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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 38  |  Issue : 3  |  Page : 237-242

Role of insight and self-efficacy in persons with obsessive–Compulsive disorder


1 Department of Clinical Psychology, Center of Excellence in Mental Health, ABVIMS and Dr. RML Hospital, New Delhi, India
2 Department of Clinical Psychology, IHBAS, Delhi, India
3 Department of Psychiatry and Drug-De Addiction Center, Center of Excellence in Mental Health, ABVIMS and Dr. RML Hospital, New Delhi, India

Date of Submission11-Jul-2020
Date of Decision29-Oct-2020
Date of Acceptance28-Nov-2020
Date of Web Publication24-May-2022

Correspondence Address:
Dr. Prerna Sharma
Department of Clinical Psychology, IHBAS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_203_20

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  Abstract 


Objectives: Obsessive–compulsive disorder (OCD) is estimated to be the 10th leading cause of disability in the world with a point prevalence of OCD at 3.3%. The present study was aimed at understanding the role of insight and self-efficacy in OCD and the relationship between these variables with OCD severity. Materials and Methods: It was a cross-sectional correlational study. The sample consisted of 100 males and females with a diagnosis of OCD. The variables were measured using the Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) Symptom Checklist, Y-BOCS II, Brown Assessment of Beliefs Scale, and Self-Efficacy Scale. Results: The study revealed that a large portion of the patients fell in the “Severe”' range on Y-BOCS. Females reported a higher percentage of contamination and ordering obsessions as compared to males. Thirty-seven percent (37%) of the patients scored “Average” on self-efficacy results. A positive correlation between OCD severity and insight was found. Conclusion: Findings have important implications in clinical settings and can be used in the development of more focused, brief intervention strategies based on insight and self-efficacy. The primary limitation of the study was that data were obtained in a tertiary care hospital from an urban setting.

Keywords: Insight, obsessive-compulsive disorder, self-efficacy


How to cite this article:
Bhardwaj N, Sharma P, Shekhawat LS. Role of insight and self-efficacy in persons with obsessive–Compulsive disorder. Indian J Soc Psychiatry 2022;38:237-42

How to cite this URL:
Bhardwaj N, Sharma P, Shekhawat LS. Role of insight and self-efficacy in persons with obsessive–Compulsive disorder. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Oct 3];38:237-42. Available from: https://www.indjsp.org/text.asp?2022/38/3/237/345814




  Introduction Top


“Insight is the patient's awareness and understanding of their attributions, feelings, behavior, and disturbing symptoms; self-understanding.”[1] With respect to obsessive–compulsive disorder (OCD), acknowledgment of the irrational and unreasonable nature of OCD symptoms by the patients has been inferred to as insight. Insight exists on a continuum, with some people acknowledging that their obsessions are illogical, and others having a very strong belief in the validity of their obsessions and compulsions. Self-efficacy refers to “an individual's belief in his or her capacity to execute behaviors necessary to produce specific performance attainments.”[2] Self-efficacy is learned, organized (in the way it is applied to the self), and dynamic in nature. A number of studies on the adoption of health practices have measured self-efficacy to assess its potential to initiate behavior change. It is imperative to see the role and interplay between insight and self-efficacy – the way an individual views self and the environment; in the manifestation and maintenance of OCD. Poor insight is correlated with poor engagement with treatment, which may lead to high dropout rates, exacerbation of symptoms, relapse, and re-hospitalization.[3] Self-efficacy impacts mental health symptoms such as depression, anxiety, worry, and social avoidance.[4] Hence, fair to good insight and higher self-efficacy have been found to play an important role in the therapeutic outcome of people with mental illnesses. Focusing on these measures in the initial phase of treatment can save time and effort for more intensive therapies, thus providing impetus for better management and prognosis for the disorder.


