www.elsevier.com/locate/psychres

Psychiatry Research 127 (2004) 267–278

Perceived parental rearing style in obsessive–compulsive disorder:

relation to symptom dimensions

Pino Alonsoa, Jose M. Menchona, David Mataix-Colsb, Josep Pifarrea,Mikel Urretavizcayaa, Jose M. Crespoa, Susana Jimeneza,

Gema Vallejoa, Julio Vallejoa,*

aObsessive–Compulsive Disorder Clinical and Research Unit, Department of Psychiatry, Hospital Prıncipes de Espana,

Ciudad Sanitaria y Universitaria de Bellvitge, c/ Feixa Llarga s/n 08907, Hospitalet de Llobregat, Barcelona, SpainbDepartment of Psychiatry, Imperial College of Science, Technology and Medicine, Charing Cross Hospital, London, UK

Received 2 May 2002; received in revised form 19 November 2002; accepted 18 February 2003

Abstract

Obsessive–compulsive disorder (OCD) runs in families, but the specific contribution of genetic and environmental factors

to its development is not well understood. The aim of this study was to assess whether there are differences in perceived

parental child-rearing practices between OCD patients and healthy controls, and whether any relationship exists between

parental characteristics, depressive symptoms and the expression of particular OCD symptom dimensions. A group of 40

OCD outpatients and 40 matched healthy controls received the EMBU (Own Memories of Parental Rearing Experiences in

Childhood), a self-report measure of perceived parental child-rearing style. The Yale–Brown Obsessive–Compulsive Scale

(Y–BOCS) and the Hamilton Depression Rating Scale (HDRS) were used to assess the severity of obsessive–compulsive

and depressive symptoms. The Y–BOCS Symptom Checklist was used to assess the nature of obsessive–compulsive

symptoms, considering the following five symptom dimensions: contamination/cleaning, aggressive/checking, symmetry/

ordering, sexual/religious and hoarding. Logistic and multiple linear regression analyses were conducted to study the

relationship between parental style of upbringing, depressive symptoms and OCD symptom dimensions. Severe OCD (Y–

BOCS: 27.0F 7.4) and mild to moderate depressive symptoms (HDRS: 14.0F 5.4) were detected in our sample. Compared

with healthy controls, OCD patients perceived higher levels of rejection from their fathers. No differences between the

groups with respect to perceived levels of overprotection were detected. The seventy of depressive symptoms could not be

predicted by scores on any perceived parental characteristics. Hoarding was the only OCD symptom dimension that could be

partially predicted by parental traits, specifically low parental emotional warmth. Social/cultural variables such as parental

child-rearing patterns, in interaction with biological and genetic factors, may contribute to the expression of the OCD

phenotype.

D 2004 Published by Elsevier Ireland Ltd.

Keywords: Family; Symptom dimensions; Depression

1. Introduction

0165-1781/$ - see front matter D 2004 Published by Elsevier Ireland Ltd

doi:10.1016/j.psychres.2001.12.002

* Corresponding author. Tel.: +34-0-93-2607659; fax: +34-0-

93-2607658.

E-mail address: jvallejo@csub.scs.es (J. Vallejo).

Obsessive–compulsive disorder (OCD) is defined

by the presence of obsessions or compulsions that

.

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278268

are a significant source of distress or that interfere

with the patient’s social functioning (American Psy-

chiatric Association, 1994). Although current neuro-

biological theories of OCD emphasize the implication

of dysfunctional corticostriatal circuits in the etiology

of the disorder, behavioral theorists have suggested

that social learning factors may also contribute to its

development in biologically vulnerable subjects. Pa-

rental child-rearing patterns have been proposed as

one of these social factors, but no agreement has been

reached either on the exact influence of parental

behaviors in the development of OCD or on its

relationship to specific obsessive–compulsive symp-

toms (Hoover and Insel, 1984; Rasmussen and

Tsuang, 1984).

Parental behaviors, especially concerning the abil-

ity to express affection and emotional warmth and to

avoid excessive protection, control and criticism,

seem to be important in the development of a

healthy personality. Rejecting and controlling parent-

ing styles have been described as being associated

with a variety of forms of psychopathology, includ-

ing depression, schizophrenia, anxiety disorders,

substance abuse, oppositional child behavior and

eating disorders (Parker et al., 1987; Gerlsma and

Emmelkamp, 1990; De Rutter, 1994; Rapee, 1997).

