Obsessive-compulsive disorder (OCD) is a chronic disorder characterized by unwanted repetitive thoughts (obsessions) and/or behaviors (compulsion) [1], affecting approximately 1%-3% of the adult population [2,3]. Obsessive-compulsive symptoms are highly distressing and hard to ignore, worsening the quality of life of patients [4-6]. OCD patients experience significant interference in various aspects of their lives, including social, occupational impairment [7,8]. Families of OCD patients also experience higher distress, compared with families with other psychiatric illnesses patients, since OCD symptoms are often related to or dependent on family members [9,10].

Family accommodation (FA) refers to a phenomenon in which family members adjust their lifestyle according to the patient’s obsessive-compulsive symptoms. In particular, family members often participate in the patients’ rituals or modify their routines to avoid triggering the patients’ symptoms [11]. FA is highly prevalent in families of patients with OCD, with up to 97% of family members reporting that they accommodate symptoms in a significant way [12,13]. Although, it may temporarily relieve a patient’s anxiety, paradoxically, it contributes to destroying the family’s quality of life [14] and reducing the effectiveness of the patient’s treatment by preventing them from exposure to obsession [13,15].

Growing body of researches focus on clinical correlates with family accommodation. For example, higher symptom severity, lower general functioning and specific OCD symptom dimensions (such as cleaning and comorbid mood symptoms) were associated with higher family accommodation [16-19]. Regarding relatives’ factors, higher family conflict, familial aggression, and feelings of anger and anxiety demonstrate higher family accommodation [19]. However, most of researches have been carried out in American and Western-European societies, and there has been a lack of cross-cultural studies examining family accommodation in OCD family.

The interviewer-rated Family Accommodation Scale for Obsessive-compulsive Disorder (FAS-IR), an instrument that assesses 12 accommodating behaviors, has been considered the gold standard for assessing the types and severity of FA [11]. However, FAS-IR has some disadvantage using in clinical practice because significant time spent in interviewer training/administrating. Further, it may miss some accommodating behaviors, as family members may feel less willing to disclose the patient’s OCD symptoms when asked directly by a clinician [20]. The self-rated version of the Family Accommodation Scale for Obsessive-compulsive Disorder (FAS-SR) is a modified version of the FAS-IR to compensate for the latter’s shortcomings by Pinto et al. [16]. The FAS-SR is a self-report measure assessing accommodating behaviors in the past week, completed by the relatives of patients with OCD. The FAS-SR has already been translated in Japan and India and demonstrated excellent internal consistency and good convergent validity with related constructs (e.g., OCD symptom severity, overall psychosocial functioning, family functioning, and distress experienced by patients’ relatives) [21,22]. Thus, the FAS-SR can be considered a practical alternative to the FAS-IR and has sufficient potential to be widely applied [13].

Patterns of caregiving and beliefs about disease vary widely across cultures and could lead to substantially different responses to patients’ obsessive-compulsive symptoms [23]. In Korea, to the best of authors’ knowledge, there exists no tools assessing FA in OCD family. Therefore, this study aimed to standardize the Korean version of the FAS-SR and explore the characteristics of family accommodation behavior in Korea.

We translated the FAS-SR, a representative scale for assessing family accommodation in obsessive-compulsive disorder, into Korean and examined its psychometric properties. The Korean version of FAS-SR showed excellent reliability and acceptable validity and it can be easily completed by relatives at the outpatient clinic setting. As far as our knowledge, this is the first study investigates both OCD patient and their family members from a family accommodation aspect.

Regarding reliability, Korean version of the FAS-SR showed excellent internal consistency (Chronbach’s alpha=0.91). The original version (Chronbach’s alpha=0.90) and the Hindi version (Chronbach’s alpha=0.93) [22] were similar to ours, whereas the Japanese version was lower (0.88) [21]. Further, the Korean version’s Spearman-Brown coefficient was higher than Hindi versions (Spearman-Brown coefficient=0.75, Guttmann’s split-half coefficient=0.71) [22] indicating that the split-half reliability of Korean version of the FAS-SR was acceptable. The ICC for each of the 19 items of the scale was higher than that of the Japanese version (ICC=0.85, p<0.01). Above results support that Korean version of the FAS-SR constitute a reliable measure for consistent symptoms.

The Korean version of FAS-SR was significantly correlated with clinical factors previously known to be related to FA, such as with relative-rated psychological distress, patients rated OC symptom severity and general functioning, indicates good convergent validity. However, contrary to our expectation, there was no correlation between the Korean version of FAS and the relative-rated FAD. Validation studies in Japan and India, the FAS-SR was significantly associated with relative-rated family function [16,21,22]. This discrepancy might come from that the composition of the relatives participating at the study varies among studies. In our study, the proportion of parents among relatives was 79.06%, which is higher than that of the Japan (48.8%) [21], India (31.7%) [22], and United states (37%) [16]. Parents tend to rate their families as more healthy than other family members with FAD.

The most common types of family accommodation in our study were item 13 (“I stopped doing things that could trigger the patient’s OCD” [80.9%]); and item 15 (“I avoided talking about OCD triggers” [78.6%]). For a Japanese study, 21 the most common type of family accommodation was item 12 (“I avoided talking about OCD triggers” [63.4%]), whereas in the original study it was item 1 (“I reassured patient that there were no grounds for OCD concern” [63.4%]). These results demonstrate that in east Asia countries, the relatives of OCD patients usually modified their behavior or routine; by contrast, in the American study, they usually provided reassurance and participated in patients’ compulsions. When implementing family-based Exposure and Response Prevention (ERP) in Korean OCD patients, reducing the tendency of relatives to modify their behavior to avoid symptom triggering might help to achieve good therapeutic effects.

A limitation of the present study is its relatively small sample size (78.57% of relatives were parents), which may limit the power of the statistical analyses and the generalizability of the results. Second, potential for sample bias should be considered, as some of the patients were under-control with treatment, whereas others were acutely ill states. Third, FAS-IR, the gold standard, was not used to confirm convergent validity. Therefore, the clinical utility of the Korean version of the FAS-SR should be further evaluated in more strictly standardized settings and assessment tool.

The results of this study are meaningful because we introduced a tool to assess family accommodation in OCD patients in Korea for the first time. The Korean version of the FAS-SR is useful as a time-efficient and cost-effective tool.