Original Paper
Psychopathology 2007;40:282–289
DOI: 10.1159/000104744
Quality of Life in Obsessive-Compulsive
Disorder: The Different Impact of
Obsessions and Compulsions
Katarina Stengler-Wenzke Michael Kroll Steffi Riedel-Heller
Herbert Matschinger Matthias C. Angermeyer
Department of Psychiatry, University of Leipzig, Leipzig, Germany
Key Words
Obsessive-compulsive disorder, subtypes and
heterogeneity  Subjective quality of life  WHOQOL-BREF
Abstract
Background: Patients with obsessive-compulsive disorder
(OCD) are troubled by repeated obsessions and/or compul-
sions, which seem senseless and frequently repugnant. Ob-
jective: The study examines the differential impact of obses-
sions and compulsions on the quality of life (QoL) of patients
with OCD. Methods: Seventy-five patients (43 females, 32
males) between 21 and 62 years old with OCD (ICD 10 F42.0–
F42.2) were recruited from the outpatient clinic for anxiety
disorders at the Department of Psychiatry of the University
of Leipzig. The severity of OCD symptoms was assessed by
the Yale Brown Obsessive-Compulsive Scale (a standardized,
clinician-administered scale), and depressiveness was as-
sessed with the Beck Depression Inventory (a self-report in-
strument). QoL was assessed by means of the WHOQOL-
BREF, a self-administered questionnaire developed by
WHO. Results: Compulsions reduced patients’ QoL in the
WHOQOL-BREF domains ‘physical well-being’, ‘psychologi-
cal well-being’ and ‘environment’, whereas obsessions did
not have any impact on QoL ratings. Depressive symptoms
© 2007 S. Karger AG, Basel
0254–4962/07/0405–0282$23.50/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/psp
Received: September 9, 2005
Accepted after revision: June 12, 2006
Published online: June 28, 2007
were a strong predictor of poor QoL in OCD patients. Con-
clusions: In order to judge the QoL of OCD patients, obses-
sions and compulsions have to be considered differently. Di-
agnosing and treating depressive symptoms is important
for improving the QoL in OCD. Copyright © 2007 S. Karger AG, Basel
Introduction
There is growing evidence suggesting that anxiety
and affective disorders may be associated with substan-
tial impairments in quality of life (QoL) [1–3]. In addi-
tion, it is generally accepted that obsessive-compulsive
disorder (OCD) is a chronic and severely disabling dis-
order ranking tenth in the World Bank’s and WHO’s
leading causes of disability [4]. OCD impacts everyday
life in academic, occupational, social, and family func-
tioning [2–5]. Therefore, it is not surprising that QoL in
OCD is lower than in the general population [3, 6, 8]. In
contrast, studies comparing OCD patients to other men-
tal disorder samples have yielded inconsistent results [2,
7–9]. These inconsistent results may come from differ-
ences among the study designs, including very different
QoL instruments and the criteria of inclusion and exclu-
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Dr. med. K. Stengler-Wenzke
Department of Psychiatry
University of Leipzig, Johannisallee 20
DE–04317 Leipzig (Germany)
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Tel. +49 341 972 4501, Fax +49 341 972 4509, E-Mail stenglk@medizin.uni-leipzig.de
sion of the samples, especially inclusion of comorbid de-
pressive symptoms.
Another important area of research in QoL and OCD
explores the association between QoL and clinical out-
come. In psychiatry in general QoL may be considered an
outcome criterion for the therapeutic process. It is impor-
tant for the therapist to find the subjective perspective of
patients as he measures functional impairment from ill-
ness and potential side effects from treatment. Such in-
sight helps the therapist create a basis to construct an ad-
equate treatment strategy for the patient. Some studies
reported that QoL improves over the course of psycho-
therapy and psychopharmacological treatment in OCD
[9–13]. However, there is some evidence that QoL in-
creases independent of symptom improvement. Whereas
Tenney et al. [12] found responders and nonresponders
showing equal improvement in QoL in OCD, Moritz et
al. [13] reported that QoL improvement was larger in
those responding to treatment than in those not respond-
ing. Yet the methodical differences of these few studies
permit no generalizations to date on the results.
While the severity of OCD is weakly correlated with
QoL, only a few studies have assessed the correlation of
QoL and subtypes of OCD, especially different symptoms
including depressiveness. For instance, Masellis et al. [14]
examined the differing impact of obsessions, compul-
sions and comorbid depression on the QoL in OCD pa-
tients. This study from Canada using the Illness Intru-
siveness Rating Scale [15] showed that QoL, measured as
