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JOURNAL OF
PSYCHIATRIC
Journal of Psychiatric Research xxx (2008) xxx–xxx
RESEARCH
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Empathy and symptoms dimensions of patients

with obsessive–compulsive disorder
Leonardo F. Fontenelle a,b,*, Isabela D. Soares c, Flavia Miele a, Manuela C. Borges a,
Angélica M. Prazeres a, Bernard P. Rangé c, Jorge Moll d
a
Anxiety and Depression Research Program, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
b
Department of Psychiatry and Mental Health, Institute of Community Health, Fluminense Federal University, Niterói, Brazil
c
Postgraduate Program in Psychology, Institute of Psychology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
d
Brain Morphometry and Investigative Neuroimaging, LABS-D’Or Hospital Network, Rio de Janeiro, Brazil

Received 7 April 2008; received in revised form 24 May 2008; accepted 27 May 2008

Abstract

Patients with obsessive–compulsive disorder (OCD) often display cognitions and/or behaviors that may well reflect the existence of
‘‘hyper-attachment” to different environmental elements, including their offspring, family members, divine entities, or even inanimate
objects. Based on the fact that both OCD symptoms and physiologic interpersonal attachment mechanisms involve overlapping ventral
fronto-limbic circuits, we hypothesized that there is a relationship between empathy, evaluated with the Interpersonal Reactivity Index
(IRI), and OCD symptom dimensions. We evaluated 53 patients with OCD and 53 age- and sex-matched individuals from the commu-
nity with the Structured Clinical Interview for the Diagnosis of DSM-IV axis I disorders, the Saving Inventory-Revised, the IRI (com-
posed of four sub-scales), the Obsessive–Compulsive Inventory – Revised, the Beck Depression Inventory, and the Beck Anxiety
Inventory. Patients with OCD displayed greater levels of affective empathy (i.e., empathic concern (p = 0.006) and personal discomfort
(p < 0.001)) than community controls. In bivariate analyses, the severity of hoarding symptoms of patients with OCD correlated with
empathic concern (r = 0.39; p < 0.001), fantasy (r = 0.36; p < 0.01), and personal discomfort (r = 0.39; p < 0.001). In partial correlation
analyses adjusting for comorbid depression and anxiety, only the association between hoarding and fantasy remained robust (r = 0.41;
p < 0.001). A model that included severity of hoarding, depression, and anxiety symptoms predicted 33% of the variance on the fantasy
scale. Our findings suggest that hoarding is linked to specific aspects of interpersonal reactivity. Comorbid depression and anxiety, how-
ever, explain a large proportion of the empathic profile exhibited by patients with OCD.
Ó 2008 Elsevier Ltd. All rights reserved.

Keywords: Obsessive–compulsive disorder; Hoarding; Empathy

1. Introduction empathy is not a unitary system but rather a loose collec-

There is no dispute that empathy – the capacity to
understand and share emotional states of others in refer-
ence to oneself – plays a critical role in human interper-
sonal engagement and social interaction (Decety and
Moriguchi, 2007). Nevertheless, it has been argued that
*
Corresponding author. Address: Rua Visconde de Pirajá 547, Sala 323,
22410-003 Ipanema, Rio de Janeiro, Brazil. Tel./fax: +55 21 2239 4919.
E-mail address: Ifontenelle@gmail.com (L.F. Fontenelle).
tion of partially dissociable neurocognitive systems. In par-
ticular, three main divisions have been made: cognitive
empathy (or Theory of Mind), emotional empathy, and
motor empathy (Blair, 2005). Several neuropsychiatric dis-
orders have been shown to present deficits in different types
of empathic abilities including schizophrenia (Montag
et al., 2007), Asperger syndrome (Rogers et al., 2007), psy-
chopathy (de Oliveira-Souza et al., 2008), brain injury
(Shamay-Tsoory et al., 2004), and frontotemporal lobar
degeneration (Rankin et al., 2005).

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doi:10.1016/j.jpsychires.2008.05.007

