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The current research is aimed to explore the Quality of Life of patients having Obsessive Compulsive Disorder in terms of Clinical Correlate and Symptom Severity. The severity of symptomology and clinically manifested psychological distress exacerbates the functional impairment of OCD's patients. The functional impairment debilitates and gradually leads to poor treatment compliance as psychotherapy is to include the dysfunction area in treatment plan. The present study is intended to understand the relationship of the associated factors that will help facilitate the better understanding on etiological and therapeutic grounds.
According to American Psychiatric Association (2000), Obsessive Compulsive Disorder OCD) is an anxiety disorder that I defined with two main symptoms: obsessions, which are intrusive, unwanted thoughts, ids, images, or impulses that and individual experienced as senseless yet anxiety evoking; and compulsions, which are desires to engage in behavioral or mental acts according to specified "rules" or in reaction to obsessions (i.e., to lower down obsessional anxiety). Rachman & Hodgson (1980) suggested that although the Diagnostic and Statistical manual of mental disorders describes OCD being a homogenous condition, with specific manifestation of obsessions about contamination, illness, harming, morality, exactness, and intrusive unwanted, disturbing images are all common presentations. The individual perform various compulsions and other types of responses aimed at neutralizing the obsession if he or she is unable to avoid situations that evoke these obsessions, such as washing, checking, arranging or mental rituals (as cited in Abramowitz, McKay, &Taylor, 2008).
Obsessions are persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate. The most common obsessions concern thought about contamination, doubting, aggressive or horrific impulses and sexual imagery. Worry can be separated and differentiated from other types of intrusive thoughts which are regarded as Obsession (Wells, 1994; Wells & Morrison, 1994 as cited in Wells, 1997). A compulsion is a repetitive behavior that is overt or covert. Overt compulsions include hand washing, checking, ordering, or alignment of objects. Covert compulsions are mental acts such as praying, counting, or repeating words. The goal of these overt and covert compulsions is to reduce or prevent anxiety or distress. When viewed from cognitive prospective they neutralize or prevent feared events. However, individuals are unaware of the trigger and may perform stereotyped acts according to idiosyncratic rules (Wells, 1997).
Â OCD sufferers generally recognize their obsessions and compulsions as irrational, and may become further distressed by this realization. Cummins (2000) suggest that it is difficult to define Quality of Life because it can be characterized in both objective and subjective terms (as cited in Barofsky, 2012). According to Spranger & Schwartz (1999), Quality of life is a multidimensional and dynamic concept: perspective can change with the onset of major illness. Relevant cognitive or affective processes in individuals when faced with changing circumstances (e.g.) in their health or lives) include making comparisons of one's situation with others who are better or worse off, cognitive dissonance reduction, re-ordering of goals and values and response shift whereby internal standards and values are -changed. People may adjust to deteriorating circumstances because they want to feel as good as possible about themselves (Ayers, et al. 2007)
OCD is capable of giving rise to other conditions. For example, as with manyÂ chronic stressors, OCD can lead toÂ clinical depressionÂ over time. The constant stress of the condition can cause sufferers to develop a deadening of spirit, a numbing frustration, or sense of hopelessness. Depression in various forms and more precisely major depressive disorder is most common to co-occur with OCD (Dunner, 2001). Social anxiety disorder, and generalized anxiety disorder among Anxiety disorder are also common in OCD patients (Dunner, 2001). Of prime interest is the co occurrence of OCD with schizophrenia (Poyurovsky et al., 2004). In the history of abnormal psychology, obsessions were in deference to an extreme form of delusions, thus making OCD patients at risk for schizophrenia. Conversely, at some point it was regarded that the two disorders can't be comorbid, moreover, that OCD is a defense against the disintegration of schizophrenia. The rates of co morbidity of the two disorders that have been assessed lately have reached as high a value as 15% (Tibbo and Warneke, 1999). Some neurologic diseases such as Parkinson's and Sydenham's chorea are sometimes accompanied by OCD (Dunner, 2001).
This section includes the review of the studies that investigated the studied variables.
