are derived from the CHIRP? (3) Does the CHIRP correlate with measures of perfectionism, inflexibility, and/or drive for order/symmetry? (4) Does the measure diverge from other measures of OCD? (5) Are OCPTs in youth associated with specific OCD symptoms dimensions?
Method Participants Participants were 96 treatment-seeking youth (56 % female) and their parents recruited from the regular clinical flow at an OCD specialty clinic at a public university in the Southeastern US. Recruitment was part of a larger study examining neuropsychological functioning among youth with OCD prior to treatment (see Lewin et al. [16]). An initial assessment was part of screening evaluation for inclusion in a study examining neuropsychological functioning in youth with OCD. Youth were between the ages of 7–17 years old (M = 11.77, SD = 2.93) and had a principal diagnosis of OCD. Exclusion criteria included the presence of autism, psychosis, bipolar disorder, physical condition (e.g., seizure disorder, visual impairment, traumatic brain injury), or mental retardation. Medication status was not exclusionary if medications were stable (i.e., no medication changes within 8 weeks). Mean duration of illness was 3.47 (3.05) years. Forty-three (45 %) received OCD psychotherapy in the past. Rates for comorbid diagnoses were the following: generalized anxiety disorder (GAD; 22 %), social phobia (2 %), separation anxiety (6 %), panic disorder (2 %), tic disorders (30 %), depressive disorders (20 %), ADHD (17 %), disruptive behavior disorder (8 %), trichotillomania (3 %), eating disorder (1 %). The racial composition of the sample was 91 % Caucasian (n = 87), 1 % Asian (n = 1), and 2 % Other/
Child Psychiatry Hum Dev
Mixed (n = 2). Three percent identified as Hispanic/Latino (n = 3). Procedures All study procedures were approved by the local institutional review board. Consent from parents and assent from youth were ascertained prior to administration of study procedures. Diagnoses were determined based on clinical interviews conducted by experienced doctoral level clinicians and confirmed via consensus review with two expert clinicians (utilizing all available information—Interviews, Parent Reports, Questionnaires) as well as semi-structured interviews (Anxiety Disorder Interview Schedule—Parent and Child Versions) administered by trained research assistants. Following the interview a trained clinician administered the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS; [17]) with both parent and child to confirm OCD diagnoses. Final ratings on the CY-BOCS were determined from an integration of parent and child responses and clinical judgment. Rater training for the ADIS and CY-BOCS included instructional training, observations of three ratings, and three ratings while observed. Parents and youth completed a demographic form along with a set of Questionnaires pertaining to the youth’s behavioral, mood, and anxiety symptoms. All study procedures were completed prior to initiating treatment. Measures Anxiety Disorder Interview Schedule: Child and Parent Versions (ADIS C/P) [18] The ADIS-C/P is a semi-structured clinician rated interview. It provides differential diagnosis for anxiety and mood disorders based on the DSM-IV-TR criteria. OCD diagnoses derived from the ADIS were all in agreement with a clinical interview completed by an independent doctoral-level clinician. Childhood Retrospective Perfectionism Questionnaire (CHIRP) [15] Description regarding the CHIRP and the modifications made to the measure for the present sample is described above. Children’s Yale–Brown Obsessive–Compulsive Scale (CYBOCS) [17] The CYBOCS is a clinician-rated interview that consists of both a ten item severity scale and checklist of obsessive–
compulsive symptoms. The CYBOCS is the considered the gold-standard to assess OCD, severity and impairment in youth [19]. Scores for obsessions, compulsions and composite total severity scores are provided. Binary outcomes for obsessive compulsive symptom dimensions were assessed via the CYBOCS-SC [20]. The presence of a symptom dimensions was determined by the presence of any clinical symptom within that dimension. The CYBOCS has demonstrated sound psychometric properties, including good reliability and validity [17, 21]. Internal consistency for the CYBOCS was good in the present sample (a = 0.85). A random 13 % of the sample were reviewed for inter-rater reliability, and reliability was deemed high (ICC = 0.96) [16]. Obsessive Compulsive Inventory: Child Version (OCI-CV) [22] The OCI-CV is a 21-item youth self-report measure that assesses specific obsessive compulsive symptom types. The items ask the youth to rate the frequency of these symptoms in the last month, from 0 (never) to 2 (often). The OCI-CV provides a composite score as well as scores for the following factorially derived subscales: hoarding, neutralizing, obsessions, washing, ordering, doubting, and checking. The OCI-CV total score and subscale scores have demonstrated strong internal consistency, test–retest reliability, and treatment sensitivity [22, 23]. Internal consistency for the OCI-CV was excellent for the present sample (a = 0.92). Child Sheehan Disability Scale: Parent (CSDS-P) [24] The CSDS-P allows parents to rate the degree of impairment a youth’s OCD symptoms have on the parent’s work, social life, and family home life as well as the parent’s perception on the degree to which the youth’s OCD symptoms have impaired his/her social, academic and family domains. The CSDS-P has demonstrated good reliability and validity [24]. In the present sample, the CSDS-P had good internal consistency (a = 0.87). The Multidimensional Anxiety Scale for Children (MASC) [25] The MASC is a youth self-report measure, which assesses general, social, and separation anxiety in youths. The MASC has 39 items on a four point Likert scale, which ranges from 0 (never true about me) to 3 (often true about me) scale and provides a total composite score. The MASC provides several subscales, including perfectionism, social anxiety, and performance fears. The measure has demonstrated good psychometric properties, including good