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2 L.F. Fontenelle et al. / Journal of Psychiatric Research xxx (2008) xxx–xxx
An important emerging concept is that empathic abili-
ties may strongly rely on the neurobiology of social attach-
ment or bonding, which has been extensively studied in
animals (Insel, 1997; Young and Wang, 2004) and, more
recently, in humans (Bowlby, 1988; Moll et al., 2006,
2008; Krueger et al., 2007). Interestingly, patients with
obsessive–compulsive disorder (OCD) often show cogni-
tions and/or behaviors that may well reflect the existence
of ‘‘hyper-attachment” or excessive bonding to different
environmental elements, including their offspring or close
family members (e.g., in post-partum ‘‘maternal preoccu-
pations” – Leckman and Herman, 2002); divine entities
(Birgegard and Granqvist, 2004) (e.g., in religious scrupu-
losity – Nelson et al., 2006) or even inanimate objects
(e.g., in the compulsive hoarding syndrome – Frost et al.,
1995). In the present paper, we will address the possible
links between OCD symptom dimensions and empathy.
Although it is unquestionable that OCD is a homoge-
neous disorder in terms of form (i.e., the presence of obses-
sive thoughts and/or compulsive rituals), there is a large
variability in terms of symptoms content. For example, in
a recent review paper of 12 principal-components and con-
firmatory factor analytic studies involving over 2000
patients with OCD, at least four symptom dimensions were
consistently extracted: symmetry/ordering, contamination/
cleaning, obsessions/checking, and hoarding (Mataix-Cols
et al., 2005). These dimensions were associated with dis-
tinctive clinical, biological and outcome features. The evi-
dence supporting the hoarding dimension was
particularly robust (Mataix-Cols et al., 2005).
In fact, the so-called ‘‘compulsive hoarding syndrome”
in OCD has been associated with several differential fea-
tures, including earlier age at onset (Samuels et al., 2002;
Fontenelle et al., 2004); worse social functioning (Saxena
et al., 2002; Frost et al., 2000; Lochner et al., 2005; Whea-
ton et al., 2008); lower insight into symptoms (Damecour
and Charron, 1998; Storch et al., 2007); higher rates of past
traumatic events (Hartl et al., 2004; LaSalle-Ricci et al.,
2006); greater frequency of certain types of OCD symp-
toms (e.g., symmetry/ordering) and comorbid axis I and
II disorders (Frost et al., 2000; Samuels et al., 2002; Fon-
tenelle et al., 2004; Lochner et al., 2005; LaSalle-Ricci
et al., 2006); specific COMT polymorphisms and linkage
to a region on chromosome 14 (Lochner et al., 2005; Sam-
uels et al., 2007a,b); higher frequency of hoarding among
first-degree members (Samuels et al., 2007a); distinguished
neuroanatomical (Saxena et al., 2004) and neuropsycholog-
ical (Lawrence et al., 2006) underpinnings; possible dopa-
minergic involvement (Stein et al., 1999), and poorer
treatment outcome to serotonin-reuptake inhibitors (Black
et al., 1998; Winsberg et al., 1999; Mataix-Cols et al.,
1999), cognitive behavioral therapy (Mataix-Cols et al.,
2002), or their combination (Frost et al., 2000).
It is difficult to speculate on the role of social cognition
in OCD in general and obsessive–compulsive symptoms
dimensions in particular, but empathic abilities could pro-
vide an additional paradigm aimed at disentangling differ-
Please cite this article in press as: Fontenelle LF et al., Empathy and symptoms dimensions of patients ..., Journal of Psychiatric Re-
search (2008), doi:10.1016/j.jpsychires.2008.05.007
ent sub-types of OCD and at searching for additional
dimensions of neurobiological significance. It could be
the case, for example, that increased levels of empathy
could lead to an overvaluation of certain thoughts (Obses-
sive–Compulsive Cognitions Working Group – OCCWG,
1997) with aggressive (i.e., ‘‘I fear acting unwanted
impulses (e.g., stabbing my children)”), sexual (i.e., ‘‘I am
afraid of having sexual behavior toward other people”),
or even contamination themes (i.e., ‘‘I am concerned that
will get others ill by spreading contaminants”), resulting
in full-formed obsessions of the so-called ‘‘obsessions-
checking” dimension of OCD.
One additional, perhaps more significant, role of
empathic abilities in OCD could be that played by a close
construct, i.e., emotional attachment, in certain hoarding
behaviors. Although DSM-IV and Yale-Brown Obses-
sive–Compulsive Scale (YBOCS) suggest that hoarding
involves only non-sentimental saving, several studies con-
tradict this assumption (Frost et al., 1998). On the basis
of some clinical observations, for example, it could be
argued that hoarding may be one way of expressing
increased levels of empathic abilities or, more speculatively,
that empathy may represent some sort of cognitive or affec-
tive counterpart of some types of hoarding.
For example, Frost and Gross found that hoarders
reported more sentimental saving and greater emotional
attachment to possessions than non-hoarders. In fact,
many hoarders see their possessions as extensions of their
bodies, i.e., when other people touch or move their belong-
ings; the hoarders tend to feel violated (Frost et al., 1995).
For other individuals, some possessions may serve as
meaningful reminders of important past social events and
getting rid of them may sound like the loss of a close friend.
Some hoarders may even impart human qualities to their
possessions or ‘‘anthropomorphize” them (Greenberg,
1987). On the other hand, hoarders may extend their emo-
tional attachment to another level, accumulating not only
objects, but also living beings, including animals and
friends; a phenomenon that could mimic increased inter-
personal empathy and social bonding.
Finally, there may be some biological commonalties
between empathy and OCD, particularly hoarding. For
example, oxytocin has been consistently implicated in the
mechanisms underlying empathy in humans. For example,
Domes et al. (2007) found that, compared to placebo, 24
UI of intranasal oxytocin improved the performance of
normal subjects on the Reading the Mind in the Eyes Test.
On the other hand, a handful of studies have found
increased levels of oxytocin in the cerebrospinal fluid of
patients with OCD (Leckman et al., 1994). Neuroimaging
studies have also provided important evidence linking
brain systems involved with attachment responses and
