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Evidence-based assessment/Obsessive-compulsive disorder (assessment portfolio)/extended version

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What is a "portfolio"?

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  • For background information on what assessment portfolios are, click the link in the heading above.
  • Does all of this feel like TMI? Click here to go to the condensed version.

Introduction

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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.

Preparation phase

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ICD-11 Criteria [1]

Obsessive-Compulsive Disorder is characterized by the presence of persistent obsessions or compulsions, or most commonly both. Obsessions are repetitive and persistent thoughts, images, or impulses/urges that are intrusive, unwanted, and are commonly associated with anxiety. The individual attempts to ignore or suppress obsessions or to neutralize them by performing compulsions. Compulsions are repetitive behaviors including repetitive mental acts that the individual feels driven to perform in response to an obsession, according to rigid rules, or to achieve a sense of ‘completeness’. In order for obsessive-compulsive disorder to be diagnosed, obsessions and compulsions must be time consuming (e.g., taking more than an hour per day), and result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Inclusions

  • anankastic neurosis
  • obsessive-compulsive neurosis

Exclusions

  • obsessive compulsive behaviour (MB23.4)


Demographics

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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] 2.3% National (U.S.) adult

sample (n=2073)

World Health Organization Composite

International Diagnostic Interview (CIDI 3.0)

Epidemiological Catchment Area (ECA) Program[3] 1.9-3.3% U.S. household sample

(n=18572)

Diagnostic Interview Schedule (DIS)
Iranian population-based study[4] 1.8% Iranian adults

(n=25180)

DIS
African-American and Caribbean Households (U.S.)[5] 1.6% NSAL adult study

(n=5191)

CIDI Short Form
Singapore Mental Health Study[6] 3.0% Epidemiological sample

(n=6616)

CIDI 3.0

Search terms:

[obsessive compulsive disorder OR ocd] AND [prevalence OR incidence] in PsycInfo and PubMed

[obsessive compulsive disorder OR ocd] AND [epidemiology] in PsycInfo and PubMed

Prediction phase

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Diagnosis

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ICD-11 Criteria [7]

Obsessive-Compulsive Disorder is characterized by the presence of persistent obsessions or compulsions, or most commonly both. Obsessions are repetitive and persistent thoughts, images, or impulses/urges that are intrusive, unwanted, and are commonly associated with anxiety. The individual attempts to ignore or suppress obsessions or to neutralize them by performing compulsions. Compulsions are repetitive behaviors including repetitive mental acts that the individual feels driven to perform in response to an obsession, according to rigid rules, or to achieve a sense of ‘completeness’. In order for obsessive-compulsive disorder to be diagnosed, obsessions and compulsions must be time consuming (e.g., taking more than an hour per day), and result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Inclusions

  • anankastic neurosis
  • obsessive-compulsive neurosis

Exclusions

  • obsessive compulsive behaviour (MB23.4)


Screening and diagnostic instruments for OCD

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Measure Format (Reporter) Age Range Administration/

Completion Time

Interrater Reliability Test-Retest Reliability Construct Validity Content Validity Highly Recommended Free and Accessible Downloads
Diagnostic Measures
Anxiety Disorders Interview Schedule[8] E G E E X
Structured Clinical Interview for DSM-IV (SCID)[9] A A E E
Yale-Brown Obsessive Compulsive Scale Symptom Checklist[10] NA NA E G X
Brown Assessment of Beliefs Scale[11] G A G G X
Revised Children’s Anxiety and Depression Scale (RCADS) Questionnaire (Child) 6-18 12 minutes G[12] G[13] G[12]

PDFs for RCADS

Subscales

Translations

User Guide

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Prescription phase

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Interpreting obsessive compulsive disorder screening measure scores

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Overview

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

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[18] [19]. 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.

Likelihood Ratio Comments
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[18]. 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. [20]

Psychometric properties of screening instruments for OCD

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Screening Measure (Primary Reference) Area Under curve (AUC) and Sample Size LR+ (Score) LR- Clinical generalizability Download Link
Y-BOCS-SR[21] 0.75

(N=162)

5.50

(7)

0.50 Moderate: OCD among pregnant and postpartum women Y-BOCS-SR
OCI-R Total[22] 0.81

(N=322)

3.66

(14)

0.44 High: OCD (n=167) versus other anxiety disorders (n=155) at outpatient anxiety clinic OCI-R Total
OCI-R Total[22] 0.82

(N=458)

2.98

(18)

0.36 High: OCD (n=215) versus other anxiety disorders (n=243) at outpatient anxiety clinic OCI-R Total
Dimensional Obsessive-Compulsive Scale[23] 0.77

(N=513)

2.33

(21)

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[11] (N=50) BABS

Process phase

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Treatments

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Cognitive behavioral therapy (CBT) and exposure and response prevention (ERP)

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  • Behavior therapy, specifically ERP, has been established as the treatment of choice for OCD [24][25].
  • 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:
    • The therapist guide: Mastery of Obsessive-Compulsive Disorder: A Cognitive Behavioral Approach[26]
    • Cognitive Therapy of Obsessive-Compulsive Disorder: A Guide for Professionals (Wilhelm & Steketee)
    • Obsessive Compulsive Disorder: Advances in Psychotherapy [27]
  • Treatment alliance is a predictor of subsequent change in OCD symptoms[28]. The therapist should provide a “validating and
encouraging” environment so that clients can tolerate the emotional arousal associated with exposures.