illness intrusiveness, was especially affected by obses-
sions, but not by compulsions. These findings are sup-
ported by a study identifying the presence of obsessions
of sexual/religious and aggressive content as a unique fac-
tor related to a poorer long-term clinical outcome in OCD
[16]. Masellis et al. [14] also reported that comorbid de-
pression severity was the single greatest predictor of
poorer QoL. This agrees with a study by Moritz et al. [13],
who found correlations between QoL, depression sever-
ity and a number of OCD symptoms. Using the SF-36
(MOS-SF 36) [17], these authors reported that the sever-
ity and number of obsessions were most strongly related
to the role-emotional and mental health subscales of the
QoL, whereas the number of compulsions showed a rath-
er even pattern of correlation with the QoL subscales.
According to the WHO, health-related subjective QoL
is conceptualized as a generic, multidimensional con-
struct that describes an individual’s subjective perception
of their own physical health, social functioning, environ-
ment, and general life quality [18]. Especially in recent
years this QoL concept has been increasingly accepted as
QoL in OCD
an important outcome measure in patients with mental
illnesses [19, 20].
While this definition describes the different dimen-
sions of the QoL concept, most of the previously devel-
oped instruments measuring health-related QoL deviate
from each other sharply in the interpretation and weigh-
ing of single dimensions [21]. Many of the previously
used QoL instruments concentrated on capturing func-
tional impairment resulting from illness symptoms, like
the Medical Outcome Study Approach (MOS-SF 36) [17],
the Sickness Impact Profile [22] or the Illness Intrusive-
ness Rating Scale [15]. Other instruments have focused
on impairment of the level of social functioning, like the
Global Assessment of Functioning Scale [23], the Shee-
han Disability Inventory [24] or the Liebowitz Self-Rat-
ing Disability Scale [25]. Further qualifications in com-
parability result from the fact that many instruments
were developed either solely for the areas of somatic clin-
ical data [26, 27], or they can only be employed for cap-
turing QoL in mental illnesses, like the Lehman Quality
of Life Interview [28] or the Lancashire Quality of Life
Profile [29]. In addition to these conceptual differences,
substantial problems also result when making interna-
tional and intercultural comparisons of results gathered
through translations of individual instruments [26, 30].
In recent years researchers have tried to allow for these
methodical limitations of various QoL instruments by
beginning various international projects to develop QoL
instruments, such as the International Life Assessment
Project [31] or the World Health Organization Quality of
Life Group (WHOQOL Group) [18]. In the context of this
development of the QoL instruments and the correspond-
ing limitations of individual instruments, using the
WHOQOL-BREF as an internationally recognized in-
strument was a corollary of this study.
The aim of this study was to examine whether the
findings obtained by Masellis et al. [14] can be replicated
using another instrument for the assessment of QoL. A
summary of the literature on QoL and OCD strongly sug-
gested using the WHOQOL-BREF for the present study
as a new international QoL instrument that is consid-
ered a valid and reliable measure for assessing QoL pro-
files in different populations, including patient samples
(WHOQOL Group) [18]. In addition, we were interested
in knowing which domains of QoL were particularly af-
fected by obsessions and compulsions. And last but not
least, in view of the consistent results of both Masellis et
al. [14] and Moritz et al. [13], we expected depressive
symptoms to be most strongly associated with QoL.
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 Subjects and Methods
Sample
Seventy-five patients with OCD (ICD 10 F42.0–F42.2) [32],
treated in the outpatient clinic for patients with OCD and anxiety
disorders at the Department of Psychiatry of the University of
Leipzig, were consecutively recruited. Four patients refused to
participate in the study. To be eligible for this study, participants
had to be between the ages of 18 and 65 years. OCD patients show-
ing psychiatric comorbidity diagnosed according to ICD 10 [32]
were excluded. Ten OCD patients were treated at the outpatient
hospital and had either a comorbid depression (n = 8) or comorbid
schizophrenia (n = 2).
Instruments
In order to assess QoL, we used the German version of the
WHOQOL-BREF [33]. The WHOQOL-BREF, an abbreviated
version of the WHOQOL-100 quality of life assessment, is a self-
administered questionnaire measuring individuals’ perceptions