pro-social behaviors. Decisions to donate to charitable
organizations and decisions to cooperate based on trust
were associated with activation of the septal and sub-gen-
ual regions (Moll et al., 2006; Krueger et al., 2007), which
are intimately linked to mechanisms of social bonding and
 ARTICLE IN PRESS
L.F. Fontenelle et al. / Journal of Psychiatric Research xxx (2008) xxx–xxx
oxytocin release by the anterior hypothalamus (Freedman
et al., 2000).
Based on the aforementioned findings, we predicted that
patients with OCD and hoarding symptoms would exhibit
increased levels of affective and cognitive empathic abili-
ties. If our hypothesis is correct, hoarding may be the ulti-
mate result of a social neurocognitive system in overdrive
or, more speculatively, the gregariousness presented by
some patients with OCD may be a forme fruste of ‘‘inter-
personal” hoarding. Speculations aside, we believe that
the study of interpersonal aspects, especially empathic con-
cern, of patients with OCD, may be of significant interest in
order to clarify the cognitive and affective aspects underling
pathological hoarding behavior in OCD.
The objectives of this study were (1) to compare patients
with OCD and individuals from the community in terms of
interpersonal reactivity according to scores obtained on the
IRI and (2) to evaluate the relationship between the sever-
ity of different OCD dimensions (according to the OCI and
the SI-R) with the patterns of interpersonal reactivity as
measured by the IRI.
2. Methods
Patients were consecutively selected among those under
treatment in (1) the Anxiety and Depression Research Pro-
gram at the Institute of Psychiatry of the Federal Univer-
sity of Rio de Janeiro (IPUB/UFRJ), (2) the Division of
Applied Psychology at the Institute of Psychology of the
same university (DPA/UFRJ), and (3) the first author’s
private practice. The inclusion criteria were (1) the diagno-
sis of OCD, with or without psychiatric comorbidity con-
firmed by means of the Structured Clinical Interview for
Axis I disorders (SCID), (2) age between 18 and 80 years,
and (3) absence of any other neurological, endocrinologi-
cal, or systemic disorder that could interfere in our results.
In the presence of any psychiatric comorbidity, only
patients who developed OCD as a primary disorder, either
in terms of chronology or in terms of severity of symptoms,
were included.
The control group consisted of individuals recruited in
the community by means of local advertisements, and
included members of the medical and administrative staff
of the Federal University of Rio de Janeiro. The inclusion
criteria for volunteers selected to participate in the control
group were (1) age between 18 and 80 years, and (2)
absence of any other neurological, endocrinological, or sys-
temic disorder that could interfere in our results. Commu-
nity controls were not evaluated a priori for the presence of
psychiatric disorders. With this strategy, we intended to
avoid the selection of a ‘‘supernormal” sample, which
would be not representative of the general population.
2.1. Procedures
The local institutional review board approved this research
protocol (SISNEP code = CAAE - 0002.0.249.000-07). All
Please cite this article in press as: Fontenelle LF et al., Empathy and symptoms dimensions of patients ..., Journal of Psychiatric Re-
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3
participants signed an informed consent after a detailed
explanation of the procedures involved in the study.
Patients with OCD, but not controls, were evaluated with
the Brazilian version of the SCID-IV (Del-Ben et al.,
2001). The SCID-IV is a semi-structured clinical interview
to be administered by the clinicians in order to identify axis
I diagnosis according to the DSM-IV criteria. Since two
different centers (IPUB/UFRJ and IP/UFRJ) were respon-
sible for the recruitment and administration of the SCID in
the majority of cases, some questions regarding the reliabil-
ity of our methods could be raised. Nevertheless, the simul-
taneous psychiatric (Anxiety and Depression Research
Program) and psychological (Division of Applied Psychol-
ogy) follow-up of a significant portion of patients allowed
us to discuss and reach a consensus on cases presenting dif-
ficult diagnoses.
A socio-demographic questionnaire was administered to
both patients and controls including the following informa-
tion: age, gender, educational level, marital and employ-
ment status, and monthly income. A clinical
questionnaire was employed to gather patients’ data on
the age at onset of sub-clinical obsessions and/or compul-
sions (i.e., the age in which the patient remember first pre-
sented obsessive–compulsive symptoms without distress or
impairment), different psychiatric comorbidities according
to the SCID, and current therapeutic strategies.
2.2. Instruments
2.2.1. Saving inventory – revised (SI-R)
The SI-R was developed by Frost et al. (2004) and val-
idated to Brazilian Portuguese by Soares (2007). The SI-R
is aimed to evaluate the severity of hoarding behaviors in
clinical and non-clinical populations. It is a self-adminis-
tered Likert Scale that includes 23 items. The items are
divided in three sub-scales: the clutter sub-scale (9 items),
the difficult discarding sub-scale (7 items) and the acquisi-
tion sub-scale (7 items). A detailed description on the psy-
chometric properties of the Brazilian version of the SI-R is
available upon request.
2.2.2. Beck depression inventory (BDI)
The BDI is one of most used self-rated instruments to
evaluate the severity of depression in different populations.
The scale has 21 items, each consisting of four statements
describing increasing intensities of symptoms of depres-
sion. Items are rated on a scale from 0 to 3, reflecting
how participants have felt over the past week. Possible
scores range from 0 to 48; higher scores reflect more severe
anxiety symptoms. The BDI was validated to Brazilian
Portuguese by Cunha (2001).
2.2.3. Beck anxiety inventory (BAI)
The BAI is a self-rated instrument to evaluate the sever-
ity of anxiety in different populations. The scale has 21
items describing subjective, somatic, or panic-related symp-
toms, each consisting of four statements about physiologi-
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4 L.F. Fontenelle et al. / Journal of Psychiatric Research xxx (2008) xxx–xxx