Most of the studies in this area have focused on the

relationship between anxiety disorders and depres-

sion and parental characteristics. In a review of the

literature related to this last issue, Rapee (1997)

describes two main child-rearing factors. One, which

includes behaviors and attitudes related to negative

or hostile feelings toward the child, is termed rejec-

tion or criticism. The second factor, which refers to

behaviors designed to protect the child from possible

harm, is called parental control or protection. A

rearing style characterized by low parental affection

and high parental control appears to be related to

anxiety disorders and depression, with the most

consistent results obtained for social phobia. Inter-

estingly, some data appear to indicate a somewhat

stronger relationship between parental rejection and

depression and between parental control and anxiety.

Nevertheless, investigation in this area suffers from

great methodological limitations. Most studies have

employed retrospective self-report measures given to

the offspring, a considerably smaller number of

studies have examined child-rearing attitudes by

directly questioning parents, and direct observations

have been rarely conducted. Other methodological

weaknesses include the use of a great variety of

methods and more or less reliable measures to assess

parental characteristics, small sample sizes and the

lack of appropriate comparison groups. Despite all

these limitations, results indicate that a small but

significant amount of variance in anxiety and de-

pression may be accounted for by perceived parental

rejection and control.

Few studies concerning the influence of early

parenting behaviors and attitudes in the development

of OCD have been conducted hitherto. Sub-clinical

obsessive–compulsive subjects have been reported to

perceive their parents as more rejecting, overprotect-

ing and less emotionally warm than normal controls

(Ehiobuche, 1988; Kimidis et al., 1992; Cavedo and

Parker, 1994). Results obtained from clinical samples

are controversial and often contradictory. Hafner

(1988) described high levels of parental overprotec-

tion in 81 subjects (mean age 35.7F 12.5) who were

registered as sufferers in the Obsessive–Compulsive

Neurosis Support Group of South Australia. Subjects

completed the Parental Bonding Instrument (PBI), a

self-report measure of an individual’s perception of

his or her parents’ rearing practices up to the age of

16 years. Methodological weaknesses of the study

include the fact that subjects were not directly

interviewed by the author, diagnosis was established

only on the basis of the results of the Padua Inven-

tory of Obsessions and Compulsions and the Brief

Symptoms Inventory, and the absence of a specific

control group. Employing the EMBU, a self-report

measure of an individual’s perception of his or her

parent’s rearing style during childhood, Hoekstra et

al. (1989) compared 119 compulsive checkers and

cleaners divided into four groups with 277 non-

clinical controls. OCD subjects perceived more re-

jection and less emotional care from their parents

than healthy controls, with higher levels of parental

overprotection being reported only by compulsive

washers. Vogel et al. (1997) employed the PBI to

compare self-reported patterns of parental bonding in

26 OCD (mean age 35.2F 12.1), 34 depressed (mean

age 38.8F 9.2) and 41 healthy subjects (mean age

37.8F 11.2). Patients with a principal diagnosis of

major depressive disorder experienced significantly

lower levels of parental care and significantly higher

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278 269

levels of maternal overprotection than healthy con-

trols, while no significant difference between OCD

and normal subjects was detected. Since the presence

of an additional diagnosis of depression in the OCD

group (46% of the patients) was associated with

significantly lower levels of parental care and higher

levels of parental overprotection, the authors sug-

gested that this parental rearing style may act as a

vulnerability factor more specifically related to the

development of depressive disorders than to OCD.

The principal limitation of this study comes from the

reduced number of OCD patients included in the

analyses. Finally, Turgeon et al. (2002) have recently

employed the PBI and the EMBU to compare

recalled parental behaviors among 43 out-patients

with OCD, 38 out-patients with panic disorder with

agoraphobia (PDA) and 120 non-anxious controls.

Patients with OCD and PDA did not significantly

differ on mean scores on any of the PBI and EMBU

scales. Participants with anxiety disorders compared

with the non-anxious group rated both their mothers

and fathers as more protective. No differences were

found between the anxious and non-anxious groups

on the Emotional Warmth, Rejection and Care scales.

Limitations of this study include the fact that patients

were not recruited from hospital settings but through

advertisements in the media, so they constitute a self-

selected sample, which may not represent general

OCD patients. Another possible weakness may come

from the recruitment of the control group, since

healthy comparison subjects were not directly inter-

viewed by the researchers but just psychiatrically

screened by a telephone interview.