Grant, Pinto, Gunnip, Mancebo, Esin, & Rasmussen (2006) carried out a study to find out the differences of OCD patients with primary OCD and sexual obsessions and OCD patients without sexual obsession on number of clinical variables. They included co morbidity, symptom severity, insight, quality of life, and social and occupational functioning under the clinical domains. 293 subjects, meting criteria for OCD, aged 19 years or older were included and interviewed. Each subject was evaluated by trained research assistants. Clinical interview for DSM-IV Axis-I disorder, Yale-Brown Obsessive Compulsive Scale (YBOCS) to assess OCD symptom severity, Subject Clinical Global Improvement scale was used to evaluate the response towards medication. Rating on the degree to which previous treatments have prove to be effective was taken on 7 point scale. Brown assessment of Beliefs Scale (BABS) was used to evaluate the insight and current Depressive symptom and QOL by were assessed by using 17-item Hamilton Rating scale for Depression and Quality of life Enjoyment and Satisfaction Questionnaire respectively. Data was analyzed by using t-test or Pearson test. The findings supported the hypothesize that earlier age of OCD, presiding entry in treatment, increased rate of aggressive and religious obsession onset was related to having OCD with sexual obsessions, and also with increaser depressive symptoms, longer duration of treatment, and higher rates of impulse control disorder.
Kumar, Sharma, Kandavel, & Reddy (2012) conducted a research to examine the contribution of cognitive appraisals to the quality of life (QoL) in patients with obsessive compulsive disorder. The research design was Cross sectional study and they hypothesized that cognitive appraisals of obsession contribute to poor quality of life in OCD patients. The objective was to explore the contribution of cognitive appraisals to the QoL with patient having OCD. Sample size was 31 consecutive patients from Behavioral Medicine Unit of the NIMHANS. Normal controls were (N=30) recruited by word of mouth from local community. Inclusion criteria were age between 18-55 years, ability to read and write English language, diagnosis of OCD according to DSM, score > 16 on YBOCS. Exclusion criteria were patients having severe co morbid psychiatric, physical and neurological disorder. The assessment was done by using mini Internal Neuropsychiatry Interview (MINI), the YBOCS severity scale, Clinical Global Impression-severity, the Depression Anxiety and Stress Scale-21, the Interpretation of Intrusive Inventory-31 and WHOQOL-BREF. Data was analyzed using independent t-test and chi-square test. Relationship between the domains of cognitive appraisal and the QoL after controlling for the duration of symptoms was analyzed by using Partial correlation. The results indicated that all the domains of cognitive appraisal have strong negative relationship with psychological domain of QoL. Thought control and inflated personal responsibility also correlated negatively with the total QoL. Cognitive appraisal specifically contributes to poorer QoL in OCD so modification of beliefs and appraisal may be essential for better QoL. Main limitations were small size, patients were recruited from Behavioral Medicine Unit of major psychiatric hospital, and findings may not be easily generalized. Sample was predominantly male so it's important to examine gender difference in cognitive appraisal and its relationship to QoL. Co-morbid psychiatric disorder may influence the QoL adversely.
Fontelle, Fontelle, Birges, Prazeres, Range, Mendlowicz and Versiani (2010), conducted in a research compared patients with OCD and normal in relations to the severity of different OCD dimensions with the levels of QoL of patients with OCD. Further, it was also investigated the socio demographic variables and co occurring depressions and anxiety symptoms have significant contribution in impairment of QoL of OCD patient. They hypothesized that universal pattern of impairment in the physical, mental, and social aspects of quality of life of patient will be associated with more significant hoarding symptoms. The patients with the diagnosis of OCD were included, age between 18-80 years and without any other neurological, endocrinological or systematic disorder. Control group was recruited as well, aged between 18-80 years, and absence of any neurological, endocrinology or systematic disorder. The measures used were Saving inventory revised (SI-R), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Obsessive Compulsive Inventory- Revised (OCI-R), Medical Outcome Study 36-item short form health survey (SF-36). Chi-square and independent student t-test was used for the comparison of categorical and continuous variables respectively. The patient who met the inclusion criteria was 135 out of which 65 were patients, and 70 were controls. The result supported the hypothesize only partially, the decline in particular aspects of patients QoL was significantly associated with hoarding and washing symptoms for but co occuring symptoms, the most prominent determinant of the impairment of QoL of subject with OCD were depressive and anxious ones. The study had limitations that sample was taken from specialized institutions, second control group was of nonclinical individuals, rating on depression scale and QoL Instrument may be dependent on state and change during continuity of OCD, they applied generic tool for measuring QoL in OCD.