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internal consistency, test–retest reliability, and convergent and divergent validity [25, 26]. The MASC demonstrated excellent internal consistency in the present sample as well (a = 0.92). The Perfectionism subscale of the MASC has also been utilized in previous studies to examine perfectionism in children and adolescents [27, 28]. Children’s Depression Inventory–Short Form (CDI-SF) [29] The CDI-SF is a ten-item youth self-report measure that assesses the presence of depressive symptoms in the past 2 weeks. The internal consistency of the CDI-SF in the present sample was good (a = 0.85). Analytic Plan Two-factor CFA models were examined to evaluate the factor structures of the CHIRP. While larger sample sizes are considered optimal, previous research indicates that CFAs can be well employed with smaller sample sizes, particularly when a simple model (e.g., few factors, no indirect effects) is tested [30]. The CFA model was constructed using Mplus version 7 [31]. The model hypothesized the presence of two theoretically based factors: perfectionism/inflexibility and preoccupation with details (see Fig. 1). As the data is categorical, the robust weighted least squares (WLSMV) estimator was used for parameter estimation. The comparative fit index (CFI) and root mean square error of approximation (RMSEA) were utilized to determine model fit [32, 33]. The following scores suggest good fit: CFI [ 0.9 [32]; RMSEA \ 0.08 [34]. Modification indices were also examined to determine model fit, where values above 10 were indicative of parameter estimations that should be modified [35]. Factor loadings B 0.40 were considered poor, while scores [0.40 were considered acceptable. Item reliability was examined via corrected item-total correlations, where items with a correlated value \0.30 are considered poor items [36]. Poor items were considered for removal from the measure, depending on corrected itemtotal correlation and theoretical relevance [35]. Cronbach’s alpha was used to assess the internal consistency of the CHIRP and their factor scores. Alphas of 0.60 were defined as ‘‘questionable’’, 0.70 as ‘‘acceptable’’, and 0.80 as ‘‘good’’ [37]. Pearson’s product moment correlation coefficients were computed to examine divergent validity and convergent validity as well as associations between CHIRP and measures of OCD symptom presentation and severity, parent-reported OCD-related impairment, and youth-reported anxiety and depressive symptoms. Finally, the relationship between OCPT and OCD symptom dimensions were evaluated utilizing logistic regressions.
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Results Model Fit The minimum fit function Chi square of the two factor 20-item CFA model was significant (v2 (196) = 231.40, p = 0.001), reflecting inadequate fit; however, the Chi square estimation is biased towards sample size, where larger sample sizes and models with more variables are more likely to result in a significant Chi square. The CFI (0.87) reflected poor fit; however, the RMSEA (0.06) reflected adequate fit. Modification indices did not suggest any parameter modifications were necessary to improve model fit. An examination of the factor loadings indicated that the following four items were a poor fit for the CFA model (see Fig. 1): 4a. If you had pets, did your child take looking after their pets to extremes; 6a. Could your child be described as someone who was inflexible?; 6c. Could your child cope with changing plans at short notice?; and 6d. Did you child like to have written plans or have intricate details about events or activities spelled out so they know what was going to happen? The second CFA model removed these four items, as well as item 4b (Does your child have any other hobby, which is taken to extreme or where they place supreme effort to the exclusion of other activities), due to the item’s poor itemtotal correlation (see Fig. 2). The minimum fit function Chi square of the re-specified CFA model was significant (v2 (89) = 123.21, p = 0.01); however, the v2 value decreased, while the p value increased, suggesting that the re-specified model was a better fit than the original model. The CFI (0.93) also improved in the new model, while the RMSEA (0.06) remained the same. Based off the above, the re-specified CFA model was considered to have acceptable model fit. Confirmatory Factor Analysis See Fig. 2 for final 15-item CFA model. Items 6c and 6e loaded poorly onto the perfectionism/inflexibility factor; however, the two items were not removed due to the theoretical relevance of the items. All other items had adequate factor loadings for each factor. Item Analysis and Internal Consistency Corrected item-total correlations are presented in Table 1. Items 4a, 4b, 6a, 6c, 6d, and 6e demonstrated low itemtotal correlations (\0.30), while all other items were adequate (see Table 1). The items that were flagged as poor items corresponded with items that also had poor factor loadings in the original CFA. These items, excluding item 6e (which was kept in the measure for theoretical relevance), were omitted from the final 15-item CHIRP.
