Evidence based assessment/Obsessive-compulsive disorder (assessment portfolio)
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|Steps 1-2: Preparation phase|
|Steps 3-5: Prediction phase|
|Steps 6-9: Prescription phase|
|Steps 10-12: Process/progress/outcome phase|
- 1 What is a "portfolio"?
- 2 Preparation phase
- 3 Prediction phase
- 4 Prescription phase
- 5 Process phase
- 6 External Links
- 7 References
For background information on what assessment portfolios are, click the link in the heading above.
Obsessive-compulsive and related disorders: The chapter on obsessive-compulsive and related disorders, which is new in DSM-V, reflects the increasing evidence that these disorders are related to one another in terms of a range of diagnostic validators, as well as the clinical utility of grouping these disorders in the same chapter. New disorders include hoarding disorder, excoriation (skin-picking) disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV diagnosis of trichotillomania (TTM) is now termed trichotillomania (hair-pulling disorder) and has been moved from a DSM-IV classification of impulse-control disorders not elsewhere classified to obsessive-compulsive and related disorders in DSM-V.
Specifiers for obsessive-compulsive and related disorders: The “with poor insight” specifier for obsessive-compulsive disorder has been refined in DSM-V to allow a distinction between individuals with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Analogous “insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. These specifiers are intended to improve differential diagnosis by emphasizing that individuals with these two disorders may present with a range of insight into their disorder-related beliefs, including absent insight/delusional symptoms. This change also emphasizes that the presence of absent insight/delusional beliefs warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder. The “tic-related” specifier for obsessive-compulsive disorder reflects a growing literature on the diagnostic validity and clinical utility of identifying individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications.
This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of OCD that they are likely to see in their clinical practice.
|Setting (Reference)||Base Rate||Demography||Diagnostic Method|
|National Comorbidity Survey Replication||2.3%||National (U.S.) adult
|World Health Organization Composite
International Diagnostic Interview (CIDI 3.0)
|Epidemiological Catchment Area (ECA) Program||1.9-3.3%||U.S. household sample
|Diagnostic Interview Schedule (DIS)|
|Iranian population-based study||1.8%||Iranian adults
|African-American and Caribbean Households (U.S.)||1.6%||NSAL adult study
|CIDI Short Form|
|Singapore Mental Health Study||3.0%||Epidemiological sample
[obsessive compulsive disorder OR ocd] AND [prevalence OR incidence] in PsycInfo and PubMed
[obsessive compulsive disorder OR ocd] AND [epidemiology] in PsycInfo and PubMed
ICD-10 Criteria 
The essential feature is recurrent obsessional thoughts or compulsive acts. Obsessional thoughts are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist. Anxiety is almost invariably present. If compulsive acts are resisted the anxiety gets worse.
- Included disorders: anankastic neurosis, obsessive-compulsive neurosis
- Excluded disorders: obsessive-compulsive personality (disorder)
- Predominantly obsessional thoughts or ruminations
- These may take the form of ideas, mental images, or impulses to act, which are nearly always distressing to the subject. Sometimes the ideas are an indecisive, endless consideration of alternatives, associated with an inability to make trivial but necessary decisions in day-to-day living. The relationship between obsessional ruminations and depression is particularly close and a diagnosis of obsessive-compulsive disorder should be preferred only if ruminations arise or persist in the absence of a depressive episode.
- Predominantly compulsive acts [obsessional rituals]
- The majority of compulsive acts are concerned with cleaning (particularly handwashing), repeated checking to ensure that a potentially dangerous situation has not been allowed to develop, or orderliness and tidiness. Underlying the overt behaviour is a fear, usually of danger either to or caused by the patient, and the ritual is an ineffectual or symbolic attempt to avert that danger.
- Mixed obsessional thoughts and acts
- Other obsessive-compulsive disorders
- Obsessive-compulsive disorder, unspecified
Specific criteria include:
- A. Either obsessions or compulsions (or both) are present on most days for a period of at least 2 weeks.
- B. Obsessions (thoughts, ideas, or images) and compulsions (acts) share the following features, all of which must be present:
- 1. They are acknowledged as originating in the mind of the patient, and are not imposed by outside persons or influences.
- 2. They are repetitive and unpleasant, and at least one obsession or compulsion that is acknowledged as excessive or unreasonable must be present.
- 3. The patient tries to resist them (but resistance to very long-standing obsessions or compulsions may be minimal). At least one obsession or compulsion that is unsuccessfully resisted must be present.
- 4. Experiencing the obsessive thought or carrying out the compulsive act is not in itself pleasurable (this should be distinguished from temporary relief of tension or anxiety.)
- C. The obsessions or compulsions cause distress interfere with the patient's social or individual functioning, usually by wasting time.
- D. Most commonly used exclusion clause. The obsessions or compulsions are not the result of other mental disorders, such as schizophrenia and related disorders or mood disorders.