Saxena, Ayers, Maidment, Vapnik, Wetherell, and Bystritsky (2010) conducted a research to compare compulsive hoarding and non compulsive hoarding OCD patients across variety of QoL domains. The objective was to quantify and compare both subjective and objective measure of QoL and functional impairment in patient with compulsive hoarding versus non hoarding OCD patient. They hypothesized that hoarders would be older and have lower FAF scores than non hoarding OCD patients. Secondly, hoarding patients would be less satisfied with their living situations, given their amount of clutter, and hoarders would have greater victimization/ safety concerns and finally hoarders would have greater financial problems and receive more social service assistance than non-hoarding OCD patients. To study this171 adult patients were selected (84 males, 87 females) with age aged 18-72. They were diagnosed OCD and treated openly between 1998 and 2005. Out of these patient 34 met criteria of having compulsive hoarding syndrome. 137 patient didn't report any hoarding symptoms. Patient presented with a wide range of co morbid diagnosis. Those with active psychosis, mania, dementia, mental retardation or other cognitive impairment were excluded. Standardized rating scales were used to assess symptom severity and level of functioning. YBOCS was used to measure OCD symptom severity. Severity of depressive and anxiety symptoms were measured by 28 item Hamilton Depression rating scale (HDRS-28) and Hamilton Anxiety Scale (Ham-A) respectively. QoL was assessed with Lehman Quality of Life Interview Short. Obtained scores for QoL between 2 groups were compared using Analysis of Variance procedures. ANCOVA were performed with covariates and also for secondary analysis on individual items. SPSS was used foe data analysis. Results showed that compulsive hoarders were significantly older that non hoarding OCD patients. QoL scores on victimization and safety factors differed significant between 2 groups. Hoarder felt less safe in streets and less satisfied with protection. Both groups had significant occupational impairment, unemployment and disability. Discrepancy in sample size between 2 patient groups and intensive patient setting were the limitations of study. Psychosocial Rehabilitation would be beneficial.
Eisen, Mancebo, Pinto, Coles, Pagano, Stout, & Rasmussen (2006) conducted a study to assess multiple aspects of QoL in individuals with OCD seeking treatment for OCD, with no exclusions based on Axis I or II disorders. They hypothesized that all aspects of QoL would be affected, and that severity of OCD symptoms and depressive symptoms would be associated with impairment in QoL. 5 years prospective naturalistic study was conducted on 197 participants with an age 18 years or older, primary OCD. An exclusion criterion was having an organic mental disorder. YBOCS, Brown assessment of Belief scale, Modified Hamilton rating scale for Depression, Quality of Life Enjoyment and Satisfaction Questionnaire, Social Occupational Functioning assessment scale, Medical outcome survey 36-item short form Health Pearson product moment correlation coefficient was conducted to assess relationship between clinical features of OCD and QoL. Results showed that YBOCS score of 20 appeared to be an inflection point where QoL becomes significantly more impaired, suggesting that functioning and QoL, may be preserved in individuals with OCD until threshold of severity is crossed. Limitations of the study were participants seeking treatment and therefore finding may not apply to those individuals who do not seek treatment. Moreover, subjects were evaluated only once. Continued observation of the study participant will be required to fully understand the interaction between severity of OCD and its impact on QoL. They further suggested that the role of treatment in improving QoL in OCD should be further investigated along with a need to assess which aspect of QoL and psychological functioning are helped by pharmacologic and CBT so that specific treatment be targeted to psycho social functioning deficits.
Guraraj, Math, Reddy, and Chandrashekar (2008) conducted research in which they hypothesized that patients suffering from severe OCD may have comparable level of global functioning, family burden and QoL and disability with patient suffering from schizophrenia. 70 subjects from National Institute of Mental Health and Neuroscience gave informed consent. Inclusion criteria were (a) a primary diagnosis of DSM IV OCD/schizophrenia (b) continuous illness for the previous 2 year (c) Clinical Global Impression Severity (CGI-S) score of > 4 (d) availability of a primary care giver involved in patient care for 2 years Mini-international Neuropsychiatry Interview was conducted to confirm the diagnosis. Global Assessment of Functioning (GAF), World Health Organization (WHO-Quality of life (QOL)(BREF Version), WHO Disability Assessment Schedule-II (WHO-DAS-II). Family Burden Schedule (FBS) were used to assess global functioning, quality of life and disability. ANCOVA was employed with age of inset and duration of illness as covariate for comparison of family burden, QoL and disability between 2 groups. Pearson correlation between socio demographic/ clinical variable, family accommodation and functioning with family burden were performed. The results demonstrated that severe OCD is associated with significant impairment in functioning and severe family burden and disability. QoL was poor and severe OCD and schizophrenia are often associated with comparable disability, family burden and poor QoL. This study has certain limitations of small size, cross sectional evaluation and unblended status of the rater to diagnosis. Findings need to be generalized to larger population of mildly ill OCD patient.