The specific influence of child-rearing patterns on

the development of different obsessive–compulsive

symptoms has also been proposed with inconclusive

results. Rachman and Hodgson (1980), who reported

that parents of OCD patients are frequently described

as overprotecting, overcontrolling and overcritical by

their children, maintained that a distinction could be

established between washers and checkers on this

topic. According to these authors, a different fear

structure, related to upbringing styles, would underlie

the most common forms of ritualistic behavior in

OCD: washing behavior would emerge from over-

protective and overcontrolling families that produce

fearful dependent children, while checking behavior

would be related to overcritical and rejecting parents

who induce excessive fears of making mistakes in

their children. However, this hypothesis has been

only partially supported by later studies. While

Turner et al. (1979) reported no significant differ-

ences between washers and checkers regarding fear

of criticism, Steketee et al. (1985) found that check-

ers more often perceived their mothers as meticulous

and demanding than washers did. Neither study

found any significant differences regarding overpro-

tection between washers and checkers.

Nevertheless, on studying influences of parental

behaviors in the development of obsessive–compul-

sive symptoms, one must not forget that OCD can

have a devastating effect on the quality of family life

(Steketee and Pruyn, 1998). Many families become

dysfunctional as a result of a family member’s OCD

symptoms. Frequently, parents and siblings become

involved in the sufferer’s avoidance behaviors and

compulsions in an effort to relieve the fear and

anxiety that the patient is feeling. Family and lei-

sure-time routines and activities are frequently mod-

ified to accommodate the OCD sufferer. All these

efforts often lead relatives to experience severe feel-

ings of frustration, anger, guilt and loneliness. Child-

rearing patterns may play a role in the development

of OCD, but one should also consider that the

primary presence of obsessive–compulsive symp-

toms in a child may also elicit certain parental

behaviors and attitudes, especially a tendency to

greater rejection and/or protection towards the affect-

ed child.

Thus, the role of parental influences in the devel-

opment of OCD and the relationship between paren-

tal child-rearing traits and OCD subtypes are still

controversial topics. Previous studies employed cat-

egorically defined and mutually exclusive OCD

subgroups, and only differences between washers

and checkers, the most frequent OCD subtypes, were

examined. To our knowledge, no previous studies

have addressed the influence of perceived parental

characteristics in the development of other frequent

obsessive–compulsive symptoms such as hoarding,

sexual/religious themes, symmetry or ordering. Since

a possible influence of current mood state on the

perception of parental rearing style has been postu-

lated and parental rejection has been described as

being associated with depression, we decided to

study whether parental rearing patterns were related

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278270

to the severity of depressive symptoms in our

sample. The three-fold purpose of the present study

was to examine whether (1) there are differences in

perceived parental child-rearing patterns between

OCD patients and healthy controls, (2) any relation-

ship exists between perceived parental characteristics

and previously identified OCD symptom dimensions,

and (3) perceived parental traits are related to the

presence of depressive symptoms in OCD.

2. Methods

2.1. Subjects

Study participants were 40 outpatients consecu-

tively admitted to the OCD Clinic of Bellvitge

University Hospital (Barcelona, Spain) between

1997 and 1999. All patients met DSM-IV criteria

for OCD (American Psychiatric Association, 1994).

Diagnosis was independently assigned by two psy-

chiatrists with extensive clinical experience in OCD,

who separately interviewed the patients using the

Structured Clinical Interview for DSM-IV Axis I

Disorders-Clinician Version (SCID-CV) (First et al.,

1997). Patients were eligible when both research

examiners agreed on all criteria. All patients gave

written informed consent after complete description

of the study. Exclusion criteria were the presence of

any other comorbid axis I disorder and/or any

neurological disorder. During the selection period,

67 outpatients of those referred for examination at

the Department of Psychiatry of our hospital fulfilled

DSM-IV criteria for OCD and were evaluated by the

examiners. Of these patients, 27 were ruled out in

accordance with the exclusion criteria: 18 (26.8%)

because of concomitant major depression or dysthy-

mia, seven (10.4%) because of comorbid anxiety

disorders other than OCD and two (2.9%) because

of fulfilling criteria for eating disorders.

Forty normal comparison subjects, recruited from

residents of the local community, were matched with

patients for gender, age, years of education and

socioeconomic status. They were asked to participate

in a study on psychological health with no payment

offered. They had no past or current history of

psychiatric or neurological diagnoses as determined

in a brief interview based on the Structured Clinical

Interview for DSM-III-R: Non-Patient Version (SCID-

NP) (Spitzer et al., 1989) and the guidelines estab-

lished by Shtasel et al. (1991) to exclude psychiatric

disorders.