of their position in life in the context of the culture and value sys-
tems in which they live and in relation to their goals, expectations,
standards and concerns. In developing the WHOQOL, numerous
centers around the world were involved. This procedure guaran-
tees cultural adequateness of the instrument [18]. In addition, the
WHOQOL allows a more comprehensive assessment of the vari-
ous domains of QoL than most other existing instruments [17].
The WHOQOL-BREF comprises 24 items categorized into four
broad domains: physical health (including pain and discomfort;
sleep and rest; energy and fatigue; mobility; activities of daily life;
dependence on medicinal substances and medical aids; work
capacity), psychological well-being (including positive feelings;
thinking, learning, memory and concentration; self-esteem;
bodily image and appearance; negative feelings; spirituality/reli-
gion/personal beliefs), social relationships (including personal re-
lationships; social support; sexual activity) and environment (in-
cluding freedom, physical safety and security; home environ-
ment; financial resources; health and social care: accessibility and
quality; opportunities for acquiring new information and skills;
participation in and opportunities for recreation/leisure activity;
physical environment, i.e. pollution/noise/traffic/climate, trans-
port). The items are rated on a 5-point scale. The WHOQOL-
BREF has been shown to display good discriminatory validity,
internal consistency and test-retest reliability [33].
The severity of OCD symptoms was assessed by the Yale
Brown Obsessive-Compulsive Scale (Y-BOCS) [34, 35]. The Y-
BOCS is a standardized, clinician-administered scale for assess-
ing the severity of clinical obsessions and compulsions. It com-
prises 10 items pertaining to obsessions and compulsions, rated
on a 5-point Likert scale ranging from 0 (no symptoms) to 4 (se-
vere symptoms); it has been shown to possess high internal con-
sistency and validity [34, 35].
Depressiveness was assessed with the Beck Depression Inven-
tory (BDI) [36]. The BDI is a 21-item (four-point scale) self-report
instrument designed to assess depressive symptom severity and
has been shown to be a reliable and well-validated measure of de-
pressive symptomatology. The total score of the BDI can range
from 0 to 63. Beck et al. [36] suggested that a cutoff point of 12/13
could be suitable to detect depression among psychiatric pa-
tients.
284 Psychopathology 2007;40:282–289
Statistical Analysis
To estimate the effects of the two subscores of the Y-BOCS,
linear regression analysis was used treating the two subscores as
well as the four domain scores of the WHOQOL-BREF as con-
tinuous variables. Categorical variables were dummy-coded. The
reference category is specified in the respective tables. Analyses
were done by Stata 8.2 [37]. The study was approved by the Ethics
Committee of the University of Leipzig.
Results
Demographic and Clinical Characteristics
The mean age of OCD patients was 38.49 (SD 8 12.9)
years (range 21–62) and 56.3% were females. Marital sta-
tus was single (43.6%), married or cohabiting (46.4), and
separated, divorced or widowed (9.8%). 13.43% had com-
pleted secondary school, 20.9% had school leaving exam-
inations, 10.45% had completed polytechnic, 22.39% col-
lege and 28.3% were university graduates or had a post-
graduate degree (4.4%). More than half of the patients
(54.9%) were unemployed. The mean duration of illness
was 17.88 (SD 8 12.53) years (range 1–42). Patients’ mean
total score on the Y-BOCS was 17.85 (SD 88.04), which is
consistent with moderately severe symptoms [38]. Almost
one third (28.2%) of the patients suffered from severe or
extremely severe symptoms. The mean subtotal scores
were 8.15 (SD 8 5.02) for obsessions and 9.69 (SD 8 5.09)
for compulsions. The BDI mean total score was 14.45
(SD 8 9.08), which is consistent with a mild form of de-
pression [36]. All sociodemographic and clinical charac-
teristics are summarized in table 1.
QoL and Symptom Severity
After checking for sociodemographic and clinical
characteristics (including depressive symptomatology),
only compulsions measured by the Y-BOCS subscore
‘compulsion’ were negatively associated with QoL (ta-
ble 2). This applies to all domains of QoL except for ‘so-
cial relationship’. There were no statistically significant
associations between obsessions and the four QoL do-
mains. Explained variance was largest for ‘psychological
well-being’ (R 2adj. = 0.644) and smallest for ‘social rela-
tionship’ (R 2adj. = 0.012).
Depressive symptoms, measured by the BDI total
score, had the strongest negative effect on QoL. Effect
sizes of the BDI total score were larger than those of the