Huppert, Simpson, Nissenson, Liebowtiz, and Foa, (2009), examined data from OCD patient enrolled in double blind, randomized clinical trial and compared their QoL and functioning to that of matched healthy controls. They hypothesized that OCD patients in remission would report similar QoL and functioning matched healthy controls (HCs), while individuals with OCD would report poorer QoL and functional impairment. Additional prediction was that OCD patients and comorbid psychiatric disorder would report the worst QoL and functional impairment. Finally, Individuals with a history of OCD (current or past) increased severity of OCD would be related to decrease in QoL and increased functional impairment, even when controlling for depression. Adult outpatients were re contacted either by ph ne or in person. Out of 122, 105 participants were located. 66 comprised the current sample. 36 HCs were included. They were matched on age, sex and ethnicity. Informed consent was taken. Structured clinical interview DSM-IV, Yale Brown Obsessive Compulsive Scale, the Hamilton Rating scale for Depression and Hamilton Rating Scale for Anxiety were used. Subjects also completed Quality of Life Enjoyment and Satisfaction Questionnaire. Social Scale-Self Report, Medical Outcome Study 36 items short form Health Survey and Sheehan Disability Scale was also administered. Four groups were formed on the basis of SCID and Y-BOCS responses (1)healthy controls with no history of psychiatric disorders (2) patient in remission not meeting OCD criteria (3) patient who met current SCID criteria for OCD only and (4) patient who met SCID criteria for OCD and another current Axis 1 psychiatric disorder (hereafter comorbid OCD). ANCOVA, Pearson, partial co relations and co relational analysis were conducted. The results showed that individuals with OCD without co morbidity both have significantly worse QoL and functioning than healthy controls. Level of functioning and QoL in individuals in remission tended to fall between that of healthy control and individuals with OCD only. In terms of severity of OCD and functional impairment, individuals with comorbid OCD were in moderate to severe range individual with OCD only were in mild to moderate range and OCD remission were in very mild range. QOL and Functional impairment was related to severity of OCD.
Prabhu, Cherian, Viswanath, Kandavel, Math, and Reddy carried out a study in 2012 on Symptom dimension in OCD and their association with Clinical characteristic and comorbid disorders. The objective of the study was to explore the connection between symptom dimension and clinical characteristics of OCD patients. Dimensional-Yale-Brown Obsessive Compulsive Scale, WHO quality of life BREF and Global Assessment of Functioning scale was administered on 161 patient who met DSM-IV criteria for OCD. Finding indicated that aggression, sexual/religious dimensions were related with the onset of OCD symptoms. Sex, family size, severity of symptoms, insight, impaired functioning and physical quality of life was connected to fear of contamination.
Kim, Ebesutani, Wall and Olatunji carried out a research study in 2011 on depression mediate the relationship between obsessive-compulsive symptoms and eating disorder symptoms in an inpatients sample. The aim of the current study was to estimate the role of depression in inpatients of eating disorder that explains the connection between eating disorder and OCD symptoms. 491 patients were included in study from eating disorder clinic with the primary diagnosis of eating disorder. Three measures were used: Eating Disorder Inventory-3, Yale-Brown Obsessive Compulsive Scale and Beck Depression Inventory -II. Structural Analyses Modeling was used to find out the interconnection between eating disorder, Obsessive compulsive disorder and depression symptoms. Results indicated that depression mediates the coalition between eating disorder symptoms and OCD symptoms.
Thus the literature review shows co-occurring psychiatric disorder, severity of OCD symptoms and Quality of Life are interrelated. It is evident that the patient with OCD symptom will have poorer Quality of life and this will be further affected by the presence of any psychiatric co morbidity. Individual with OCD have anticipation of feared situations and they also experiences feelings of guilt, low self esteem, tiredness, and difficulty in making decisions. In such cases it may be difficult to separate Depression, anxiety and OCD. The patient in response to disturbing obsessions will develop symptoms of depression as well. Moreover depression may often result from the on-going distress caused by the problems at work and at home that are often associated with symptoms of OCD.