2.2. Clinical assessment

Information was obtained on both sociodemo-

graphic—age, sex, years of education, years living

at parents’ home and socioeconomic level following

the Hollingshead and Redlich (1958) classification—

and clinical variables (age at onset of OCD defined as

age when symptoms became a significant source of

distress and interfered with the patient’s social func-

tioning). The severity of OCD was assessed using a

clinician-administered version of the Yale–Brown

Obsessive–Compulsive Scale (Y–BOCS) (Goodman

et al., 1989), which establishes the following severity

levels: subclinical (scores of 0–7), mild (8–15),

moderate (16–23), severe (24–31) and extreme

(32–40). A clinician-administered version of the 21-

item Hamilton Depression Rating Scale (HDRS)

(Hamilton, 1960) was used to assess the severity of

depressive symptoms (scores of 0–63).

The nature of OCD symptoms was ascertained

via a clinician-administered version of the Y–BOCS

Symptom Checklist (Goodman et al., 1989). This is

a comprehensive list of more than 50 examples of

obsessions and compulsions that can be grouped into

13 major categories. Despite some differences, recent

factor-analytic studies have been fairly consistent in

reducing the symptoms of OCD into a few clinically

meaningful dimensions (Baer, 1994; Leckman et al.,

1997; Mataix-Cols et al., 1999; Summerfeldt et al.,

1999) that at least in adult patients, tend to remain

stable over time (Mataix-Cols et al., 2002b). These

dimensions are the following: (1) symmetry obses-

sions and repeating, counting and ordering compul-

sions; (2) hoarding obsessions and compulsions; (3)

contamination obsessions and cleaning compulsions;

(4) aggressive obsessions and checking; and (5)

sexual/religious obsessions. Following the methodol-

ogy of previous studies (Baer, 1994; Mataix-Cols et

al., 1999), for each of these categories, if a patient

identified at least one of the specific symptoms

under that category as a principal or major problem,

that category was assigned a score of 2. If a patient

endorsed at least one of the specific symptoms but

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278 271

did not consider it to be a major problem, that

category was assigned a score of 1. Finally, a score

of 0 was assigned if a patient did not endorse any of

the symptoms under that category. In this study, the

patients’ scores on the five symptom dimensions

identified in a previous study (Mataix-Cols et al.,

1999), namely ‘Symmetry/ordering’, ‘Hoarding’,

‘Contamination/cleaning’, ‘Aggression/checking’

and ‘Sexual/Religious obsessions’, were computed

by summing the scores of the symptom categories

under each dimension and then used in all subse-

quent analyses.

2.3. Measurement of parental rearing-style

The EMBU (Egna Minnen av Barndoms Uppfos-

tran or Own Memories of Parental Rearing Experi-

ences in Childhood) was used to assess the study

participants’ memories about their parents’ rearing

practices. The EMBU is an 81-item self-report mea-

sure of an individual’s perception of his or her parent’s

rearing style during childhood (no specific reference is

made to any time frame for which subjects are

requested to remember their parent’s attitudes). All

items are separately scored for the father and the

mother on 4-point scales ranging from 1 (‘no, never’)

to 4 (‘yes, most of the time’). The EMBU, initially

developed in Sweden by Perris et al. (1980), has been

adapted for use in over 25 countries and validated for

different national contexts (Arrindell et al., 1986). The

validated Spanish version of the EMBU was

employed in the present study (Arrindell et al., 1988).

The EMBU consists of 14 subscales, each of

which contains items that give an indication of the

degree to which each parent was described as abusive,

depriving, punitive, shaming, rejecting, overprotec-

tive, overinvolved, tolerant, affectionate, performance

oriented, guilt engendering, stimulating, favoring sib-

lings and favoring the subject. In addition to these a

priori dimensions, the EMBU contains two general

questions that are also separately scored for the father

and the mother: one concerned with the degree of

consistency in parental rearing behavior and the other

with the degree of strictness of parental rearing style.

Factor analysis of the original EMBU version identi-

fied the following four primary dimensions: rejection,

emotional warmth, overprotection and favoring

subject, which are determined for both parents

independently (Arrindell and Van der Ende, 1984).

Nevertheless, because it was not possible to reach a

sufficient level of cross-national constancy in the

favoring subject dimension, only the other three fac-

tors were considered in the translated versions. The

EMBU has been widely used in studies of rearing style

and different psychopathological conditions in several

countries, and its psychometric properties have been

found to be adequate (Anasagasti and Denia, 1988;

Benjaminsen et al., 1990; Khalil and Stark, 1992).