Child Psychiatry Hum Dev Fig. 1 Two-factor CFA model of the 20-item CHIRP
The frequency of endorsements of individual items for the 15-item CHIRP is presented in Table 2. Items reflecting inflexibility (i.e., difficulty with periods of transition, child can be described as stubborn) were most frequently endorsed. Average score for the 15-item CHIRP total was 4.99 (SD = 2.99). Cronbach’s alpha was acceptable for the 15-item CHIRP total (a = 0.76). Acceptable internal consistency was also demonstrated for the perfectionism/ inflexibility (a = 0.71) and preoccupation with details (a = 0.71) factors. Correlations Among Study Measures As seen in Table 3, the 15-item CHIRP was both moderately and significantly correlated with the OCI-CV total, as
well as the OCI-CV subscales of washing, ordering, and doubting. The CHIRP was also significantly correlated with child reported depressive symptoms (CDI), child reported internalizing symptoms (MASC total), as well as child-reported perfectionism symptoms (MASC perfectionism). However, the CHIRP was not significantly correlated with obsessive–compulsive symptom severity (CYBOCS), or parent reported disability (SDS-P). The CHIRP perfectionism/inflexibility subscale was significantly associated with the child-reported washing symptoms (OCI-CV) and child reported perfectionism (MASC Perfectionism), but was not associated with OCICV subscales of doubting, obsessions, ordering, hoarding or neutralizing, as well as MASC subscales of social anxiety or performance fears (see Table 3). The CHIRP
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Child Psychiatry Hum Dev Fig. 2 Two-factor CFA model of the modified 15-item CHIRP
preoccupation with details subscale was significantly associated with the OCI-CV subscales of doubting, washing, and ordering, but was not associated with obsessions, hoarding and neutralizing subscales The preoccupation with details subscale was also not associated with the MASC subscales of perfectionism, social anxiety, and performance fears.
checking, symmetry, and contamination dimensions (see Table 4). In other words, those with increased OCPTs were 1.26 times more likely to have checking symptoms, 1.21 times more likely to have symmetry symptoms, and 1.23 times more likely to have contamination symptoms. The CHIRP did not significantly predict the hoarding or sexual/ religious dimensions.
Associations with Symptom Dimensions
Discussion Five logistic regressions were employed to examine the association between OCPTs (based on the 15-item CHIRP) and OCD symptoms dimensions (as determined by the CYBOCS-SC). A composite score of the 15-item CHIRP was utilized as the independent variable. These analyses suggested that the 15-item CHIRP significantly predicted the probability of having OCD symptoms that were within the
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Despite the increased interest in understanding and evaluating comorbid OCPD and OCD, there are currently no measures that assess for OCPTs in youth with OCD. From the results of this study, the modified 15-item CHIRP has demonstrated adequate psychometric properties and would be an acceptable measure to evaluate the presence of
Child Psychiatry Hum Dev Table 1 Item reliability for 20-item CHIRP Item
Mean if item removed
Variance if item removed
Corrected item-total correlation
Cronbach’s alpha if item deleted
1a
6.20
11.55
0.490
0.71
1b
6.10
11.81
0.379
0.72
1c
6.28
12.02
0.378
0.72
1d
6.21
11.96
0.362
0.72
2a
6.26
12.10
0.336
0.73
2b
6.29
11.81
0.459
0.72
2c
6.35
12.18
0.374
0.72
2d
6.23
11.83
0.414
0.72
3a
6.42
12.43
0.360
0.73
3b
6.28
12.16
0.330
0.73
3c 4a
6.28 6.51
12.06 13.15
0.362 0.171
0.72 0.74
4b
6.36
12.52
0.258
0.73
5a
6.09
11.94
0.337
0.73
5b
6.24
12.09
0.333
0.73
6a
5.99
12.34
0.218
0.74
6b
5.88
12.13
0.300
0.73
6c
6.08
13.56
-0.120
0.76
6d
6.09
12.63
0.136
0.74
6e
6.01
12.18
0.265
0.73
Table 2 Frequency of endorsement on the 15-item CHIRP Item
Yes (%)
1a. At school does your child put more effort into their school work because of attention to detail or perfectionism, than their friends/classmates?
