Demoralization in patients with Obsessive-compulsive disorder: a preliminary report

Demoralization in patients with Obsessive-compulsive disorder: a preliminary report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Demoralization in patients with Obsessive-compulsive disorder: a preliminary report Annalisa Maraone, Matteo Panfili, Valentina Roselli, Daniele D’Agostini, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8841229/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Background Obsessive–compulsive disorder (OCD) is a chronic, early-onset condition often associated with high rates of treatment resistance. Depression is one of the most frequent comorbidities and is linked to poorer therapeutic outcomes. Recently, the concept of Demoralization Syndrome, has been proposed as distinct from Major Depressive Disorder. Given the disabling nature of OCD, it is relevant to evaluate distinctly Demoralization and Depression states considering that the two conditions may have different treatment implications. Methods The aim of the present preliminary study was to evaluate the presence of demoralization in subjects with OCD and its relationship with the severity of OCD-related symptoms. Adults with a primary diagnosis of OCD were consecutively recruited from the OCD outpatient clinic of Policlinico Umberto I. Eligible participants were assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) for OCD severity, the Demoralization Scale (DS) for demoralization symptoms, and the Patient Health Questionnaire (PHQ) and Hamilton Depression Rating Scale (HAM-D) for clinical relevant depressive symptoms using established cutoffs. Results A total of 43 adults with OCD, consecutively screened and enrolled, were included. Both depressive symptoms and demoralization symtoms were highly prevalent, with clinically significant demoralization observed in 88% of patients. A subset of individuals exhibited demoralization without clinical relevant depression, suggesting a partial distinction between the two constructs. Demoralization severity showed a strong association with overall OCD severity, particularly with obsessions rather than with compulsions, and this relationship remained significant even after controlling for depressive symptoms. Conclusion Demoralization is highly prevalent in our sample and can occur independently of clinically significant depression. Recognizing demoralization as a distinct construct may improve diagnostic precision and guide tailored therapeutic interventions, complementing standard treatments for OCD and depression. Further research, including longitudinal studies, is needed to clarify its impact on the course of the disorder. Obsessive-compulsive disorder Depression Demoralization Syndrome Integrated interventions Psychotherapy Figures Figure 1 Background Obsessive-compulsive Disorder (OCD) is a severe and early onset neuropsychiatric disorder that affects from 1% to 3% of the general population [1,2]. It is frequently developed during childhood or adolescence and is clinically characterized by obsessions, recurrent and intrusive thoughts, and/or compulsions, that are repetitive behaviors. OCD often follows a chronic course, with high rates of treatment resistance and refractoriness. Several studies have identified various factors that may negatively influence treatment outcomes, leading to reduced therapeutic response [3–5] and increased chronicity. Among the factors that most significantly affect the course of the disorder there are the age of onset, the presence or absence of motor tics, the duration of untreated illness (DUI), and comorbidity with other psychiatric disorders [6,7]. Depression appears to have a high comorbidity with OCD and the scientific literature is rich in data on the close comorbidity between OCD and Depression [8] described the presence of depressive symptoms in 56.6% of the OCD patients. This association is present both in developmental age [8] and in adulthood [9] and the presence of depressive symptoms seems to negatively influence the outcome of the therapeutic intervention [10]. Additionally, data also underlines the need to reduce the latency time of intervention for patients who show depressive symptoms [11,12], in order to both improve the efficacy of treatments and prevent the worsening of the clinical picture. In the last ten years, the construct of Demoralization Syndrome has been introduced as a new concept of reactive depression for patients affected by chronic medical, neurodegenerative and psychiatric pathologies (such as psychosis). This syndrome is marked by a distinct constellation of symptoms, including a pervasive sense of hopelessness, a loss of meaning and purpose in life, feelings of helplessness and entrapment, a perceived personal failure in coping with stressful circumstances, as well as pronounced pessimism and diminished motivation or drive to act [13]. The concept of demoralization has been defined by Frank [14] as a mental state characterized by the lack of spirit or courage that leads the subject to disorder and confusion. Subsequent experimental clinical studies have recognized demoralization as a defined identity in the context of affective disorders [15] that differs from Depression for the lack of anhedonia, loss of pleasure and interest in life activities [10], which are essential criteria for the diagnosis of Depression [16]. Considering OCD a chronic and very often disabling pathology, it is possible to hypothesize that patients affected by OCD may show depressive symptoms that fall within the Demoralization Syndrome. Identifying and distinguishing demoralization from Depression is crucial for selecting a more appropriate therapeutic