Although results on the EMBU dimensions are

usually independently determined for the father and

the mother, we decided to consider a global parental

score (defined as the sum of father’s and mother’s

scores) to assess not only the rearing style associated

with one parent or another, but the influence of

parental rearing practices jointly.

2.4. Statistical analysis

Differences between the OCD and control groups

in demographic and clinical variables—including the

three subscales of the EMBU for both parents jointly

and each parent separately—were investigated with

one-way analyses of variance (ANOVAs) for contin-

uous variables and chi-square tests for categorical

variables. Mann–Whitney U tests were used for

continuous variables when the Levene test for homo-

geneity of variances was significant. To control for

error derived from multiple comparisons, the Bonfer-

roni correction was employed (significance level was

established at 0.016 when comparing both groups on

the three main dependent variables, i.e. the subscales

of the EMBU).

Multiple linear regression analyses (stepwise meth-

od) were conducted to assess whether certain parental

child-rearing patterns predicted the presence of spe-

cific obsessive–compulsive symptom dimensions. In

these models, the patients’ scores on each of the

subscales of the EMBU were entered as independent

variables and the scores on the five previously iden-

tified OCD symptom dimensions (Mataix-Cols et al.,

1999) as dependent variables. To control for the effect

of symptom severity and depression, all analyses were

repeated entering the total Y–BOCS and HDRS

scores first in the models (enter method).

Correlations between scores on perceived parental

child-rearing patterns and clinical variables such as

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278272

age at onset of OCD, severity of OCD and presence of

depressive symptoms were examined with Pearson

correlation coefficients. In order to further examine

the possible relationship between perceived parental

child-rearing patterns and the presence of depressive

symptoms in OCD, patients were classified into the

following two groups according to their scores on the

HDRS: those with at least moderate depression

(HDRSz 17; n = 14) and those with sub-clinical or

mild depression (HDRS< 17; n = 26). This dichoto-

mous variable was then used as the dependent vari-

able in a logistic regression analysis (stepwise

method) where patients’ scores on each of the sub-

scales of the EMBU were entered as independent

variables.

The significance level was set at 0.05, and all

analyses were conducted using the SPSS statistical

package (version 10.0).

3. Results

The demographic and clinical variables of the

patient and control groups are shown in Table 1.

There were no differences between the two groups

with respect to sex, age, years of education, years

living in the parental home or socioeconomic level.

Patients’ scores on the Y–BOCS suggested the

presence of severe OCD symptoms in our sample.

Table 1

Demographic and clinical characteristics of OCD patients and healthy com

OCD (n= 40) Controls (n

Variable N % N

Sex, male 20 50.0 20

Socioeconomic level

Low-medium 12 30.0 12

Medium 18 45.0 18

Medium-high 10 25.0 10

Mean S.D. Range

Age, years 29.2 9.6 17–55

Education, years 10.9 2.7

Living at parents’ home, years 25.4 6.4

Illness onset, years 16.8 6.2 6–38

Y–BOCS, total 27.0 7.4

Y–BOCS, obsessions 13.6 4.1

Y–BOCS, compulsions 13.3 4.4

HDRS 14.0 5.4

Patients’ scores on the HDRS were in the mild to

moderate range. No patient met DSM-IV criteria for

major depression, since the presence of a comorbid

axis I disorder was an exclusion criterion. Frequencies

of the major symptom dimensions of the Y–BOCS

Symptom Checklist are listed in Table 2.

As shown in Table 3, OCD patients perceived their

fathers as more rejecting (U = 458.5, Z =� 3.0, P=

0.003) than controls. Lower paternal emotional warmth

was also described by OCD patients, but differences

did not reach statistical significance since the use of the

Bonferroni correction raised the level of significance to

0.016. When considered jointly, OCD patients per-

ceived their parents as less emotionally warm than

controls did, although this difference was not statisti-

cally significant after application of the Bonferroni

correction. No difference between the groups could

be detected regarding parental overprotection.

In the OCD group, multiple linear regression

analyses revealed strong negative partial correlations

between scores on the hoarding dimension and per-

ceived parental emotional warmth (R2 = 0.24,

beta =� 0.49, t =� 3.46, P= 0.001). These results

remained unchanged when total Y–BOCS and HDRS

scores were forced first into the models. None of the

other OCD symptom dimensions were significantly

related to perceived parental child-rearing patterns.