32
1b. In your opinion does your child spend more time on homework than others?
41
1c. Is your child’s work always exceptionally neat? (e.g., do they redo a piece of work if it had errors in it even if there was just one mistake?
26
1d. Does your child always strive for the best mark at school or get upset if they are not always top of the class?
31
With regard to self-care and appearance, is your child excessively concerned with: 2a. Making sure their appearance is just right (e.g., their hair parting is straight or symmetrical, etc., without bumps, etc.?) 2b. Making sure their clothes are coordinated (e.g., colour and style)
26 25
2c. Order and symmetry with their appearance (e.g., hair/hems/cuffs)
25
2d. Does your child spend excessive time and effort on matters of personal hygiene (e.g., cleaning their teeth, washing their hands, etc.)?
19
3a. Does your child spend an excessive amount of time making their room tidy and organised?
10
3b. Do they like to make sure that everything was ‘‘just so’’ and in its proper place?
26
3c. Is your child excessively concerned about order and symmetry (e.g., lining things up)?
25
5a. Is your child excessively careful to obey rules and not put a foot wrong?
42
5b. Is your child excessively careful and cautious (e.g., with a tendency to hoard money, sweets, toys, etc.)
28
6b. Does your child find periods of transition more difficult than their peers, e.g., difficult to adjust to changes in school, home or the family?
63
6e. Could your child be described as stubborn (determined)? For example, if they made up their mind to do something, would they carry it through no matter what?
52
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Child Psychiatry Hum Dev Table 3 Associations between study measures
CHIRP 15-item total
CHIRP perfectionism
CHIRP self-care
CY-BOCS total
0.128
0.164
0.032
OCI total
0.382**
0.238*
0.381**
OCI doubting
0.279**
0.150
0.304**
OCI obsessions
0.145
0.138
0.07
OCI washing
0.352**
0.226*
0.343**
OCI ordering
0.324**
0.146
0.385**
OCI hoarding
0.071
0.022
0.096
OCI neutralizing
0.163
0.123
0.138
MASC total
0.235*
0.243*
0.238*
MASC perfectionism
0.231*
0.234*
0.129
MASC social anxiety
0.062
0.071
0.027
MASC performance fears
0.023
0.026
0.009
CDI
0.229*
0.123
0.250*
SDS-P
0.095
0.136
0.010
CHIRP Childhood Retrospective Perfectionism Questionnaire, OCI Obsessive Compulsive Inventory, MASC The Multidimensional Anxiety Scale for Children, CDI Child Depression Inventory, SDS-P— Sheehan Disability Scale—Parent * p \ 0.05; ** p \ 0.01 Table 4 Logistic regression of CHIRP predicting likelihood of symptom dimensions Symptom dimension
B
SE
df
Odds ratio
95 % CI
Checking
0.23
0.09
1
1.26*
1.04–1.51
Symmetry/order
0.19
0.10
1
1.21*
1.01–1.47
Sexual/religious
0.08
0.07
1
1.08
0.95–1.23
Hoarding
0.07
0.07
1
1.07
0.93–1.23
Contamination
0.21
0.08
1
1.23*
1.05–1.45
* p \ 0.05
OCPTs in youth with OCD. The CFA indicated that the majority of CHIRP items had strong factor loadings on the perfectionism/inflexibility and preoccupation with details factors. The two items that had poor loadings (6b and 6e) were kept within the model based on theoretical relevance as previous factor analyses of OCPD diagnostic criteria have identified rigidity and inflexibility as core features of OCPD [38, 39]. The CHIRP total and the two subscales demonstrated acceptable internal consistency. The significant associations between the CHIRP Perfectionism/Inflexibility subscale and the MASC Perfectionism subscale as well as the significant associations between the CHIRP preoccupation with details subscale and the OCI-CV Doubting and Ordering subscales are suggestive of convergent validity. The two subscales did not converge with the OCI-CV Obsessions and Neutralizing subscales, or the MASC Social Anxiety and Performance subscales, demonstrating divergent validity. The 15-item CHIRP was not associated with OCD severity or parent-reported OCD-related impairment;
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however, this is in line with findings from previous research with adults with comorbid OCPD and OCD [6, 40]. These findings may be attributed to the developmental age of the sample as personality traits are fluid during childhood and adolescence and, therefore, may be more susceptible to change. OCPTs may also contribute to greater psychosocial impairment rather than functional impairment, particularly as parents may accommodate youth to ensure that functional impairment is minimized. Parents may also maintain (or reinforce) specific aspects of the youth’s OCPTs (e.g., perfectionist tendencies, rigidity to routines); therefore, parents may not perceive these behaviors to be problematic or excessive. Youth with increased OCPTs were also found to have a greater likelihood of having OCD symptoms in particular symptom dimensions, specifically symptoms related to checking, contamination or symmetry. Similarly, studies with adults have noted that OCPD is associated with greater contamination, symmetry, and doubting symptoms [4, 7, 13]. While these results are compelling, longitudinal studies are necessary to evaluate the trajectory of childhood OCPTs into adulthood and determine whether OCPTs may serve as a marker for OCD youth who are at risk of developing OCPD. From our current sample, other than tic disorder, GAD was the most prevalent comorbid diagnosis. As perfectionism is common in GAD, there is a possibility that the perfectionism features captured by the CHIRP may be reflective of GAD rather than OCPD. However, studies of GAD have found that rather than perfectionism or need for control, intolerance of uncertainty is the main feature that