approach. In fact, while depression usually responds to pharmacological treatment with antidepressants, demoralization appears to respond more effectively to humanistic-existential psychotherapy [17,18]. Considering the above, the aim of the present preliminary study was to evaluate the presence of demoralization in subjects with OCD and its relationship with the severity of OCD-related symptoms. Materials and Methods Participants were consecutively recruited (between December 2021 and July 2024) among patients referring at the OCD outpatient clinic of Policlinico Umberto I University Hospital. Inclusion criteria for the present study were diagnosis of OCD, adulthood (i.e. included individuals were at least 18 years old); exclusion criteria were: concomitant psychotic disorder, current substance use disorders, refusal to sign informed consent. All participants gave their written informed consent to be included in the study. The present research is part of a research protocol on psychopathological features of OCD approved by the Ethics Committee of Policlinico Umberto I University Hospital (Rif. 6897 - Prot. 0784/2022). In relation to the present research, patients were assessed using the Italian versions of the following scales. Yale-Brown Obsessive Compulsive Scale (YBOCS) [19]: total score and subscores on the severity of obsessions and compulsions were calculated; Demoralization Scale (DS) was used to assess demoralization symptoms [20,21], with DS scores ≥ 25 being considered as suggestive of clinically significant demoralization symptoms (as observed in previous studies [22]; Patient Health Questionnaire (PHQ) and Hamilton Depression Rating Scale (HAM-D) were used to assess the presence of clinically-relevant depressive symptoms (specifically: PHQ scores ≥ 8 and HAM-D scores ≥ 8 were considered suggestive of clinically significant depressive symptoms, as observed in previous studies [23,24]. 2.1. Statistical analysis Statistical analyses were performed using SPSS version 20. Descriptive analyses are presented as mean ± standard deviation or as percentages. Inferential analyses were based on Spearman correlations; to explore whether the relationship of demoralization levels with OCD severity was independent by clinically significant depressive symptoms, Spearman partial correlations were also performed, including clinically significant depressive symptoms (PHQ cutoff or HAM-D cutoff) as covariate. Statistical significance was set at p < 0.05. A non-parametric test was chosen as certain explored variables were non-normally distributed. Results The sample consisted of 43 OCD patients. There were no refusals. The main social and clinical characteristics of study participants are described in Table 1. Participants (n) 43 Gender (Male/Female) 19/24 Age (years, mean±ds) 38.14±16.50 Smokers use n. (%) n. 14 (32.6%) Alcohol use n. (%) n. 17 (39.5%) Recreational substances use n. (%) n. 1 (2.3%) Having an academic degree n. (%) n. 14 (32.6%) OCD psychopathological onset n. (%) n. 36 (83.7%) Other psychopathological onset n. (%) n. 7 (16.3%) Mean age of OCD onset (years, mean±ds) 18.81±11.21 Mean disease duration (years, mean±ds) 19.32±13.80 Taking psychiatric medication n. (%) n. 35 (81.4%) Undergoing psychotherapy n. (%) n. 11 (25.6%) Comorbidity with Tourette Syndrome n. (%) n. 5 (11.6%) Comorbidity with other psychiatric conditions n. (%) n. 17 (39.5%) Familiarity for psychiatric disorders n. (%) n. 7 (16.3%) Table 1: Social and clinical Characteristics of Study Participants At the first evaluation, mean YBOCS total score was 25.69±7.79, mean YBOCS obsessions score was 13.23±3.96, mean YBOCS compulsions score was 12.46±4.45. Mean DS score was 49.30±17.52; 38 subjects (88.4%) had DS scores ≥25, suggesting clinically significant demoralization symptoms (20). Mean PHQ score was 11.72±6.26; 31 subjects (72.1%) had PHQ scores ≥8, suggesting clinically significant depressive symptoms (21). Mean HAM-D score was 9.70±3.53; 33 subjects (76,7%) had HAM-D scores ≥8, suggesting clinically significant depressive symptoms. Based on the described cutoff scores of PHQ, HAM-D and DS, we observed differences in the amount of subjects having clinically significant depressive symptoms and/or clinically significant demoralization symptoms. Based on PHQ and DS: 31 subjects (72.1%) had clinically significant depressive symptoms, and all of them also had clinically significant demoralization symptoms; on the other hand, of the 38 subjects (88.4%) having clinically significant demoralization symptoms, 7 did not have clinically significant depressive symptoms. Based on HAM-D and DS: 29 subjects exhibited both clinically significant depressive symptoms and clinically significant demoralization symptoms, 4 patients showed only clinically significant depressive symptoms, and 9 patients showed only clinically significant demoralization symptoms. DS was significantly associated with YBOCS total score (rho=0.324, p=0.034) and YBOCS obsessions score (rho=0.415, p=0.006) (Figure 1), while it was not significantly associated with YBOCS compulsions score. Further, when PHQ cutoff was used as covariate DS was still significantly associated with YBOCS total score (rho=0.332, p=0.031) and with YBOCS obsessions score (rho=0.451, p=0.003); similarly, when HAM-D cutoff was used as a covariate, DS was still significantly associated with Y-BOCS total score (rho=0.316, p=0.042) and with Y-BOCS obsession subscore (rho=0.401, p=0.008). Among the subcomponents of YBOCS obsessions score, DS was significantly positively associated with the severity of: interference due to obsessive thoughts (rho=0.311, p=0.043), distress associated with obsessive thoughts (rho=0.360, p=0.018), resistance against obsessions (rho=0.450, p=0.002), and degree of control over obsessive thoughts (rho=0.323, p=0.034). These associations remained significant after covarying either for PHQ cutoff or for HAM-D cutoff (with the exception of the relationship with interference due to obsessive thoughts, which lost significance after covarying for HAM-D). Discussion The present study, to the best of our knowledge, is one of the first to explore the presence of demoralization in OCD patients, whereas most of the existing literature on the topic has focused on its presence in somatic illnesses [25]. In relation to the overall clinical features of the sample, the results of this study, consistently with the scientific literature, showed that comorbidity in OCD is frequent: in the sample examined, nearly four out of ten patients (39.5%) had a comorbid psychiatric disorder, and 14% of patients met DSM-5 criteria for a comorbid depressive disorder. Based on PHQ self-report scale, the percentage of patients presenting clinically relevant depressive symptoms rose to 72.1%, indicating a high prevalence of depressive experiences among patients with OCD, in line with the existing literature; the use of HAM-D also enabled us to evaluate results also using a clinician-rated instruments, revealing that 76.7% of patients presented clinically relevant depressive symptoms. This study aimed to investigate whether the affective condition characterizing OCD could, at least in part, be attributed to a state of demoralization. The results highlight a significant presence of demoralization symptoms in patients with OCD: 38 patients (88.4%) showed significant demoralization according to the described cut-off, suggesting the presence of feelings of hopelessness, helplessness, and loss of meaning in OCD patients, regardless of a comorbid diagnosis of depressive disorder. The results are in line with previous studies indicating a higher prevalence of demoralization syndrome in individuals affected by mental disorders [26,27]. In the general population, demoralization syndrome has been described in 2–5% of individuals [26,28], with prevalence rates rising to approximately 50% among patients with cancer or with severe chronic illness [29–31]. Futhermore, the prevalence of demoralization is elevated in individuals diagnosed with mental disorders [26,32], and that this condition exhibits a degree of independence from clinical depression. Indeed, our results showed that a portion of patients with significant demoralization did not exhibit clinically-relevant depressive symptoms (both measuring depression with PHQ and with HAM-D). These results appear to strengthen the hypothesis that demoralization and depression constitute two at least partially distinct psychopathological entities and emphasize the importance of further investigating this population to avoid the risk of underestimating the emotional distress of some patients if assessment were limited exclusively to depressive disorder [33]. Consistent with the theoretical conception that defines demoralization as an existential and motivational construct, the Demoralization Syndrome appears to be closely linked to the subjective experience of depressive suffering, which influences the perceived psychological well-being but does not necessarily align with the objectively observed symptoms severity. Moreover, the severity of obsessions and certain subcomponents of obsessions (described through the Y-BOCS, as the interference due to obsessive thoughts, the distress associated with obsessive thoughts, the resistance against obsessions and the degree of control over obsessive thoughts) have showed a significant correlation with demoralization, also independently by the presence of clinically-relevant depressive symptoms. These specific components, due to their inherent nature, may have an impact on the existential dimension more than the purely affective dimension [34]. Considering the typically chronic and disabling course of OCD, the high number of patients resistant and/or refractory to the conventional pharmacological treatments and the phenomenological features of the disorder (such as the intrusiveness of obsessions, feelings of loss of control, ego-dystonicity), it is plausible to hypothesize that experiences of helplessness, pessimism, and loss of hope may play a crucial role in the disorder's impact on patients's lives. The core dimensions of demoralization syndrome, as emphasized in the literature, call for targeted and integrated therapeutic interventions. In this context, the differentiation between the psychopathological features of demoralization and those of depression may underlie distinct treatment trajectories, reinforcing the need for precise diagnostic assessment and individualized clinical approaches. Besides, given the high antidepressant dosages typically administered to patients with OCD, the persistence of demoralization symptoms suggests that alternative therapeutic approaches—such as existentially oriented interventions—should be considered. Several limitations should be considered when interpreting the results of this study. First, this is a pilot investigation aimed at describing demoralization in patients with OCD, and the statistical analyses are limited to the preliminary data currently available. Furthermore, the cross-sectional design of the study does not allow to evaluate the inferences of demoralization on follow up, longitudinal studies are necessary to examine the potential impact of demoralization on both the short- and long-term course of OCD. In conclusion, based on the findings of this preliminary study on demoralization in patients with OCD, it appears essential to further investigate and delineate this psychopathological construct, which may warrant distinct clinical assessment strategies and an integrated therapeutic approach. Declarations Ethics approval and consent to participate The studies involving humans were approved by Ethics Committee of Policlinico Umberto I University Hospital of Rome (protocol 0784/2022). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Funding sources None Availability of data and materials The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Authors’ contributions AM: Conceptualization, Supervision, Writing – original draft, Writing – review & editing. MP: Formal analysis, Investigation, Review & editing. VR: Investigation, Software, Writing – original draft. DD: Investigation, Software. IP and TA: Data curation, Methodology. LT: Conceptualization, Supervision. FSB: Formal analysis, Methodology, Supervision, Validation, Writing – original draft. MP: Conceptualization, Supervision, Validation, Writing – review & editing. Acknowledgments We thank all patients who participated in the study and the staff who supported our effort. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. References Strom NI, Soda T, Mathews CA, Davis LK. A dimensional perspective on the genetics of obsessive-compulsive disorder. Transl Psychiatry. 2021;11(1):401. doi: 10.1038/s41398-021-01519-z. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. 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Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 13 Apr, 2026 Reviews received at journal 09 Apr, 2026 Reviewers agreed at journal 08 Apr, 2026 Reviews received at journal 23 Mar, 2026 Reviewers agreed at journal 22 Mar, 2026 Reviewers invited by journal 20 Mar, 2026 Editor assigned by journal 11 Feb, 2026 Submission checks completed at journal 11 Feb, 2026 First submitted to journal 10 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8841229","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":610983930,"identity":"0a35f761-8779-4742-9732-5cbf6580dd0f","order_by":0,"name":"Annalisa 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relationship of DS score (on X axis) with YBOCS total score and YBOCS obsessions\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8841229/v1/a19ee1d578e285903db5e985.png"},{"id":105408752,"identity":"c1844e1a-9479-4477-a7b3-2d88928a629f","added_by":"auto","created_at":"2026-03-25 17:07:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":531090,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8841229/v1/786c2ea2-0fe1-4386-843f-4a206c20cda8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Demoralization in patients with Obsessive-compulsive disorder: a preliminary report","fulltext":[{"header":"Background","content":"\u003cp\u003eObsessive-compulsive Disorder (OCD) is a severe and early onset neuropsychiatric disorder that affects from 1% to 3% of the general population [1,2]. It is frequently developed during childhood or adolescence and is clinically characterized by obsessions, recurrent and intrusive thoughts, and/or compulsions, that are repetitive behaviors.\u003c/p\u003e \u003cp\u003eOCD often follows a chronic course, with high rates of treatment resistance and refractoriness. Several studies have identified various factors that may negatively influence treatment outcomes, leading to reduced therapeutic response [3\u0026ndash;5] and increased chronicity.\u003c/p\u003e \u003cp\u003eAmong the factors that most significantly affect the course of the disorder there are the age of onset, the presence or absence of motor tics, the duration of untreated illness (DUI), and comorbidity with other psychiatric disorders [6,7].\u003c/p\u003e \u003cp\u003eDepression appears to have a high comorbidity with OCD and the scientific literature is rich in data on the close comorbidity between OCD and Depression [8] described the presence of depressive symptoms in 56.6% of the OCD patients. This association is present both in developmental age [8] and in adulthood [9] and the presence of depressive symptoms seems to negatively influence the outcome of the therapeutic intervention [10]. Additionally, data also underlines the need to reduce the latency time of intervention for patients who show depressive symptoms [11,12], in order to both improve the efficacy of treatments and prevent the worsening of the clinical picture.\u003c/p\u003e \u003cp\u003eIn the last ten years, the construct of Demoralization Syndrome has been introduced as a new concept of reactive depression for patients affected by chronic medical, neurodegenerative and psychiatric pathologies (such as psychosis). This syndrome is marked by a distinct constellation of symptoms, including a pervasive sense of hopelessness, a loss of meaning and purpose in life, feelings of helplessness and entrapment, a perceived personal failure in coping with stressful circumstances, as well as pronounced pessimism and diminished motivation or drive to act [13]. The concept of demoralization has been defined by Frank [14] as a mental state characterized by the lack of spirit or courage that leads the subject to disorder and confusion.\u003c/p\u003e \u003cp\u003eSubsequent experimental clinical studies have recognized demoralization as a defined identity in the context of affective disorders [15] that differs from Depression for the lack of anhedonia, loss of pleasure and interest in life activities [10], which are essential criteria for the diagnosis of Depression [16].\u003c/p\u003e \u003cp\u003eConsidering OCD a chronic and very often disabling pathology, it is possible to hypothesize that patients affected by OCD may show depressive symptoms that fall within the Demoralization Syndrome.