Y-BOCS subscores in all domains of the WHOQOL-
BREF, except for ‘environment’ (0.244) (fig. 1). The larg-
est effect sizes of BDI were found with ‘psychological
well-being’ (1.161) and ‘physical well-being’ (0.726). When
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Table 1. Sociodemographic (and clinical) characteristics of pa- Discussion
tients
Compulsions and QoL
OCD (n = 71)
In contrast to the study by Masellis et al. [14], who found
Age, years (mean 8 SD) 38.49 (12.9) that QoL is affected by obsessions but not by compulsions,
Gender, % our findings imply the exact opposite. Compulsions and
Female 56.34 not obsessions were found to be negatively associated
Male 43.66 with QoL. This applied to the domains ‘physical well-be-
Marital status, %
Single 43.66 ing’, ‘psychological well-being’ and ‘environment’.
Married or cohabiting 46.48 The domain ‘physical well-being’ contains questions
Separated, divorced, widowed 9.86 about physical health, sleep, pain and coping with every-
Level of education completed, % day life. OCD patients with compulsions, e.g. excessive
Did not complete secondary school – washing and cleaning, are not only impaired in their dai-
Completed secondary school education 13.43
School leaving examinations (‘Mittlere Reife’) 20.9 ly physical activities. They also suffer from conditions
Completed polytechnic (‘Fachhochschule’) 10.45 resulting from their behavior, e.g. contact dermatitis [39,
Completed college 22.39 40]. In addition, some compulsions are very excessive,
University graduate 28.36 time-consuming and may cause physical strain, emo-
Completed postgraduate degree 4.48 tional stress and poor sleep [41].
Occupational status, %
Employed 45.07 The domain ‘environment’ includes questions about
Unemployed1 54.93 physical safety and security, home environment, health
Duration of illness, years (mean 8 SD) 17.88 (12.53) and social care and other questions about one’s daily life.
Y-BOCS scores (mean 8 SD) Because patients with compulsions such as contamina-
Obsessions 8.15 (5.02) tion and cleaning often experience feelings of anxiety,
Compulsions 9.69 (5.09)
Total 17.85 (8.04) danger, and constant worry in their own environment,
BDI, total score (mean 8 SD) 14.45 (9.08) they wash or control constantly – in brief: they are always
busy [42]. Therefore, social and family life is heavily re-
1
The group of ‘unemployed individuals’ (54.93%) also in- stricted [43]. Often they are not able to do leisure activi-
cludes people eligible for military service, persons doing commu- ties, and sometimes patients are even unable to seek pro-
nity service (instead of military service), pensioners and retired
persons, students, apprentices, housewives, people who are tem- fessional help.
porarily unemployed, e.g. on maternity leave, etc. Questions in the domain ‘psychological well-being’ are
associated with negative feelings of mood, sadness, anxi-
ety, and dissatisfaction with oneself. Furthermore, there
are questions about the meaning of life and about the de-
gree to which people are able to enjoy their lives. ‘Psycho-
omitting the BDI score in the regression model R 2, ‘phys- logical well-being’ in this sense may be reduced in OCD
ical well-being’ diminished from 58 to 32%, ‘environ- patients, because compulsions especially are often sense-
ment’ from 22 to 16%, and ‘psychological well-being’ less or bizarre, and are experienced agonizingly.
from 64 to 4%. The domain ‘social relationship’, which especially con-
The analysis of interaction effects between compul- tains questions about satisfaction with personal relation-
sion and BDI shows that the effect of compulsion depends ships and with support by friends, was not affected by the
on the degree of depressiveness. The effect of compulsion compulsions. At first glance this finding is surprising,
increases as depressiveness increases. No significant in- since the social life of OCD patients seems to be affected
teraction effects between obsession and the BDI could be by the symptoms. However, this might be attributed to
detected. In table 3 the estimated parameters for compul- the extremely difficult family relationships of OCD pa-
sion for BDI scores 0, the sample mean and the maximum tients. It is well-known that many of the OCD patients are
value (39) are reported. Thus the effect of compulsions completely dependent on their family members. Clinical
among those not having any depressive symptoms can be observations suggest that family members of OCD pa-
ignored. tients are often involved in patients’ rituals: it seems to be
a characteristic of patients with OCD to include their rel-
atives in the process of coping with symptoms of the ill-
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QoL in OCD Psychopathology 2007;40:282–289 285