Child Psychiatry Hum Dev
is involved in the development and maintenance of GAD related worries [41]. In OCD and OCPD, however, perfectionism is a core feature of these disorders and manifests differently between OCD and OCPD. Perfectionism in OCD is strongly associated with doubt. The need to do something in precisely the right way drives an OCD individual to engage in rituals until a ‘‘just right’’ feeling is achieved. When perfect certainty is not achieved, those with OCD experience intense feelings of doubt, which may manifest into checking and repeating rituals [42, 43]. In OCPD, perfectionism is associated with ‘‘self-imposed high standards of performance’’ [3], rather than motivated by feelings of doubt/anxiety that arises when perfection is not achieved. The perfectionism items in the CHIRP specifically targeted the type of perfectionism associated with OCPD. Items included questions such as ‘‘Did your child always strive for the best mark in school?’’ and ‘‘Did you put more effort into your schoolwork because of attention to detail or perfectionism?’’ The present study had several limitations. First, while the sample size was considered adequate, the CFA model may have benefited from a larger sample. Second, there was no comparison group that could be utilized to evaluate the possible differences in OCPT symptoms within the OCD group. Third, as the CHIRP is a binary measure that only allows for yes/no answers, the measure may not have captured the continuum at which OCPTs may manifest in youth, thereby constraining the responses with floor and ceiling effects. Fourth, as only parent report responses on the CHIRP were taken into account, child reports may result in different outcomes; however, studies have noted that parent reports may be more accurate than child reports [21]. Fifth, the reliability of the original CHIRP was not strong and only one validation study was conducted for this measure. Still, the modified CHIRP demonstrated improved psychometric properties compared to the original CHIRP. Finally, all participants were part of treatment-seeking families, whereas non-treatment seeking families may experience a higher prevalence of OCPTs. Within these limitations, this was the first study to examine the psychometric properties of the CHIRP in youth with OCD, as well as the first to investigate the presence of OCPTs in this population. Additionally, as previous studies have only examined OCPTs in childhood retrospectively, this is also the first study to examine OCPTs in childhood in present time. Several directions for future investigation are highlighted. First, studies should work towards replication and further validation of the measure in a larger sample size as well as in non-OCD samples. While associations between the two factors and subscales on the MASC suggested convergent and divergent validity, this should be further examined by utilizing clear convergent measures (specific measures of perfectionism/inflexibility and preoccupation to details)
Study in non-OCD samples will help determine if the rate of OCPTs in OCD samples is developmentally normative for this age group or pathological. Second, studies should evaluate the role of family accommodation in OCD youth with OCPTs, as well as the rate of behavioral difficulties (e.g., oppositional behaviors) and psychosocial impairment. Finally, the impact of OCPTs on treatment outcome in youth with OCD should also be examined.
Summary While OCPTs in adulthood are often associated with a number of psychiatric conditions (e.g., OCD, anorexia), there is evidence that suggests that these traits may manifest during childhood. Unfortunately, research in OCPTs in childhood is hindered by the lack of psychometrically valid measures. In this study we found that a modified 15-item CHIRP may be an appropriate measure of childhood OCPTs. While OCPTs were not associated with OCD severity or impairment, there were associations found between OCPTs and various symptoms dimensions, including contamination, symmetry and doubting symptoms. Consideration of the presence of OCPTs can provide important information in regards to prognosis, treatment development, and treatment success among youth with OCD.
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