No significant correlations were observed between

scores on perceived parental traits and age at onset of

parison subjects

= 40)

% v2 d.f. P

50.0 0.00 1 1.00

0.00 2 1.00

30.0

45.0

25.0

Mean S.D. Range F d.f. P

31.0 7.7 19–53 0.77 1.78 0.38

11.0 2.8 0.02 1.78 0.87

25.2 5.2 0.02 1.78 0.87

Table 2

Frequencies of the major symptom dimensions of the Yale–Brown

Obsessive–Compulsive Checklist in a group of 40 OCD patients

Absent

symptom

Present

symptom

Major

symptom

N % N % N %

Hoarding 30 75.0 8 20.0 2 5.0

Aggressive/checking 10 25.0 15 37.5 15 37.5

Contamination/cleaning 20 50.0 11 27.5 9 22.5

Sexual/religious 26 65.0 8 20.0 6 15.0

Symmetry/ordering 20 50.0 12 30.0 8 20.0

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278 273

OCD, OCD severity or presence of depressive symp-

toms (Table 4). Logistic regression analysis showed

that the severity of depressive symptomatology could

not be predicted by perceived parental child-rearing

patterns.

4. Discussion

Patients with OCD perceived higher levels of

rejection from their fathers than healthy controls.

Lower levels of emotional warmth from their fathers

and both parents considered jointly were also de-

scribed by OCD sufferers, although these differences

did not reach statistical significance. No significant

difference regarding parental overprotection was

detected between the groups. The presence of hoard-

Table 3

Parental rearing style assessed by the EMBU in OCD patients and health

OCD (n= 40) Controls

Variable Mean S.D. Mean

Father

Rejectiona 39.8 15.4 31.0

Emotional warmth 43.1 11.8 49.2

Overprotectiona 32.6 10.2 30.0

Mother

Rejectiona 38.2 12.2 33.7

Emotional warmth 49.8 11.7 53.5

Overprotectiona 34.1 9.6 34.3

Parents

Rejectiona 78.0 26.9 65.1

Emotional warmth 92.9 21.9 102.1

Overprotectiona 66.7 19.4 64.8

a Mann Whitney U-tests were used when variances were not homogenb Application of the Bonferroni correction raised the significance leve

ing symptoms was the only clinical dimension that

could be partially predicted by perceived parental

traits. Specifically, patients with high scores on the

hoarding dimension perceived their parents as being

less emotionally warm than patients with other symp-

toms. The severity of depressive symptoms in OCD

patients could not be predicted by scores on any

perceived parental characteristics.

Previous research on the contribution of parental

rearing practices to the development of OCD had

yielded mixed results. While some authors described

high levels of parental overprotection in OCD patients

(Hafner, 1988; Merkel et al., 1993; Turgeon et al.,

2002), others reported more rejection and less caring

than in normal controls (Hoekstra et al., 1989) or no

significant differences between patients and healthy

subjects (Vogel et al., 1997). Our results support

previous reports on the existence of differences in

perceived parental styles of upbringing in OCD,

mainly concerning rejection and emotional care, but

do not support the previously reported relationship

between parental overprotection and OCD. The influ-

ence of parental overprotection in the development of

anxiety disorders or depression is still a controversial

topic. An affectionless, controling rearing style (low

parental affection and high parental control) has been

reported to be associated with different anxiety dis-

orders and depression (Gerlsma and Emmelkamp,

1990). Some studies have suggested that a specific

y controls

(n= 40)

S.D. F/U d.f./Z P

7.6 458.5 � 3.0 0.003

10.6 5.82 1.78 0.019b

5.5 711.5 � 0.4 0.62

6.7 685.0 � 1.1 0.26

9.0 2.40 1.78 0.12

5.5 732.0 � 0.6 0.51

11.1 580.0 � 1.8 0.07

18.4 3.99 1.78 0.04b

8.7 713.0 � 0.47 0.63

eous.

l to 0.016.