  Materials and Methods Top


Participants

The participants in this cross-sectional study were those seeking treatment from psychiatry outpatient services and indoor patient department in a tertiary care institute of North India. The study protocol was approved by the Ethics Review Board of the Institute. Participants were recruited through purposive sampling and were assessed only once. The purpose of the study was explained, and confidentiality was assured to the participants. Those who provided written informed consent were included. The participants included were both males and females diagnosed with OCD (F.42) as per ICD-10, within the age group of 18–65 years. Participants were recruited from OCD clinic where they were seeking treatment. Persons with any other comorbid psychiatric/neurological conditions except nicotine dependence were excluded from the study. Sociodemographics profile and clinical characteristics for each patient were recorded. Assessments were conducted using standardized scales. The researcher was trained in the administration of the questionnaires and conducted five pilot interview sessions under supervision before data collection for the present study was started. The duration of the study was 9 months, in which a total of 100 males and females were included in the study. We recruited an adequate number of participants (n = 100) to be able to detect a medium effect size (0.03) with power of 0.8 for correlational analysis in this cross-sectional observational study. One hundred and thirteen patients of OCD were referred by treating psychiatrist after providing the information regarding the purpose and the procedure of the study, 13 patients refused owing to their personal reasons. Finally, a total of 100 persons with OCD were enrolled for analysis. The average time taken for the administration of the tools was 25 min. Patients sought treatment as usual in the psychiatry outpatient department for pharmacological as well as therapeutic interventions.

Assessment

OCD phenomenology and symptom severity were assessed using the Yale Brown Obsessive–Compulsive Scales (Y-BOCS) – checklist and symptom severity.[5] Y-BOCS is the most widely used instrument used to assess OCD symptoms and their severity. It is freely available for use. The list generates a target symptoms list by ticking both current and past symptoms. The Y-BOCS-II-SC shows good convergence with self-reported obsessive–compulsive symptoms. Y-BOCS provides a five rating dimension for obsessions and compulsions: time spent, interference with functioning or relationships, degree of distress, resistance, and control. It is scored on a 0-4 Likert scale from 0 = no symptoms to 4 = extreme symptoms. The patient is categorized as having subclinical, mild, moderate, severe, and extreme OCD. The scale has good internal consistency and interrater reliability.[6] Brown Assessment of Beliefs Scale (BABS) is freely available online for clinical use to rate the degree of conviction and insight, in patients regarding their beliefs.[7] This semi-structured instrument consists of seven items. Each item is rated on 4-point Likert type scale. It demonstrated excellent interrater and test–retest reliability and strong internal consistency.[8] Self-efficacy scale (SES),[9] The Hindi version was purchased for the purpose of this study. This self-administrated scale is used for 14 years and above. It consists of 22 items, measuring across eight factors: self = regulatory skills, self-influence, self-confidence, social achievement, self, self-evaluation, self-esteem, and self-cognition. Items are rated on 5-point Likert type scale, categorized from very poor to above average self-efficacy scores.

Statistical analyses

Descriptive statistics was used for analysis of sociodemographic, clinical variables, and categorical variables of Y-BOCS-SC, Y-BOCS II, BABS, and SES. Insight was considered as continuous variable and was described as range and percentiles. Data were checked for normality using the Kolmogorov–Smirnov test. Mean differences were computed with Student's t-test/Chi-squared test was applied to compare two groups. Pearson correlation coefficients were calculated to see the relationship of OCD severity, insight, and self-efficacy. Analysis was conducted using SPSS software version 21.0 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. USA).


  Results Top


Sociodemographic and clinical characteristics

The sample consisted of 100 patients, aged between 18 and 65 years. Out of the 100 patients, 56% were male and 44% females. The majority of the sample was educated up to the secondary level (43%). More than half of the sample (65%) was unemployed. Fifty-three percent (53%) of the sample was married, 81% of the individuals belonged to Hindu religion. Sample predominantly belonged to middle socioeconomic status (59%) and from an urban background (59%). The majority of the patients (80%) were living in nuclear family setup. Twelve percent (12%) of the sample reported a comorbid physical illness, for which treatment was being sought [Table 1].
Table 1: Sociodemographic and clinical characteristics of the participants (n=100)

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Clinical characteristics on Yale-brown obsessive–compulsive scale, Yale-brown obsessive–compulsive scale symptom checklist

The mean value of OCD severity score was 24.29 (±6.38); 44% of the sample lied in severe range (24–31) on Y-BOCS. Nearly 27% had moderate severity and 12% has mild severity at the time of interview. Patients with mild severity had a maximum three symptom domains, patients with moderate severity had 4–7 number of symptom domains, and patients with severe OCD had 8–11 number of symptom domains. Nearly 51% of samples had 4–7 symptom domains, which had moderate severity. Contamination/cleaning domain (73%) was the most frequently recurring symptom. Hoarding (13%) and ordering (10%) were the least occurring OCD symptoms. Symmetry-related obsessions (34%) were found to present equally across both genders.