\u003c/p\u003e \u003cp\u003eIdentifying and distinguishing demoralization from Depression is crucial for selecting a more appropriate therapeutic approach. In fact, while depression usually responds to pharmacological treatment with antidepressants, demoralization appears to respond more effectively to humanistic-existential psychotherapy [17,18].\u003c/p\u003e \u003cp\u003eConsidering the above, the aim of the present preliminary study was to evaluate the presence of demoralization in subjects with OCD and its relationship with the severity of OCD-related symptoms.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eParticipants were consecutively recruited (between December 2021 and July 2024) among patients referring at the OCD outpatient clinic of Policlinico Umberto I University Hospital. Inclusion criteria for the present study were diagnosis of OCD, adulthood (i.e. included individuals were at least 18 years old); exclusion criteria were: concomitant psychotic disorder, current substance use disorders, refusal to sign informed consent. All participants gave their written informed consent to be included in the study. The present research is part of a research protocol on psychopathological features of OCD approved by the Ethics Committee of Policlinico Umberto I University Hospital (Rif. 6897 - Prot. 0784/2022).\u003c/p\u003e \u003cp\u003eIn relation to the present research, patients were assessed using the Italian versions of the following scales. Yale-Brown Obsessive Compulsive Scale (YBOCS) [19]: total score and subscores on the severity of obsessions and compulsions were calculated; Demoralization Scale (DS) was used to assess demoralization symptoms [20,21], with DS scores\u0026thinsp;\u0026ge;\u0026thinsp;25 being considered as suggestive of clinically significant demoralization symptoms (as observed in previous studies [22]; Patient Health Questionnaire (PHQ) and Hamilton Depression Rating Scale (HAM-D) were used to assess the presence of clinically-relevant depressive symptoms (specifically: PHQ scores\u0026thinsp;\u0026ge;\u0026thinsp;8 and HAM-D scores\u0026thinsp;\u0026ge;\u0026thinsp;8 were considered suggestive of clinically significant depressive symptoms, as observed in previous studies [23,24].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Statistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS version 20. Descriptive analyses are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or as percentages. Inferential analyses were based on Spearman correlations; to explore whether the relationship of demoralization levels with OCD severity was independent by clinically significant depressive symptoms, Spearman partial correlations were also performed, including clinically significant depressive symptoms (PHQ cutoff or HAM-D cutoff) as covariate. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. A non-parametric test was chosen as certain explored variables were non-normally distributed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe sample consisted of 43 OCD patients. There were no refusals. The main social and clinical characteristics of study participants are described in Table 1.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eParticipants (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e43\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eGender (Male/Female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e19/24\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eAge (years, mean\u0026plusmn;ds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e38.14\u0026plusmn;16.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eSmokers use n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 14 (32.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eAlcohol use n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 17 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eRecreational substances use n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHaving an academic degree n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 14 (32.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eOCD psychopathological onset n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 36 (83.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eOther psychopathological onset n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 7 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eMean age of OCD onset (years, mean\u0026plusmn;ds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e18.81\u0026plusmn;11.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eMean disease duration (years, mean\u0026plusmn;ds)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e19.32\u0026plusmn;13.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eTaking psychiatric medication n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 35 (81.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eUndergoing psychotherapy n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 11 (25.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eComorbidity with Tourette Syndrome n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 5 (11.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eComorbidity with other psychiatric conditions n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 17 (39.