cal and cognitive components of anxiety. It was specifically gorical variables compared by means of the v2 test and
designed to reduce the overlap between depression and their continuous variables (including their scores on the
anxiety scales by measuring anxiety symptoms shared min- BDI, BAI, OCI-R, SI-R and IRI) compared by means of
imally with those of depression. Items are rated on a scale the Student’s t-test. We adopted standard deviation as
from 0 to 3, reflecting how participants have felt over the measure of variability. For the correlation analyses, only
past week. Possible scores range from 0 to 63; higher scores patients with OCD were selected. Bivariate Pearson’s cor-
reflect more severe anxiety symptoms. The BAI was vali- relation analyses were performed using IRI, OCI-R, and
dated to Brazilian Portuguese by Cunha (2001). the SI-R total and partial scores. Partial analyses including
these variables and controlling for the BDI and BAI scores
2.2.4. Obsessive–compulsive inventory – revised (OCI-R) were also performed. The level of statistical significance
The OCI-R, developed by Foa et al. (2002), is a revised was 5%.
and shorter version of the Obsessive–Compulsive Inventory
(OCI), an instrument created by the same group of investi- 3. Results
gators (Foa et al., 1998). The OCI-R evaluates the severity
of a series of obsessive–compulsive symptoms. The OCI-R 3.1. Description of the sample
is a Likert scale that contains 18 items and is self-adminis-
tered. It provides a total score and six sub-scores, including At first, a total of 135 participants fulfilled our inclusion
washing, checking, ordering, rumination, hoarding, and criteria: 65 patients with OCD and 70 community individ-
neutralization. Recently, the OCI-R was translated and uals. The volunteers were predominantly female individu-
adapted to Brazilian Portuguese by Souza et al. (2008). als (n = 82; 60.7%) with a current mean age of 37.3
(±13.5) years. Sixty-nine (51.1%) participants were single,
2.2.5. Interpersonal reactivity index (IRI) 48 (35.6%) were married, 7 (5.2%) were divorced, 6
The IRI, developed by Davis (1983), is the most used (4.4%) were separated and 5 (3.7%) were widowed. The vol-
self-administered instrument to assess the different compo- unteers had a mean of 13.2 ± 4.1 years of education and 78
nents of empathy. The IRI includes 28 items divided in four (57.8%) were employed. Their mean monthly income was
sub-scales (2 cognitive and 2 affective scales). Each answer 2.120 (±2.172) reais (about 1.100 American dollars).
score can vary from 0 (does not describe me well) to 4 A comparison between the socio-demographic charac-
(describes me very well). The scores of each sub-scale are teristics of our patients with OCD and volunteers from
calculated individually. The IRI does not provide a total the community is depicted in Table 1. Although the mean
score since each sub-scale evaluates an independent compo- monthly income of patients with OCD was lower than that
nent of empathy (D’Orazio, 2004). We employed a Brazil- of community controls, this difference did not reach statis-
ian Portuguese version of the IRI provided by Oliveira- tical significance.
Souza and Moll (unpublished version). In terms of OCD patients, 47 (72.3%) were selected from
The IRI cognitive sub-scales include the ‘‘perspective the sample being treated in the Anxiety and Depression
taking” and the ‘‘fantasy” sub-scales. The ‘‘perspective tak- Research Program from the IPUB/UFRJ, 10 (15.4%) from
ing” sub-scale evaluates the tendency that an individual has the Division of Applied Psychology of the IP/UFRJ, and 8
to adopt, spontaneously, the psychological point-of-view (12.3%) from the first authors’ private practice. Although it
of another person (e.g., I sometimes try to understand was tempting to compare patients recruited in different cen-
my friends better by imagining how things look from their
perspective). The ‘‘fantasy sub-scale” evaluates the ten-
dency that the individual has to identify him or herself with Table 1
fictitious personages, such as book, films, or plays charac- Comparison of socio-demographic features of patients with OCD and
community controls
ters (e.g., I really get involved with the feelings of the char-
acters in a novel). The IRI affective sub-scales include the Socio- Patients with Community Tests results
demographic OCD (SD) controls (SD)
‘‘empathic concern” and the ‘‘personal discomfort” sub-
features
scales. The empathic concern sub-scale refers to the feelings
Age (year) 39.3 (± 13.8) 35.5 (±13.0) t = 1.6;
of compassion, tenderness and concern for the others (e.g.,
df = 133; p = 0.1
I often have tender, concerned feelings for people less for- Gender v2 = 1.1, df = 1;
tunate than me). The ‘‘personal discomfort” sub-scale eval- Female 36 (55.4%) 46 (65.7%) p = 0.3
uates self-oriented anxiety and discomfort resulting from Male 29 (44.6%) 24 (34.3%)
tense personal situations (e.g., I sometimes feel helpless Marital status v2 = 1.7, df = 1;
Married 19 (29.2%) 28 (40.0%) p = 0.2
when I am in the middle of a very emotional situation).
Non-married 46 (70.8%) 42 (60.0%)
Educational level 13.0 (±3.9) 13.4 (±4.3) t = 0.5;
2.3. Statistical analyses (year) df = 132; p = 0.6
Monthly income 1.577 (±1121) 2.497 (±2615) Z = 1.08;
Fifty-three patients with OCD and 53 age- and gender- p = 0.3
matched individuals from the community had their cate- Note. SD: standard deviation.