On BABS, mean and standard deviation (SD) scores on insight in patients of OCD were found to be 8.16 ± 3.717. This may be inferred to as “Fair” level of insight (Phillips, 2017). Only two participants (2%) in the data scored equal to/above the cutoff score (18) on BABS signifying the presence of delusional beliefs.

On self-efficacy, 3737% had “Average” score of self-efficacy; more males reported “Average” scores in comparison to females. Furthermore, more females scored within the Below Average” category of self-efficacy. Only 4% of the patients (exclusively females) reported “Very Poor” Self-efficacy. Overall females were found to have lower level of self-efficacy, with only three females and ten males obtaining “Above Average” scores.

Correlation between obsessive–compulsive disorder severity, insight, self-efficacy, and number of obsessive–compulsive disorder domains

There was a positive correlation between OCD severity and Insight (r = 0.335, P < 0.01) which means that higher OCD severity lower the insight (higher scores on BABS) in OCD patients. Self-efficacy was not found to have a significant relationship with OCD Severity although number of OCD types is significantly correlated to self-efficacy (r = 0.266, P < 0.01). The higher the number of OCD domains in a person, higher the self-efficacy [Table 2].
Table 2: Correlation coefficients (r) of the interval level variables (n=100)

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Differences in variables across gender

Significant difference (t{98} = 3.30, P < 0.01) was found between the two groups of males and females across the level of self-efficacy. Females scored lower on self-efficacy (μ = 3.02, SD = 1.05) in comparison to the males (μ =3.68, SD = 0.94). Significant difference in the number of OCD symptom domains was also found between the two genders where by men had a higher mean value (μ = 5.20, SD = 2.47) in comparison to the females (μ = 3.95, SD = 2.08), and this difference was found to be significant (t{98} = 2.74, P < 0.01) [Table 3].
Table 3: Difference between males and females on outcome measures (n=100)

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  Discussion Top


The present study was designed to understand the role of insight and self-efficacy in persons with OCD. The majority of the sample was educated up to secondary level, married, belonging to middle socioeconomic strata, urban background living in the nuclear setup, and mostly unemployed. Reasons for unemployment were discontinuation of work due to severity of symptoms owing to burden of illness. Almost equal prevalence ratio of OCD in male to female as found in our study is replicable to the Indian population with OCD. Studies quote an almost equal prevalence of OCD (1:1.67) across genders with a slight skew toward the males in some others.[10] Being male also seems to be a risk factor in early onset cases.[11] Nearly 37% of the sample belonged to the age group of 26–35 years. This age group of young adults is most productive years and adults with OCD in this age may have lower success due to loss of productive years because of disability. Nearly 92% of patients had a history of previous treatment, which suggests prolonged illness, hence adding to the loss of productive years. Earlier evidence shows economic impairment and unemployment as well as low academic success have been related to OCD.[11] With the loss of income due to unemployability and challenges of urban living as well as the responsibility of taking care of nuclear family system, it is a challenge for people with OCD to seek regular, weekly consultations for therapy because of various psychosocial factors.

The present study found a positive correlation between OCD severity and insight. In our sample, higher the OCD severity, lower the level of insight in the OCD patient. Insight is considered a predictor of success in the treatment of OCD. Individuals with poor insight tend to become refractory to treatment.[12] Poor insight has also been linked to greater symptom severity, an increased risk of comorbid symptoms, worse adaptive functioning, and worse treatment outcomes for OCD. Reduced insight is related to a longer duration of illness, early onset of symptoms, chronic course, and increased family history of OCD.[13] Future investigations with a larger sample size could draw significant results.

OC symptoms (washing, checking and precision) were also seen to be compensating for poor academic scores and self-efficacy. These symptoms are also linked to a significant increase in general self-efficacy.[14] OCD control-related beliefs are an important component of OCD phenomenology and suggest that a multidimensional understanding of low perceived control including elements of self and world controllability that should be incorporated into contemporary cognitive-behavioral models of OCD.[15] Most patients scored less than average on self-efficacy. In past researchers found that generalized self-esteem and social adequacy in persons with OCD when compared against a nonclinical control group was found to be significantly lower.[16] Addressing self-ambivalence in OCD could be helpful in enhancing self-efficacy to have a better therapeutic outcome.[17] The number of symptom domains was significantly related to self-efficacy in OCD patients. The persons with more symptoms were found to have increased self-efficacy. These patients had more compulsive symptoms such as checking and cleaning. These findings suggest that compulsive behaviors are performed by patients as behavioral strategies to increase feelings of self-efficacy. Patients may feel better and in control of their surroundings by performing the compulsions, especially if insight into the illness is also poor.