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eFamiliarity for psychiatric disorders n. (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003en. 7 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eTable 1: Social and clinical Characteristics of Study Participants\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt the first evaluation, mean YBOCS total score was 25.69\u0026plusmn;7.79, mean YBOCS obsessions score was 13.23\u0026plusmn;3.96, mean YBOCS compulsions score was 12.46\u0026plusmn;4.45. Mean DS score was 49.30\u0026plusmn;17.52; 38 subjects (88.4%) had DS scores \u0026ge;25, suggesting clinically significant demoralization symptoms (20). Mean PHQ score was 11.72\u0026plusmn;6.26; 31 subjects (72.1%) had PHQ scores \u0026ge;8, suggesting clinically significant depressive symptoms (21). Mean HAM-D score was 9.70\u0026plusmn;3.53; 33 subjects (76,7%) had HAM-D scores \u0026ge;8, suggesting clinically significant depressive symptoms.\u003c/p\u003e\n\u003cp\u003eBased on the described cutoff scores of PHQ, HAM-D and DS, we observed differences in the amount of subjects having clinically significant depressive symptoms and/or clinically significant demoralization symptoms. Based on PHQ and DS: 31 subjects (72.1%) had clinically significant depressive symptoms, and all of them also had clinically significant demoralization symptoms; on the other hand, of the 38 subjects (88.4%) having clinically significant demoralization symptoms, 7 did not have clinically significant depressive symptoms. Based on HAM-D and DS: 29 subjects exhibited both clinically significant depressive symptoms and clinically significant demoralization symptoms, 4 patients showed only clinically significant depressive symptoms, and 9 patients showed only clinically significant demoralization symptoms.\u003c/p\u003e\n\u003cp\u003eDS was significantly associated with YBOCS total score (rho=0.324, p=0.034) and YBOCS obsessions score (rho=0.415, p=0.006) (Figure 1), while it was not significantly associated with YBOCS compulsions score. Further, when PHQ cutoff was used as covariate DS was still significantly \u0026nbsp;associated with YBOCS total score (rho=0.332, p=0.031) and with YBOCS obsessions score (rho=0.451, p=0.003); similarly, when HAM-D cutoff was used as a covariate, DS was still significantly associated with Y-BOCS total score (rho=0.316, p=0.042) and with Y-BOCS obsession subscore (rho=0.401, p=0.008).\u003c/p\u003e\n\u003cp\u003eAmong the subcomponents of YBOCS obsessions score, DS was significantly positively associated with the severity of: interference due to obsessive thoughts (rho=0.311, p=0.043), distress associated with obsessive thoughts (rho=0.360, p=0.018), resistance against obsessions (rho=0.450, p=0.002), and degree of control over obsessive thoughts (rho=0.323, p=0.034). These associations remained significant after covarying either for PHQ cutoff or for HAM-D cutoff (with the exception of the relationship with interference due to obsessive thoughts, which lost significance after covarying for HAM-D).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study, to the best of our knowledge, is one of the first to explore the presence of demoralization in OCD patients, whereas most of the existing literature on the topic has focused on its presence in somatic illnesses [25].\u003c/p\u003e \u003cp\u003eIn relation to the overall clinical features of the sample, the results of this study, consistently with the scientific literature, showed that comorbidity in OCD is frequent: in the sample examined, nearly four out of ten patients (39.5%) had a comorbid psychiatric disorder, and 14% of patients met DSM-5 criteria for a comorbid depressive disorder. Based on PHQ self-report scale, the percentage of patients presenting clinically relevant depressive symptoms rose to 72.1%, indicating a high prevalence of depressive experiences among patients with OCD, in line with the existing literature; the use of HAM-D also enabled us to evaluate results also using a clinician-rated instruments, revealing that 76.7% of patients presented clinically relevant depressive symptoms.\u003c/p\u003e \u003cp\u003eThis study aimed to investigate whether the affective condition characterizing OCD could, at least in part, be attributed to a state of demoralization. The results highlight a significant presence of demoralization symptoms in patients with OCD: 38 patients (88.4%) showed significant demoralization according to the described cut-off, suggesting the presence of feelings of hopelessness, helplessness, and loss of meaning in OCD patients, regardless of a comorbid diagnosis of depressive disorder. The results are in line with previous studies indicating a higher prevalence of demoralization syndrome in individuals affected by mental disorders [26,27]. In the general population, demoralization syndrome has been described in 2\u0026ndash;5% of individuals [26,28], with prevalence rates rising to approximately 50% among patients with cancer or with severe chronic illness [29\u0026ndash;31].\u003c/p\u003e \u003cp\u003eFuthermore, the prevalence of demoralization is elevated in individuals diagnosed with mental disorders [26,32], and that this condition exhibits a degree of independence from clinical depression. Indeed, our results showed that a portion of patients with significant demoralization did not exhibit clinically-relevant depressive symptoms (both measuring depression with PHQ and with HAM-D). These results appear to strengthen the hypothesis that demoralization and depression constitute two at least partially distinct psychopathological entities and emphasize the importance of further investigating this population to avoid the risk of underestimating the emotional distress of some patients if assessment were limited exclusively to depressive disorder [33]. Consistent with the theoretical conception that defines demoralization as an existential and motivational construct, the Demoralization Syndrome appears to be closely linked to the subjective experience of depressive suffering, which influences the perceived psychological well-being but does not necessarily align with the objectively observed symptoms severity.