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Table 2. Predictors of QoL of patients with OCD (nonstandardized regression coefficients)

Predictor variables Physical well-being Psychological well-being Social relationship Environment

B SE p< B SE p< B SE p< B SE p<

Gender (female) 2.90 3.23 0.374 2.46 3.26 0.455 5.52 6.39 0.392 5.81 3.31 0.086
Age –0.31 0.17 0.071 0.11 0.17 0.506 0.58 0.33 0.088 –0.31 0.17 0.081
Education1
School leaving examination
(‘Mittlere Reife’) 5.27 5.64 0.355 –5.12 5.71 0.373 9.05 11.17 0.422 –7.5 5.79 0.204
Completed polytechnic
(‘Fachhochschule’) 1.57 6.48 0.809 –6.48 6.55 0.327 –13.04 12.82 0.314 –0.46 6.65 0.945
Completed college –2.14 5.82 0.714 8.38 5.89 0.161 –0.69 11.52 0.952 10.33 5.98 0.090
University graduate 0.63 5.01 0.900 –6.73 5.07 0.190 1.83 9.92 0.854 –1.85 5.14 0.720
Completed postgraduate degree 9.19 8.49 0.285 –5.77 8.59 0.505 –0.95 16.81 0.955 –5.64 8.72 0.520
Occupational status2 (employed) –1.40 3.56 0.695 –4.53 3.60 0.214 –5.72 7.05 0.421 –5.69 3.66 0.126
Duration of illness, years –0.03 0.18 0.852 –0.09 0.18 0.624 –0.27 0.35 0.440 0.30 0.18 0.101
Y-BOCS subscores
Obsession –0.33 0.33 0.322 0.12 0.34 0.712 0.54 0.66 0.422 0.33 0.34 0.340
Compulsion –1.37 0.36 0.000 –0.98 0.37 0.010 –0.49 0.72 0.501 –1.43 0.37 0.000
BDI (total score) –0.96 0.16 0.000 –1.53 0.17 0.000 –0.68 0.33 0.044 –0.37 0.17 0.035
Constant 104.82 9.26 0.000 84.92 9.36 0.000 42.31 18.32 0.025 95.00 9.50 0.000
F(12.49) = 8.25; F(12.49) = 10.21; F(12.49) = 1.06; F(12.49) = 2.45;
p = 0.000 p = 0.000 p = 0.413 p = 0.014
R2adj.= 0.588 R2adj.= 0.644 R2adj.= 0.012 R2adj.= 0.222
1 Reference category = high school not completed.
2 Reference category = unemployed.

Table 3. Estimated parameters for compulsion for BDI scores 0,

the sample mean and the maximum value 39 (coefficients of re-
gression)

WHOQOL domains BDI sample

minimum (0) mean maximum (39)

Physical well-being –0.561 –1.319** –2.605**

Psychological well-being –0.249 –0.929* –2.083**
Environment –0.907 –1.411*** –2.267**
Social relationship –1.018 – –

* p < 0.05; ** p < 0.001; *** p = 0.000.