It was observed that limited research was conducted on symptom severity and comorbid clinical disorders as correlates of quality of life in various areas of life. An indigenous study was conducted by Rasul and Farooqi in 2009. The aim of the study was to investigate whether there are gender differences in perceived quality of life of patient suffering from Obsessive Compulsive Disorders. Findings indicate impaired Quality of life with significant gender difference.
An indigenous study was carried out by Saleem and Mahmood in 2010 on Social, Cultural and Clinical Presentation of Symptoms of Obsessive Compulsive Disorder. The research aimed to study Obsessive Compulsive Disorder through a phenomenological approach. This study involves three stages. During first stage semi structured interviews were carried out with twenty patients with firm diagnosis to elicit the presenting symptoms. For validation, frequency with which those symptoms occur and their relative importance was rated on four point scale by experience Clinical Psychologist. The results of this stage showed that Clinical psychologist regarded compulsion to be of more diagnostic importance than compulsions in OCD as well as they considered compulsion more common than obsession in OCD. In the final stage, a list comprising 36 symptoms along with measures of anxiety, depression and other OCD symptoms checklist from a subscale of Symptom checklist-R was given to 83 patients with OCD and 67 patients that were non OCD. The results showed that compulsions were reported to be similar to those already shown by other studies while social, cultural and religious background influence the content of obsessions. Moreover, the term Napak was another term used for dirt, impurity and germs.
A study was conducted by Amin and Mahmood in 2010 with an objective to explore relationship between Obsessive Compulsive symptoms of OCD and problems faced by the students. 208 (119 males and 89 females) graduating students age ranged 18 to 24 were included as the sample of the study through purposive sampling. Measures used were Obsessive Compulsive Symptom Checklist (OSCS) and Student Problem Checklist (SPCL). Result showed significant correlation between the two measures. 11.06% of students scored similar to the patient population on OSCS.
Another study was conducted by Chaudhry and Rahman in 2002, the study was aimed to investigate the demographic characteristics of Obsessive Compulsive Disorder and its co morbidity with depression with schizophrenia. The findings of this study suggest that depression was more associated with OCS than schizophrenia.
A study was conducted by Jabeen and Kausar in 2008 on Prevalence, Symptomatology, Phenomenology and Etiology of Obsessive Compulsive Disorder in Punjab. This study had several objective including studying the prevalence of OCD, development of obsessive compulsive symptom checklist and finally to examine the expression of symptoms and phenomenology of OCD. To estimate the prevalence of OCD, three years records of psychiatry units of main teaching hospitals of Punjab province was taken. Depression was most commonly occurring disorder in female and OCD being the 5th most occurring among anxiety disorders. Indigenous symptom checklist was developed in different phases. Principal Component Analyses indicated in 5 types of symptoms for obsessions and for compulsions. Reliability for this scale was found to be satisfactory. To meet the third objective that is to determine the manifestation and phenomenology of OCD in Pakistan. OCD symptom checklist was administered on 200 OCD patients. MANOVA and paired sample t-test was used as a statistical procedures. The results of this study were also discussed in socio and religious context.
Sadia and Sitwat conducted a study in 2006 on Role of Family Functioning in Development of Obsessive Compulsive Disorder. The qualitative study was carried out with an aim of investigating the role of perceived family functioning in the development of OCD, to compare the family functioning between clinical and non-clinical participants and to contrast the healthy and unhealthy styles of family functioning that triggers the development of OCD. Phenomenological approach was used with Constructivist paradigm with 5 OCD patients and 5 healthy individuals age ranged 18 years. Purpoisve sampling was used and then symptom checklist-R was administered to screen out OCA or any other psychological disorder. In pilot study, in-depth interviews were conducted with was than transcribed in native language. Contrasting themes and common themes were established and were explained with respect to the literature and theory.