Screening and diagnostic instruments for OCD
|Measure||Format (Reporter)||Age Range||Administration/
|Interrater Reliability||Test-Retest Reliability||Construct Validity||Content Validity||Highly Recommended||Free and Accessible Downloads|
|Anxiety Disorders Interview Schedule||E||G||E||E||X|
|Structured Clinical Interview for DSM-IV (SCID)||A||A||E||E|
|Yale-Brown Obsessive Compulsive Scale Symptom Checklist||NA||NA||E||G||X|
|Brown Assessment of Beliefs Scale||G||A||G||G||X|
|Revised Children’s Anxiety and Depression Scale (RCADS)||Questionnaire (Child)||6-18||12 minutes||G||G||G||
PDFs for RCADS
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable
- Yale-Brown Obsessive Compulsive Scale (Y-BOC)S
- With Symptom Checklist (Y-BOCS-SC) or self-report (Y-BOCS-SR)
Recommended self-report questionnaires
- Dimensional Obsessive Compulsive Scale (DOCS)
- Obsessive Compulsive Inventory – Revised
- Interpretation of Intrusions Inventory
Interpreting obsessive compulsive disorder screening measure scores
The purpose of this subsection is to use Bayesian probability theory in order to accurately predict the diagnosis of obsessive compulsive disorder, given base diagnosis rate in the region and likelihood ratios in diagnostic likelihood ratios.
Area under curve (AUC)
The area under the curve (AUC, or AUROC) is equal to the probability that a classifier will rank a randomly chosen positive diagnosis of obsessive compulsive disorder higher than a randomly chosen negative diagnosis of obsessive compulsive disorder.
Likelihood ratios (also known as likelihood ratios in diagnostic testing) are the proportion of cases with the diagnosis scoring in a given range divided by the proportion of the cases without the diagnosis scoring in the same range . The table below shows area under the curve (AUCs) and likelihood ratios in diagnostic testing for potential screening measures for obsessive compulsive disorder. It should be noted that all studies used some version of a K-SADS interview by a trained rater, combined with review by a clinician to establish consensus.
|Larger than 10, smaller than 0.10||Frequently clinically decisive|
|Ranging from 5 to 10, 0.20||Helpful in clinical diagnosis|
|Between 2.0 and 0.5||Rarely result in clinically meaningful changes of formulation|
|Around 1.0||Test result did not change clinical impressions at all|
"LR+" refers to the change in likelihood ratio associated with a positive test score, and "LR-" is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. On the other hand, likelihood ratios larger than 10 or smaller than 0.10 are frequently clinically decisive, 5 or 0.20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinical significance|clinically meaningful changes of formulation. 
Psychometric properties of screening instruments for OCD
|Screening Measure (Primary Reference)||Area Under curve (AUC) and Sample Size||LR+ (Score)||LR-||Clinical generalizability||Download Link|
|0.50||Moderate: OCD among pregnant and postpartum women||Y-BOCS-SR|
|0.44||High: OCD (n=167) versus other anxiety disorders (n=155) at outpatient anxiety clinic||OCI-R Total|
|0.36||High: OCD (n=215) versus other anxiety disorders (n=243) at outpatient anxiety clinic||OCI-R Total|
|Dimensional Obsessive-Compulsive Scale||0.77
|0.43||High: OCD (n=315) versus other anxiety disorders (n=198) at outpatient clinics across the U.S.||DOCS|
|Brown Assessment of Beliefs Scale||(N=50)||BABS|
Cognitive behavioral therapy (CBT) and exposure and response prevention (ERP)
- Behavior therapy, specifically ERP, has been established as the treatment of choice for OCD .
- Therapy incorporates ERP and emphasizes cognitive change.
- Therapist will help individual identify anxiety-provoking thoughts and situations.
- Therapist will develop a treatment plan and idiographic “fear hierarchy.”
- Individuals will learn to encounter situations that invoke anxiety without engaging in rituals used to dispel anxiety (ERP).
- Exposures will be done gradually at a pace that is comfortable for the client.
- Therapy will include homework assignments and is designed to offer lifelong skills.
- Therapy includes verbal techniques such as psychoeducation and cognitive restructuring.
- Manuals for reference:
- Treatment alliance is a predictor of subsequent change in OCD symptoms. The therapist should provide a “validating and
- encouraging” environment so that clients can tolerate the emotional arousal associated with exposures.
- Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat OCD.
- These antidepressants include:
- High doses (relative to doses prescribed for depression) are needed for individuals with OCD.
Process and outcome measures
Clinically significant change benchmarks with common instruments and mood rating scales
|Measure||Subscale||Cut-off scores|| Critical Change |
|Benchmarks Based on Published Norms|
|Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR)||Total||10.6||14.4||12.6||4.7||3.9||2.4|
|Obsessive-Compulsive Inventory – Revised (OCI-R)||Total||1.0||41.0||23.0||14.8||12.5||7.6|
|Dimensional Obsessive Compulsive Scale (DOCS)||Total||n/a||31.7||19.0||10.3||8.7||5.3|
|Responsibility for Harm||n/a||8.7||4.4||2.4||2.0||1.2|
Note: “A” = Away from the clinical range – moving at least 2 standard deviations away from clinical mean; “B” = Back into the nonclinical range – moving within 2 standard deviations of the nonclinical mean; “C” = Closer to the nonclinical than clinical mean – crossing the weighted average of the two groups.
- Quality of Life
- Sheehan Disability Scale
- Medical Outcomes Study (MOS) 36-Item Short Form (SF-36) Health Survey
- Compulsions scale of YBOCS
- SUDS Ratings
- Society of Clinical Child and Adolescent Psychology
- EffectiveChildTherapy.Org information on rule-breaking, defiance, and acting out
- For information on conducting Exposure Therapy for anxiety disordered youth, see www.BravePracticeForKids.com
|Click here for references|