Table 4

Correlations between scores on perceived parental child-rearing patterns assessed by the EMBU and clinical variables (age at onset of OCD,

severity of OCD and depression) in a group of 40 OCD patients

Age at onset of OCD Y–BOCS HDRS

r P r P r P

Father

Rejection � 0.18 0.26 0.11 0.48 0.03 0.81

Emotional warmth � 0.07 0.66 � 0.28 0.07 � 0.25 0.10

Overprotection 0.01 0.9 0.01 0.92 � 0.09 0.57

Mother

Rejection � 0.24 0.12 0.01 0.94 � 0.07 0.66

Emotional warmth 0.19 0.23 � 0.18 0.24 � 0.25 0.11

Overprotection 0.04 0.78 � 0.001 0.99 � 0.12 0.45

Parents

Rejection � 0.21 0.18 0.07 0.66 � 0.01 0.94

Emotional warmth 0.06 0.69 � 0.25 0.11 � 0.27 0.08

Overprotection 0.03 0.84 0.008 0.96 � 0.10 0.50

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278274

relationship may exist between particular child-rear-

ing patterns and specific emotional traits: parental

control may be more closely related to anxiety where-

as parental rejection may be more specifically related

to depression. Other authors (Parker, 1979) have

suggested that the interaction between these two

child-rearing factors may be more important in the

development of anxiety or depression than the sepa-

rate influence of each one of them. Further studies are

needed to clarify whether rejection and overprotection

play a distinct role in the origins of anxiety and

depression.

Regarding the relationship between parental child-

rearing patterns and the development of specific OCD

symptoms, our results do not support previous hy-

pothesized differences between washers and checkers

(Rachman and Hodgson, 1980). We found no signif-

icant associations between contamination/cleaning or

aggressive/checking dimensions and any of the three

parental rearing style factors defined by the EMBU.

The presence of hoarding obsessions or compulsions

was the only OCD symptom dimension that could be

significantly predicted by perceived parental traits,

specifically by low parental emotional warmth.

The presence of hoarding obsessions and compul-

sions in OCD appears to be related to some particular

clinical characteristics. Hoarding OCD is associated

with higher levels of comorbidity (i.e. anxiety, de-

pression, personality disorders), as well as work and

social disability compared with non-hoarding OCD

and other anxiety disorders (Frost et al., 2000; Mataix-

Cols et al., 2000). Furthermore, these patients are less

likely to be married (Frost and Gross, 1993) and a

substantial number of treatment-seeking hoarders are

socially phobic (Steketee et al., 2000). Hoarding OCD

has also been associated with poorer treatment re-

sponse to serotonergic agents and cognitive-behavior-

al therapy (Black et al., 1998; Mataix-Cols et al.,

2002a). Alsobrook et al. (1999) have recently reported

that a significant greater genetic component can be

established in OCD patients with symmetry/ordering

symptoms. The results of the current study may

suggest that social variables such as parental child-

rearing style could especially contribute to the devel-

opment of other OCD symptoms such as hoarding

obsessions and compulsions.

As previously discussed, a relationship between

parental child-rearing style and the development of

disorders other than OCD has also been proposed.

Perceived parental overprotection and rejection have

been linked to the development of agoraphobia (De

Rutter, 1994), and Parker et al. (1987) reported that

neurotic depressives perceived their parents as less

caring and more protective than melancholic depres-

sives and healthy subjects did, and that this ‘affec-

tionless control’ style of upbringing was highly

discriminating for neurotic depression. We found no

significant relationship between perceived parental

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278 275

characteristics and the presence of depressive symp-

toms in OCD patients. Nevertheless, our negative

results may be explained by the fact that patients in

this study were ‘pure’ obsessive–compulsive sub-

jects; none of them satisfied DSM-IV criteria for

major depressive disorder or dysthymia, and they only

showed mild or moderate depressive symptoms sec-

ondary to the distress caused by their OCD symptoms.

From a clinical perspective, these results support

the importance of involving family members in the

treatment of obsessive–compulsive children. OCD

often produces severe stress on family members of

affected children, because of their involvement in the

patient’s compulsions or avoidance behaviors as well

as because of modification of family and leisure time

routines to accommodate the patient. Parents of OCD

patients often feel confused and anxious when faced

with their children’s obsessive–compulsive behav-

iors, and their responses to OCD symptoms are

frequently inconsistent or erratic. Rigid, demanding

and highly critical families generate feelings of guilt,

increase anxiety in affected children, and discourage

them from engaging in active treatment for OCD.

Thus, altering family communication style and learn-

ing alternative responses to the patient’s OCD symp-

toms may be an important issue especially to facilitate

gains of cognitive-behavioral treatment (Steketee and

Van Noppen, 1998).

Several limitations of the present study need to be

addressed. Although the dimensional approach adop-

ted in this study has the potential advantage of

overcoming the difficulty of recruiting a sufficient

sample size of each OCD clinical subtype, some

symptom dimensions (i.e. sexual/religious, symme-

try/ordering, hoarding) were present in a reduced

proportion of patients. So, the sample size might have

been insufficient to detect a significant relationship

between some of these clinical dimensions and paren-

tal rearing factors. The results of the current study

need to be replicated in larger samples to address this

issue as well as to confirm the stability of the detected

association between hoarding and perceived parental

emotional warmth.