\u003c/p\u003e \u003cp\u003eMoreover, the severity of obsessions and certain subcomponents of obsessions (described through the Y-BOCS, as the interference due to obsessive thoughts, the distress associated with obsessive thoughts, the resistance against obsessions and the degree of control over obsessive thoughts) have showed a significant correlation with demoralization, also independently by the presence of clinically-relevant depressive symptoms. These specific components, due to their inherent nature, may have an impact on the existential dimension more than the purely affective dimension [34]. Considering the typically chronic and disabling course of OCD, the high number of patients resistant and/or refractory to the conventional pharmacological treatments and the phenomenological features of the disorder (such as the intrusiveness of obsessions, feelings of loss of control, ego-dystonicity), it is plausible to hypothesize that experiences of helplessness, pessimism, and loss of hope may play a crucial role in the disorder's impact on patients's lives.\u003c/p\u003e \u003cp\u003eThe core dimensions of demoralization syndrome, as emphasized in the literature, call for targeted and integrated therapeutic interventions. In this context, the differentiation between the psychopathological features of demoralization and those of depression may underlie distinct treatment trajectories, reinforcing the need for precise diagnostic assessment and individualized clinical approaches. Besides, given the high antidepressant dosages typically administered to patients with OCD, the persistence of demoralization symptoms suggests that alternative therapeutic approaches\u0026mdash;such as existentially oriented interventions\u0026mdash;should be considered.\u003c/p\u003e \u003cp\u003eSeveral limitations should be considered when interpreting the results of this study. First, this is a pilot investigation aimed at describing demoralization in patients with OCD, and the statistical analyses are limited to the preliminary data currently available. Furthermore, the cross-sectional design of the study does not allow to evaluate the inferences of demoralization on follow up, longitudinal studies are necessary to examine the potential impact of demoralization on both the short- and long-term course of OCD.\u003c/p\u003e \u003cp\u003eIn conclusion, based on the findings of this preliminary study on demoralization in patients with OCD, it appears essential to further investigate and delineate this psychopathological construct, which may warrant distinct clinical assessment strategies and an integrated therapeutic approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe studies involving humans were approved by Ethics Committee of Policlinico Umberto I University Hospital of Rome (protocol 0784/2022). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAM: Conceptualization, Supervision, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing. MP: Formal analysis, Investigation, Review \u0026amp; editing. VR: Investigation, Software, Writing \u0026ndash; original draft. DD: Investigation, Software. IP and TA: Data curation, Methodology. LT: Conceptualization, Supervision. FSB: Formal analysis, Methodology, Supervision, Validation, Writing \u0026ndash; original draft. MP: Conceptualization, Supervision, Validation, Writing \u0026ndash; review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all patients who participated in the study and the staff who supported our effort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStrom NI, Soda T, Mathews CA, Davis LK. A dimensional perspective on the genetics of obsessive-compulsive disorder. Transl Psychiatry. 2021;11(1):401. doi: 10.1038/s41398-021-01519-z.\u003c/li\u003e\n\u003cli\u003eKessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21(3):169-84. doi: 10.1002/mpr.1359.\u003c/li\u003e\n\u003cli\u003eAlbert U, Barbaro F, Bramante S, et al. Duration of untreated illness and response to SRI treatment in obsessive-compulsive disorder. Eur Psychiatry. 2019;58:19-26. doi: 10.1016/j.eurpsy.2019.01.017.\u003c/li\u003e\n\u003cli\u003eAlbert U, De Ronchi D, Maina G, Pompili M. Suicide risk in obsessive-compulsive disorder and exploration of risk factors: a systematic review. Curr Neuropharmacol. 2019;17(8):681-96. doi: 10.2174/1570159X16666180620155941.\u003c/li\u003e\n\u003cli\u003eDell\u0026apos;Osso B, Buoli M, Hollander E, Altamura AC. Duration of untreated illness as a predictor of treatment response and remission in obsessive-compulsive disorder. World J Biol Psychiatry. 2010;11(1):59-65. doi: 10.3109/15622970903418544.\u003c/li\u003e\n\u003cli\u003eDell\u0026apos;Osso B, Benatti B, Buoli M, et al. The influence of age at onset and duration of illness on long-term outcome in patients with obsessive-compulsive disorder: a report from the International College of Obsessive Compulsive Spectrum Disorders (ICOCS). Eur Neuropsychopharmacol. 2013;23(8):865-71. doi: 10.1016/j.euroneuro.2013.05.004.\u003c/li\u003e\n\u003cli\u003eDell\u0026apos;Osso B, Benatti B, Hollander E, et al. Childhood, adolescent and adult age at onset and related clinical correlates in obsessive-compulsive disorder: a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS). 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J Affect Disord. 2013;150(2):384-8. doi: 10.1016/j.jad.2013.04.028\u003c/li\u003e\n\u003cli\u003eAccinni T, Maraone A, Bonucci A, et al. Prevalence of demoralization and depressive symptoms in a sample of patients with supraventricular tachyarrhythmias: preliminary results. Front Psychiatry. 