In 2010, Ghafoor and Mohsin conducted a study on relationship of religiosity, guilt, and self esteem in individuals having Obsessive Compulsive Disorder (OCD). Correlational research design was used and purposive sampling was used to include 200 (100 males and 200 females) OCD patients. 5 measures were administered including Clark-Beck Obsessive Compulsive Inventory, Religious Activity Scale, Rosenberg Self-esteem Scale and Guilt Assessment scale for Obsessive Compulsive Disorder. Descriptive analyses, correlational analysis and multiple regression analysis was used as statistical procedure. Findings resulted in a positive interaction between guilt score and OCD scores. Guilt regarding washing compulsions, checking compulsions and interpersonal conflicts were more prominent determinants of OCD.
Most of the studies did not consider some factors that have closer relevance for quality of life including length of illness, illness subtypes, number of symptoms, insight, etc. Along with them there is a lack of specific quality of life instruments for OCD used in these researches (Ritsner and Awad, 2007).
According to Medlowicz and Stein, future research on the impact of these disorders on the quality of life will give a clear understanding and will increase public awareness of anxiety disorders being serious mental disorders for their preventions and treatment (Ritsner and Awad, 2007).
In the light of these researches, there is a need to explore the dimensions of manifested Symptoms severity and clinical correlates in relation quality of life of patients of OCD. OCD is a debilitating mental disorder that greatly influences the individual life. It has an impact on the functionality of a patient that is in turn determined by the symptom severity. The study will provide the sufficient evidence of the contributing relation of these factors in exacerbating the functional impairment in patient's physical and psychological health, social relationships and environmental interaction. The empirical understanding of associated factors related to illness will provide treatment guidelines for the professionals working with OCD patients that are with or without other psychiatric comorbidities and dimensions of symptoms of OCD.
Objectives of the study
So present study is aimed as follows:
To investigate the Symptom severity among OCD patients and physical, psychological health, Social and Environmental related Quality of life.
To explore the relationship of Symptom Severity of OCD patients with other clinical correlates and co morbidities.
To find out the clinical correlates in relation to physical, psychological health, Social and Environmental related Quality of life.
To explore the predicting relation between Symptom severity, Clinical correlates and QoL.
Patients having OCD with more symptom severity will have impaired Quality of life.
OCD patients with associated depression will have more impaired Quality of life.
OCD patients with associated Anxiety will have impaired Quality of life.
OCD patients with associated stress will have impaired Quality of life.
Correlational research design will be used in the present study.
Purposive Sampling strategies will be used. Inclusion criteria will be diagnosed patients of OCD with an age 18 and above. Sample size will be between 60 -80 individuals with diagnosis of OCD.
The WHOQOL-BREF, urdu version (The WHOQOL Group, 1998) is a cross-culturally valid measure of QOL with good to excellent reliability and validity (Skevington, Lotfy & O'Connell, 2004). The brief scale consists of 26 items, five-point rating likert scale, and lower scores mean poorer QOL. It provides measurement on four domains of QOL: physical (e.g., pain, energy, sleep, mobility etc.), psychological (e.g., positive and negative feelings, self-esteem etc.), social (relationships, social support, & sex) and environment (e.g., safety and security, finance, home environment, leisure etc.). (See Appendix)
Obsessive Compulsive Inventory- Revised (OCI-R)
The Obsessive Compulsive Inventory is a self report scale that was developed for evaluating symptoms of OCD. OCI-R comprised of 18 questions and the responses are given of 5 point likert scale. However, total score for OCI-R is obtained by adjoin item scores. The possible obtained score can range from 0-72. The obtained score of 28 is regarded as mean score for person having OCD. Obtained score of 21 is regarded as preferred cut off score, all the score above this will foreshow the existence of OCD. (See appendix)
Depression Anxiety Stress Scales (DASS)
It is a measure of negative emotional state of depression, anxiety, and stress in ages 14 and above. It consists of 3 scales and 42 items; for each item rating is obtained on 3 point Likert scale. It provides measurement on 3 scales: Depression, anxiety, stresses scales (Lovibond, & Lovibond, 1995). (See appendix)
The participants will be explained about the purpose and objective of the research study before hand. Informed consent will be taken and confidentiality will be ensured. Only those individuals will be included in the research that is willing to participate voluntarily.
Written permission will be taken from the organizations, institutes or hospitals in which study will be embarked upon.
Measure included in the research study will study will be used after taking formal written permission from the relevant authors.
Pearson Product Moment and Regression Analysis will be the predictors of Quality of life. ANOVA will be employed to find the difference of OCD patients with and without comorbid, anxiety, depression and stress on Quality of life.