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 ARTICLE IN PRESS

L.F. Fontenelle et al. / Journal of Psychiatric Research xxx (2008) xxx–xxx 5

ters, the low numbers precluded valid analyses. In general
lines, however, they were similar from the socio-demo-
graphic point-of-view.
Patients with OCD reported the onset of obsessions and
compulsions at 14.5 ± 10.5 and 15.9 ± 12.7 years, respec-
tively. In terms of comorbid disorders, 35.9% of the
patients with OCD exhibited a current major depressive
episode; 6.3% had social phobia and 6.3% presented a dys-
thimic disorder. The low prevalence of comorbid condi-
tions may be attributed by transversal nature of the study
and by the fact that patients were under psychological
and/or pharmacological treatment. For example, 79.7%
of patients were under a serotonin reuptake inhibitor,
40% were using a benzodiazepine, and 32.3% were under
an antipsychotic. Further, 32.3% of the patients were being
treated with cognitive behavioral therapy.
3.2. Main findings
Patients with OCD and controls were matched accord-
ing to age and gender, generating two groups of 53 partic-
ipants each, for the comparison of the profiles of response
on the IRI, as seen in Table 2. All patients with OCD
(n = 65) were included in the bivariate Pearson’s correla-
tion analyses (Table 3) and the partial analyses controlling
for the BDI and BAI scores (Table 4).
Patients with OCD displayed greater levels of affective
empathy (i.e., empathic concern (p = 0.006) and personal
discomfort (p < 0.001)) than community controls. In bivar-
iate analyses, the severity of hoarding symptoms of patients
with OCD correlated with empathic concern (r = 0.39;
p < 0.001), fantasy (r = 0.36; p < 0.01), and personal
(r = 0.39; p < 0.001). In partial correlation analyses adjust-
ing for comorbid depression and anxiety, only the associa-
tion between hoarding and fantasy remained robust
(r = 0.41; p < 0.001). Female patients with OCD displayed
significantly greater scores on the personal distress scale
than male patients (t = 3.21, df = 50, p = 0.002).
Since only the IRI fantasy scores were independently
associated with a particular obsessive–compulsive symp-
tom dimension, we decided to perform a specific stepwise
regression analysis using fantasy as the dependent variable
and the BAI, BDI, OCI-R dimensions, and the SI-R scores
as independent ones. We found that a model that included
severity of depression, anxiety, and hoarding predicted
33% of the variance on the fantasy scale (Table 5).
4. Discussion
We found that patients with OCD presented signifi-
cantly higher levels of affective empathy (i.e., empathic con-
cern and personal discomfort) than community individuals.
Although, as predicted, statistically significant correlations
were found between the two forms of affective empathy and
the severity of hoarding behaviors, similar correlations
were found between empathic concern and personal dis-
comfort with other obsessive–compulsive symptoms, such
as ordering, checking and washing. Further, a subsequent
analysis revealed that the severity of comorbid symptoms
of depression and anxiety largely explained the correlations
between affective empathy and obsessive–compulsive
symptoms in patients with OCD.
Leckman and Cohen (1999) suggested that patients with
Tourette syndrome (TS), a condition biologically linked to
some forms of OCD, are ‘‘sensitive to the feelings and
experiences of others, and have a thinner barrier to stimu-