2024;15:1355031. doi: 10.3389/fpsyt.2024.1355031.\u003c/li\u003e\n\u003cli\u003eTomba E, Bech P. Clinimetrics and clinical psychometrics: macro- and micro-analysis. Psychother Psychosom. 2012;81(6):333-43. doi: 10.1159/000341757.\u003c/li\u003e\n\u003cli\u003eGrassi L, Pasquini M, Kissane D, et al. Exploring and assessing demoralization in patients with non-psychotic affective disorders. J Affect Disord. 2020;274:568-75. doi: 10.1016/j.jad.2020.05.043.\u003c/li\u003e\n\u003cli\u003eSonino N, Ruini C, Navarrini C, et al. Psychosocial impairment in patients treated for pituitary disease: a controlled study. 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Psychother Psychosom. 2023;92(3):139-47. doi: 10.1159/000530760.\u003c/li\u003e\n\u003cli\u003eGirone N, Leuzzi R, Bucca C, et al. Stress events, phenotypes, and duration of untreated illness in obsessive-compulsive disorder. Psychiatry Res. 2025;354:116773. doi: 10.1016/j.psychres.2025.116773.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"annals-of-general-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"agps","sideBox":"Learn more about [Annals of General Psychiatry](http://annals-general-psychiatry.biomedcentral.com/)","snPcode":"12991","submissionUrl":"https://submission.nature.com/new-submission/12991/3","title":"Annals of General Psychiatry","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Obsessive-compulsive disorder, Depression, Demoralization Syndrome, Integrated interventions, Psychotherapy","lastPublishedDoi":"10.21203/rs.3.rs-8841229/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8841229/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eObsessive\u0026ndash;compulsive disorder (OCD) is a chronic, early-onset condition often associated with high rates of treatment resistance. Depression is one of the most frequent comorbidities and is linked to poorer therapeutic outcomes. Recently, the concept of Demoralization Syndrome, has been proposed as distinct from Major Depressive Disorder. Given the disabling nature of OCD, it is relevant to evaluate distinctly Demoralization and Depression states considering that the two conditions may have different treatment implications.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe aim of the present preliminary study was to evaluate the presence of demoralization in subjects with OCD and its relationship with the severity of OCD-related symptoms. Adults with a primary diagnosis of OCD were consecutively recruited from the OCD outpatient clinic of Policlinico Umberto I. Eligible participants were assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) for OCD severity, the Demoralization Scale (DS) for demoralization symptoms, and the Patient Health Questionnaire (PHQ) and Hamilton Depression Rating Scale (HAM-D) for clinical relevant depressive symptoms using established cutoffs.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 43 adults with OCD, consecutively screened and enrolled, were included. Both depressive symptoms and demoralization symtoms were highly prevalent, with clinically significant demoralization observed in 88% of patients. A subset of individuals exhibited demoralization without clinical relevant depression, suggesting a partial distinction between the two constructs. Demoralization severity showed a strong association with overall OCD severity, particularly with obsessions rather than with compulsions, and this relationship remained significant even after controlling for depressive symptoms.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDemoralization is highly prevalent in our sample and can occur independently of clinically significant depression. Recognizing demoralization as a distinct construct may improve diagnostic precision and guide tailored therapeutic interventions, complementing standard treatments for OCD and depression. Further research, including longitudinal studies, is needed to clarify its impact on the course of the disorder.\u003c/p\u003e","manuscriptTitle":"Demoralization in patients with Obsessive-compulsive disorder: a preliminary report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 17:07:30","doi":"10.21203/rs.3.rs-8841229/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-13T09:15:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T14:34:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255288613168052937979225959080729081944","date":"2026-04-08T08:19:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-23T23:10:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176825140958285032682110385296648322115","date":"2026-03-22T14:01:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-20T08:43:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-11T09:39:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-11T09:38:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Annals of General Psychiatry","date":"2026-02-10T12:00:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"annals-of-general-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"agps","sideBox":"Learn more about [Annals of General Psychiatry](http://annals-general-psychiatry.biomedcentral.com/)","snPcode":"12991","submissionUrl":"https://submission.nature.com/new-submission/12991/3","title":"Annals of General Psychiatry","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c19e7288-d223-40d9-99a2-605cb5512256","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T09:27:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-25 17:07:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8841229","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8841229","identity":"rs-8841229","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}