On the other hand, the presence of personality

disorders was not specifically assessed in our study.

Comorbid personality disorders have been reported to

be present in approximately 50% of OCD patients

(Baer et al., 1990). Moreover, two recent studies have

reported a close association between hoarding symp-

toms and comorbid axis II diagnoses, especially from

the anxious–fearful cluster (Frost et al., 2000; Mataix-

Cols et al., 2000). Therefore, the association between

perceived parental emotional warmth and hoarding

detected in our study may be confounded by the

presence of abnormal personality traits. Future studies

would benefit from the assessment of personality

disorders to control for their effect.

This study was only based on retrospective reports

of parental rearing style, so a memory bias cannot be

disregarded. Direct observational studies of parent–

child interactions or studies combining data from

offspring, parents and siblings on perceived child-

rearing practices may increase validity of the results in

this area, although each source of information has its

own limitations and biases. As specific mood-congru-

ent memory biases associated with depression have

been described, the presence of depressive symptoms

and overall illness severity were taken into account in

the statistical analyses, and results were not confound-

ed by correlation with either of the two factors. On the

other hand, previous findings with the EMBU suggest

that evaluating retrospective data does not threaten the

reliability and validity of the information obtained

since it can be interpreted as a measure of the

phenomenological impact of parental behaviors

(Arrindell et al., 1983).

Although normal comparison subjects were care-

fully selected and screened to rule out any past or

current history of psychiatric or neurological disorder,

the presence of subthreshold obsessive–compulsive

symptoms was not assessed in the control group.

Several studies have reported that a high percentage

of the normal population have some obsessions and

compulsions, and it has been postulated that obses-

sive–compulsive phenomena form a continuum with

few symptoms and minimal severity at one end, and

many symptoms and severe impairment at the other

(Rachman and DeSilva, 1978). Therefore, some of our

healthy control subjects may exhibit subclinical ob-

sessive–compulsive symptoms, which could influ-

ence the results of the study.

Finally, the presence of obsessive–compulsive

traits or any other psychiatric conditions in the parents

of the OCD group was not studied. Clinical and sub-

clinical obsessional features as well as other anxious

and affective disorders have been reported in parents

P. Alonso et al. / Psychiatry Research 127 (2004) 267–278276

of OCD patients (Rasmussen and Tsuang, 1986), and

they may play an important role in parental rearing

practices. Future studies should take into account this

factor, since the study of the relationship between

parental psychopathology and child-rearing patterns

would increase our understanding of family influences

on the development of OCD.

In conclusion, OCD patients perceive their fathers

as being more rejecting than control subjects. Patients

with hoarding symptoms perceive their parents as less

emotionally warm than patients without these symp-

toms. Whether this reflects actual rearing practices or

the patients’ biased perception needs to be further

investigated using more objective measures. If repli-

cated, the current findings would suggest that parental

style of upbringing, as well as other social variables,

may interact with genetic and biological factors to

shape the OCD phenotype in vulnerable subjects.

Recent published articles have focused on the rela-

tionship between functional and anatomical variability

of different brain areas and behavioral styles (Sugiura

et al., 2000; Pujol et al., 2002). Parental child-rearing

practices may contribute to the development of dis-

torted beliefs about responsibility, threat estimation,

perfectionism, control or tolerance for ambiguity,

which are frequently exhibited by patients with

OCD (Steketee et al., 1998). Parental behaviors and

attitudes may also be related to the development of

patterns of temperament and character described in

OCD (high harm avoidance, low novelty-seeking and

cooperativeness) (Lyoo et al., 2001). Studies on the

relationship between parental bonding styles and

cognitive domains or personality characteristics in

OCD patients, and between these aspects and the

morphology or function of different brain regions,

may constitute a way to analyze the interaction of

social/cultural variables and biological factors in

OCD. Further research on this interaction could help

us to understand the complex etiology and heteroge-

neity of OCD.

Acknowledgements

This study was supported in part by grant FIS 99/

1260 from the Spanish Ministerio de Sanidad y

Consumo and grant 010210 from Fundacio La Marato

TV3. PA was funded by the Generalitat of Catalonia

(1999FI-00726). DM-C was funded by a Marie Curie

grant from the EU.

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