Table 2
Comparison between the Interpersonal Reactivity Index of patients with OCD and community controls
IRI Patients with OCD (SD) Community individuals (SD) Results
Perspective taking 16.26 (±4.96) 16.81 (±3.51) t = 0.65; df = 93.6; p = 0.51
Fantasy scale 14.15 (±6.54) 12.43 (±5.04) t = 1.51; df = 97.6; p = 0.13
Empathic concern 20.83 (±4.63) 18.32 (±4.66) t = 2.77; df = 104; p = 0.006
Personal discomfort 17.32 (±6.75) 10.45 (±5.13) t = 5.90; df = 97.0; p < 0.001
Note. IRI: Interpersonal Reactivity Index; DF: degree of freedom; SD: standard deviation. As can be seen, some DF were slightly lower than 104 due to
few missing values.

Table 3
Bivariate correlation matrix of IRI’s sub-scores and psychopathological scores of patients with OCD (n = 65)
OCI-R SI-R
Checking Neutralization Obsession Ordering Washing Hoarding Total Clutter Dif. dis. Acquisition
IRI – PT 0.009 0.080 0.043 0.038 0.018 0.010 0.021 0.010 0.020 0.104
IRI – FS 0.228 0.289* 0.141 0.120 0.132 0.319** 0.392*** 0.415*** 0.364** 0.207
IRI – EC 0.247* 0.151 0.197 0.384** 0.384** 0.295* 0.364** 0.379** 0.301* 0.250*
IRI – PD 0.289* 0.251* 0.427*** 0.280* 0.329** 0.387*** 0.395*** 0.337** 0.419** 0.287*
Note. IRI: interpersonal reactivity index; PT: perspective taking; FS: fantasy scale; EC: empathic concern; PD: personal discomfort; OCI-R: obsessive–
compulsive inventory – revised; SI-R: saving Inventory – revised.
*
p < 0.05.
**
p < 0.01.
***
p < 0.001.

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Table 4
Partial correlation matrix of the IRI sub-scores and the psychopathological scores among patients with OCD (n = 65), controlling for BDI and BAI scores
OCI-R SI-R
Checking Neutralization Obsession Ordering Washing Hoarding Total Clutter Dif. dis. Acquisition
IRI – PT 0.005 0.073 0.050 0.022 0.033 0.015 0.056 0.014 0.014 0.146
IRI – FS 0.185 0.241 0.092 0.071 0.078 0.307* 0.417*** 0.464*** 0.352** 0.170
IRI – EC 0.003 0.063 0.019 0.079 0.219 0.053 0.076 0.133 0.027 0.009
IRI – PD 0.034 0.034 0.226 0.100 0.059 0.137 0.046 0.002 0.126 0.005
Note. IRI: interpersonal reactivity index; PT: perspective taking; FS: fantasy scale; EC: empathic concern; PD: personal discomfort; OCI-R: obsessive–
compulsive inventory – revised; SI-R: saving inventory – revised.
*
p < 0.05.
***
p < 0.001.
**
p < 0.01.

Table 5 opmental disorders were preliminarily excluded (n = 2).