Fig. 1. Effect sizes of Y-BOCS subscores (obsession and compul-

sion) and BDI total score on WHOQOL-BREF domain.
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ness [44]. Relatives often become part of the rituals and,
even in the patients’ absence, take over behavioral rules
determined by the compulsions. Having this in mind, pa-
tients may see their so-defined social relationships as be-
ing supportive, thereby assessing this domain of subjec-
tive QoL as not impaired.
Depression and QoL
Depressive symptoms were negatively associated with
QoL. This applied to all domains investigated. Although
cases of major depression diagnosed according to ICD 10
[32] were excluded, coexisting depressive symptoms
showed the greatest impact on QoL. Many studies have
described the relationship between depressive symptoms
and subjective QoL [45–47]. However, there is general
agreement that subjective QoL may be regarded as mul-
tifactorially determined constructs not redundant with
self-rated depression [48, 49]. Nevertheless, it is true that
QoL domains resemble diagnostic criteria for depressive
symptoms and impairments. This underscores the prob-
lem of a partial overlap between the constructs of QoL
and depression [50].
In our study, ‘psychological well-being’ was the most
impaired WHOQOL domain in the case of depression.
Questions in this domain explore sadness, anxiety, and
dissatisfaction with oneself. Furthermore, there are ques-
tions about the meaning of life and the degree to which
people are able to enjoy their lives. The questions in this
domain are obviously associated with depression [1].
‘Physical well-being’, including questions about physi-
cal health, sleep, and pain, was the second most impaired
domain with depression. The items of this domain were
also linked with depressiveness. In our study, the negative
impact of depressive symptoms on these two WHOQOL-
BREF domains (psychological and physical well-being) is
greater than the effect of compulsion.
Limitations
First, the sample investigated recruits from our special-
ized outpatient clinic and is thus unlikely to be a represen-
tative sample of OCD patients in Germany. Further studies
would clearly benefit from investigating larger representa-
tive OCD patient samples. Second, the cross-sectional na-
ture of the design precludes identifying a causal relation-
ship between symptom functioning and QoL. Third, rat-
ings on depression scales (e.g. BDI) and on QoL instruments
(e.g. WHOQOL-BREF) might be state-dependent and may
change during the course of OCD. Therefore, a longitudi-
nal study design is required to investigate the stability of
symptoms and their impact on QoL.
QoL in OCD
Conclusions
When comparing our results with those of Masellis et
al. [14], a major difference emerges. Masellis et al. [14]
found that obsessions do affect QoL, whereas our study
revealed that compulsions have a negative impact on
QoL. Two explanations are possible. First, Masellis et al.
[14] and our study both used very different QoL instru-
ments, which complicates a comparison of the results.
Masellis et al. [14] assessed QoL using the Illness Intru-
siveness Rating Scale, which is designed to measure ob-
jective and perceived interference of symptoms across 13
life domains considered important to QoL [15]. Individ-
ual item ratings are summed to provide an overall index
of illness intrusiveness. In contrast, QoL was assessed in
our study using the WHOQOL-BREF [18] and including
assessment of different QoL domains with different par-
tial scores. Second, in both studies only small patient
samples were investigated. Therefore, different subtypes
of obsessions included different coping strategies of ob-
sessions, e.g. compulsions as coping with obsessions have
not been accounted for in this study. It is possible that the
meaning of ‘obsessions’ and ‘compulsions’ is similar in
some cases. Lee et al. [51] proposed that obsessions are
categorized into two subtypes, i.e. autogenous obsessions
and reactive obsessions, which differ in terms of identify-
ing their evoking stimuli, contents, and subsequent cog-
nitive processes. These authors hypothesized that indi-
viduals with so-defined reactive obsessions attempt to
employ overt and actual compulsive behaviors (e.g. wash-
ing, checking, hoarding) to prevent the unwanted possi-
ble consequences of their thoughts. The distinction be-
tween primary intrusive compulsive thoughts and sec-
ondary compulsive habits associated with them was also
discussed in a recent publication by Bürgy [52]. Thus the
conflicting results reported by Masellis et al. [14] and by
our current study should be tested in a study design tak-
ing into account the distinction between compulsive
thoughts in a larger patient group.
However, results reported by Masellis et al. [14] are
similar to our own findings regarding the impact of sub-
jective depression measured by BDI in patients with
OCD. Therefore, patients’ subjective assessment of de-
pressiveness is very important in studying the QoL of
OCD patients.
The present findings have clear practical implications.
Given the importance of the different symptoms, specif-
ic interventions for obsessions, compulsions and second-
ary depressive symptoms are warranted to improve psy-
chosocial functioning and QoL.
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