On gender differences, females were found be less self-efficacious than their male counterparts. More males belonged to “average” range on self-efficacy, whereas females mostly belonged to the “below average” range of self-efficacy. In addition, only females scored in “very poor” category of self-efficacy and no male scored having very poor self-efficacy. Gender as a social construct is inherently significant. Gender and cultural roles expected from females at large may play a role in their unique manifestations of different psychiatric symptoms. Women were more likely to present symptoms of the aggressive, contamination/cleaning, and hoarding dimension.[18] The difference in phenomenological presentations of OCD across gender is well studied.[18] Self-efficacy also varies across gender owing to cultural difference. However, the ability to cope with a psychiatric condition may also be different in females due to factors such as lack of awareness owing to lack of education, less access to treatment options, financial dependence, and lack of autonomy to take health-based decisions in many parts of the low- and middle-income countries like India.[19] Males report a higher number of symptoms and higher self-efficacy as well which is supported with previous literature.[20] Male patients may have the opportunity to perform their compulsions uninterruptedly at home or outside, whereas females may be socially hindered or discouraged from doing the same due to socially imposed restrictions or other gender roles.

A study showed the effects of a 1 day cognitive behavioral therapy (CBT) psychoeducational workshop on self could be explored and extended for OCD as well before more traditional models of therapy are used with persons with OCD.[21] Recommendation of the current study includes utilizing brief techniques such as Schwartz “cognitive-bio-behavioral self-treatment”[22] method to teach patients on how to manage symptoms on their own based on increasing self-efficacy as they wait to get enrolled into traditional, long-term therapy. Well-extended literature must be produced to corroborate with the current findings. The findings based on gender and focusing on their unique needs can go a long way in maintaining treatment effects in patients well after psychotherapy interventions. In low-resource settings where less trained professionals are available as well as tertiary care settings where the burden of care is extensive, these findings may influence the choice between conducting brief therapies which focus on prognostic factors such as insight and self-efficacy before undertaking intensive Cognitive Behavioral Therapies (CBT)/Exposure and Response prevention (ERP) sessions due to feasibility. In our study, low insight could indicate less psychological sophistication in majority of the sample who is also less educated; hence, intensive therapies such as CBT or cognitive restructuring might take a longer time or may not be even possible in some cases.

Limitations of the study

Comorbid psychiatric illness in the sample was not taken into account; if it had any influence on self-efficacy or insight. We did not take into account if patients were seeking psychotherapy previously or simultaneously during the interview, which may have bearing on the findings. A larger sample size could have allowed for more rigorous statistical analysis; regression analysis could have been performed to understand the predictors of said results. Since it was a cross-sectional study, a longitudinal study would be able to follow-up on changes in patients' insight and self-efficacy posttherapy, further delineating the variables' role.


  Conclusion Top


From the public health perspective, briefer and shorter interventions could take lesser time and less trained professionals. Interventions where self-efficacy is assessed and compared to baseline results after engaging the client with briefer therapies such as problem-solving techniques, stress management strategies, and other coping-related fundamentals may prolong the effects of therapy, improve overall functionality and general well-being. Keeping the potential of such trainings in view community health workers, counselors could be trained to deliver basic counseling for patients in developing insight and teaching mastery experiences which are components of self-efficacy. For future directions, longitudinal studies could be planned to compare the treatment as usual with intensive psychotherapies for OCD versus focused and shorter interventions to incorporate self-efficacy and insight enhancement. Pre- and post-studies could be planned to test the efficacy and effectiveness of such models.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Kalafat T, Kağan M, Boysan M, Güngör İ. Associations between academic competence and obsessive-compulsive symptoms among adolescents. Procedia Soc Behav Sci 2010;5:309-13.  Back to cited text no. 14
    
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Tripathi A, Avasthi A, Grover S, Sharma E, et al. Gender differences in obsessive-compulsive disorder: Findings from a multicentric study from northern India. Asian J Psychiatry 2018;37:3-9.  Back to cited text no. 19
    
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Brown JS, Elliott SA, Boardman J, Andiappan M, Landau S, Howay E. Can the effects of a 1-day CBT psychoeducational workshop on self-confidence be maintained after 2 years? A naturalistic study. Depress Anxiety 2008;25:632-40.  Back to cited text no. 21
    
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    Tables

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