Multiple stepwise regression analyses with the fantasy scale of the IRI as
the dependent variable (R2 = 0.33)
B EP B t Significance
BDI .332 .094 .570 3.522 0.001
BAI .207 .083 .413 2.505 0.01
SI-R .126 .049 .455 2.568 0.01
Note. BAI: Beck anxiety inventory; BDI: Beck depression inventory; SI-R:
saving inventory – revised.
lation” (also termed ‘‘somatosensory hyper-awareness”).
Although this was an untested clinical observation, find-
ings from other controlled studies on TS are interesting
in this regard. Harrison et al. (2007) compared the profile
of response on the IRI of patients with TS with (n = 30)
and without (n = 40) echopraxia. In this study, patients
with TS and echopraxia exhibited higher scores on the
IRI’s empathic concern, personal discomfort, and fantasy
scores than patients with TS without echopraxia. Although
this evaluation was somewhat restricted, it would also be
interesting to test whether patients with TS and obses-
sive–compulsive symptoms describe increased levels of
interpersonal reactivity. Interestingly, echophenomena
were already associated with the presence of increased
obsessionality in TS (Robertson et al., 1988).
The fact that patients with OCD displayed increased lev-
els of empathic concern than community controls is appar-
ently in contrast to some recent findings. For example,
Bejerot et al. (2001) described autistic traits in up to 20%
of their OCD patients. This same group has insisted on
the existence of an autistic sub-type of patients with
OCD that would be characterized, among other features,
by increased severity of hoarding behaviors (Bejerot,
2007). Since pervasive developmental disorders are associ-
ated with decreased levels of empathy (Rogers et al.,
2007), we believe that the inconsistence between our study
findings and those described by these authors (Bejerot
et al., 2001) can be ascribed to the different psychopatho-
logical concepts of pathological hoarding behaviors
(Maier, 2004) and to our inclusion criteria: Firstly, patho-
logical hoarding may include diverse forms of symptoms,
such as compulsive, impulsive, or stereotypic behaviors
(Maier, 2004). Secondly, in our study, patients with devel-
These conceptual and methodological aspects may have
contributed to a sample free of severe pathologies of the
central nervous system whose repetitive behaviors may be
best understood as stereotypes, and not obsessive–compul-
sive behaviors.
We found that correlations between empathic concern
and obsessive–compulsive symptoms were no longer signif-
icant when the effects of comorbid anxiety and depression
were controlled for. Since correlation analyses do not allow
inferences about causalities, these findings can be inter-
preted in at least two not mutually excludable ways: (1)
empathic concern is a symptom of anxious or depressed
patients with OCD and/or (2) increased levels of empathic
concern among patients with OCD is a risk-factor for
greater severity of comorbid anxiety and/or depression.
In support for the first assertion, Griens et al. (2002)
found that changes in the Neuroticism and Extraversion
dimensions of the NEO Five-Factor Inventory (which
assesses the five major domains of the five-factor model
of personality (neuroticism, extraversion, openness, agree-
ableness, and conscientiousness)) and, most importantly,
in the ‘‘interpersonal awareness” scores of the Interper-
sonal Sensitivity Measure (IPSM), related strongly to the
decrease in depression severity of 80 patients with depres-
sive disorders after 12 weeks of treatment with psychother-
apy and/or drugs. Therefore, we cannot discard the
possibility that empathic concern represents a ‘‘state”, as
opposed to a ‘‘trait” feature attributable to greater levels
of depression (and maybe anxiety) symptoms.
If increased levels of empathic concern predisposes to
depression, guilt feelings may mediate this relationship
(O’Connor et al., 2007). For example, a study with daugh-
ters of depressed mothers found that increased levels of
empathy related to the maternal suffering were associated
to inadequate problem-solving strategies and feelings of
being guilty for the mother’s psychiatric disorder (Kil-
mes-Dougan and Bolger, 1998). Since OCD is associated
with increased levels of pathological responsibility and
guilt (Rachman, 1993; Salkovskis et al., 1999), being more
empathic can lead those individuals to be more distressed
and to present greater severity of depression and anxiety
symptoms. For example, obsessive–compulsive symptoms

Please cite this article in press as: Fontenelle LF et al., Empathy and symptoms dimensions of patients ..., Journal of Psychiatric Re-
search (2008), doi:10.1016/j.jpsychires.2008.05.007
 ARTICLE IN PRESS
L.F. Fontenelle et al. / Journal of Psychiatric Research xxx (2008) xxx–xxx
(e.g., contamination obsessions and avoidant behaviors)
may inhibit the initiative and execution of altruistic actions
that would otherwise be performed by empathic individu-
als, increasing guilt and depressive feelings. The recent evi-
dence pointing to the involvement of the sub-genual–septal
area in major depression (Drevets et al., 1998; Mayberg
et al., 2005) and in normal social attachment responses
(Bartels and Zeki, 2004; Aron et al., 2005; Moll et al.,
2006; Krueger et al., 2007) strongly support this view.
The levels of personal discomfort, i.e., the emotional
response that involves fear of discomfort from witnessing
stressful circumstances or a negative emotional state in
other people, were significantly greater among patients
with OCD than among individuals from the community.
Although the intensity of personal discomfort correlated
with all the OCI-R dimensions, analyses of covariance
showed that the BDI and BAI scores explained the signif-
icance of these findings. Indeed, although elevated levels of
IRI’s personal discomfort were seen in different psychiatric
disorders, including schizophrenia (Montag et al., 2007);
Asperger syndrome (Rogers et al., 2007); and frontotempo-
ral dementia (Rankin et al., 2005), analyses of covariance
aimed at excluding the role of affective symptoms were
not performed in these studies. Since personal discomfort
belongs to the affective dimension of empathy, we believe
that this sort of analyses should be an essential part of
these types of studies. This approach may unveil whether
personal discomfort is a primary condition or secondary
to comorbid anxiety and depression.
According to Davis (1983), the IRI fantasy scale taps
respondents’ tendencies to transpose themselves imagina-
tively into the feelings and actions of fictitious characters
in books, movies, and plays. Unexpectedly, we found a cor-
relation between the fantasy scale of the IRI and the sever-
ity of hoarding behaviors that remained significant after
excluding the effects of the severity of anxiety and depres-
sion symptoms. A subsequent stepwise regression analysis
revealed that a model that included severity of depression,
anxiety, and hoarding symptoms predicted 33% of the var-
iance on the fantasy scale (Table 5).
In his original study, Davis (1983) found that the fan-
tasy scale was associated with shyness, loneliness, and
social anxiety in males, and with increased ‘‘emotionality”
and verbal fluency in general. Similar neurocognitive
results were found by Rankin et al. (2005), who observed
that 25% of the fantasy scale scores where explained by
the phonemic fluency. Davis (1983) suggested that individ-
uals with high scores on the fantasy scale were uncomfort-
able in social settings, isolated, emotional, and intelligent.
Therefore, it would be predictable that these patients
devote their time and intellectual involvement to the non-
social worlds of books, movies, and television – as the con-
tent of the fantasy scale items implies. Indeed, this profile is
very similar to the one found in patients with pathological
hoarding in several studies.
For example, Fontenelle et al. (2004) found that patients
with OCD and pathological hoarding presented increased
Please cite this article in press as: Fontenelle LF et al., Empathy and symptoms dimensions of patients ..., Journal of Psychiatric Re-
search (2008), doi:10.1016/j.jpsychires.2008.05.007
7
educational levels than regular patients with OCD. From
the neurocognitive point-of-view, Hartl et al. (2004)
observed that patients with pathological hoarding did not
exhibit the impaired verbal learning strategies exhibited
by patients with OCD in general. In terms of social aspects,
difficulties exhibited by patients with pathological hoarding
were reported in a related study (Soares et al., unpublished
thesis) where 62% of the scores on the SF-36 sub-scores
‘‘social aspects” of patients with OCD were explained by
a model that included the total scores of the IC-R.
It could be argued that shyness, loneliness, and social
anxiety in hoarders can be hardly consistent with increased
affective empathic levels, and, as initially predicted, exces-
sive attachment or increased social bonding. We suggest,
however, that the negative social effects of severe hoarding
behaviors may hamper the full expression of increased
empathic abilities that these patients may present.
Admittedly, our study has a number of drawbacks:
Firstly, it enrolled a small number of research subjects. Sec-
ondly, the comparison group included medical and admin-
istrative staff at our research institution, hardly a random
control group. Thirdly, our patients with OCD were under
drug and/or cognitive behavioral treatments and it would
have been interesting to compare empathic abilities
between those groups. Nevertheless, since there was a great
overlap between patients being treated with drugs (almost
80%) and patients being treated with cognitive behavior
therapy (32%), the small number of patients being treated
exclusively with one or another therapeutic strategy would
compromise valid statistical analyses. It would also be
interesting to study OCD patients’ before and after treat-
ment to check whether their distinctive empathic abilities
are ‘‘state” or ‘‘trait” features. Finally, it must also be sta-
ted that the fantasy scale of the IRI have been criticized for
being overly broad (Baron-Cohen and Wheelwright, 2004),
including not only aspects related to cognitive empathy,
but also imagination (‘‘I daydream and fantasize, with
some regularity, about things that might happen to me”)
and emotional self-control (‘‘In emergency situations, I feel
apprehensive and ill at ease”).
In sum, while depression and anxiety explained
increased levels of empathic concern and personal discom-
fort of patients with OCD, increased levels of fantasy were
especially associated with hoarding behaviors. These find-
ings are consistent with the view that hoarding constitutes
a dimension of OCD that is associated with increased levels
of psychopathology. Given the ever-rising literature on
social cognition and the fact that these new paradigms
can help to identify neglected behavioral phenotypes, an
approach based on social neuroscience may provide a fruit-
ful avenue of research to redraw the diagnostic frontiers of
different neuropsychiatric disorders.
Conflicts of interest
All authors of the manuscript entitled ‘‘Empathy and
symptoms dimensions of patients with obsessive–compul-
 ARTICLE IN PRESS
8 L.F. Fontenelle et al. / Journal of Psychiatric Research xxx (2008) xxx–xxx
sive disorder” declare that they have no conflicts of
interest.
Contributors
Find below the list of authors of the manuscript entitled
‘‘Empathy and symptoms dimensions of patients with
obsessive–compulsive disorder” and how they have con-
tributed to the study.
Drs. Leonardo F. Fontenelle, Isabela D. Soares, Ber-
nard P Rangé, and Jorge Moll designed the study and
wrote the protocol. Drs. Isabela D. Soares, Flavia Miele,
and Manuela C. Borges managed the literature searches
and analyses. Dr. Angélica M. Prazeres undertook the sta-
tistical analysis, and Drs. Leonardo F. Fontenelle and Jor-
ge Moll wrote the first draft of the manuscript. All authors
contributed to and have approved the final manuscript.
Funding
Funding for the manuscript entitled ‘‘Empathy and
symptoms dimensions of patients with obsessive–compul-
sive disorder” study was provided by the Conselho Nacion-
al de Desenvolvimento Cientfico e Tecnolgico (CNPq); the
CNPq had no further role in study design; in the collection,
analysis and interpretation of data; in the writing of the
report; and in the decision to submit the paper for
publication.
Acknowledgement
We thank Prof. Ricardo de Oliveira-Souza, who assisted
with the discussion of the manuscript ‘‘Empathy and symp-
toms dimensions of patients with obsessive–compulsive
disorder”.
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