Medication

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Process and outcome measures

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Clinically significant change benchmarks with common instruments and mood rating scales

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Measure Subscale Cut-off scores Critical Change
(unstandardized scores)
Benchmarks Based on Published Norms
A B C 95% 90% SEdifference
Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR) Total 10.6 14.4 12.6 4.7 3.9 2.4
Obsessions 6.6 7.6 7.0 2.5 2.1 1.3
Compulsions 3.5 8.2 6.1 3.6 3.0 1.8
Obsessive-Compulsive Inventory – Revised (OCI-R) Total 1.0 41.0 23.0 14.8 12.5 7.6
Washing n/a 7.4 3.1 3.4 2.9 1.7
Checking n/a 8.0 3.7 3.0 2.5 1.5
Ordering n/a 10.5 4.6 3.1 2.6 1.6
Obsessing n/a 8.3 4.7 3.8 3.2 1.9
Hoarding n/a 9.8 4.1 2.8 2.4 1.4
Neutralizing n/a 6.2 2.3 3.0 2.5 1.5
Dimensional Obsessive Compulsive Scale (DOCS) Total n/a 31.7 19.0 10.3 8.7 5.3
Contamination n/a 7.8 3.4 2.4 2.0 1.2
Responsibility for Harm n/a 8.7 4.4 2.4 2.0 1.2
Unacceptable Thoughts n/a 9.6 5.4 2.5 2.1 1.3
Symmetry n/a 7.9 3.6 2.2 1.8 1.1

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.

Process measures

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References

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Click here for references
  1. ↑ "ICD-10 Version:2016". apps.who.int. Retrieved 2018-03-01.
  2. ↑ Ruscio, AM; Stein, DJ; Chiu, WT; Kessler, RC (January 2010). "The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication.". Molecular psychiatry 15 (1): 53-63. PMID 18725912. 
  3. ↑ Karno, M; Golding, JM; Sorenson, SB; Burnam, MA (December 1988). "The epidemiology of obsessive-compulsive disorder in five US communities.". Archives of general psychiatry 45 (12): 1094-9. PMID 3264144. 
  4. ↑ Mohammadi, MR; Ghanizadeh, A; Rahgozar, M; Noorbala, AA; Davidian, H; Afzali, HM; Naghavi, HR; Yazdi, SA et al. (14 February 2004). "Prevalence of obsessive-compulsive disorder in Iran.". BMC psychiatry 4: 2. PMID 15018627. 
  5. ↑ Himle, JA; Muroff, JR; Taylor, RJ; Baser, RE; Abelson, JM; Hanna, GL; Abelson, JL; Jackson, JS (2008). "Obsessive-compulsive disorder among African Americans and blacks of Caribbean descent: results from the National Survey of American Life.". Depression and anxiety 25 (12): 993-1005. PMID 18833577. 
  6. ↑ Subramaniam, M; Abdin, E; Vaingankar, JA; Chong, SA (December 2012). "Obsessive--compulsive disorder: prevalence, correlates, help-seeking and quality of life in a multiracial Asian population.". Social psychiatry and psychiatric epidemiology 47 (12): 2035-43. PMID 22526825. 
  7. ↑ "ICD-10 Version:2016". apps.who.int. Retrieved 2018-03-01.
  8. ↑ Brown, T.A., Di Nardo, P.A., Barlow, D.H., 1994. Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV-L). Psychological Corporation, San Antonio, TX.
  9. ↑ First, M. B., & Gibbon, M. (2004). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). In M. J. Hilsenroth, D. L. Segal, M. J. Hilsenroth, D. L. Segal (Eds.) , Comprehensive handbook of psychological assessment, Vol. 2: Personality assessment (pp. 134-143). Hoboken, NJ, US: John Wiley & Sons Inc.
  10. ↑ 10.0 10.1 Steketee, G. "The Yale-Brown Obsessive Compulsive Scale: Interview versus self-report". Behaviour Research and Therapy 34 (8): 675–684. doi:10.1016/0005-7967(96)00036-8. http://linkinghub.elsevier.com/retrieve/pii/0005796796000368. 
  11. ↑ 11.0 11.1 Eisen, J. L., Phillips, K. A., Baer, L., Beer, D. A., & al, e. (1998). The brown assessment of beliefs scale: Reliability and validity. The American Journal of Psychiatry, 155(1), 102-8. Retrieved from http://libproxy.lib.unc.edu/login?url=https://search.proquest.com/docview/220481418?accountid=14244
  12. ↑ 12.0 12.1 Chorpita, Bruce F.; Moffitt, Catherine E.; Gray, Jennifer (2005-03). "Psychometric properties of the Revised Child Anxiety and Depression Scale in a clinical sample". Behaviour Research and Therapy 43 (3): 309–322. doi:10.1016/j.brat.2004.02.004. ISSN 0005-7967. http://dx.doi.org/10.1016/j.brat.2004.02.004. 
  13. ↑ Chorpita, Bruce F; Yim, Letitia; Moffitt, Catherine; Umemoto, Lori A; Francis, Sarah E (2000-08). "Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child anxiety and depression scale". Behaviour Research and Therapy 38 (8): 835–855. doi:10.1016/s0005-7967(99)00130-8. ISSN 0005-7967. http://dx.doi.org/10.1016/s0005-7967(99)00130-8. 
  14. ↑ Goodman, Wayne K. (1989-11-01). "The Yale-Brown Obsessive Compulsive Scale". Archives of General Psychiatry 46 (11). doi:10.1001/archpsyc.1989.01810110048007. ISSN 0003-990X. http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archpsyc.1989.01810110048007. 
  15. ↑ Abramowitz, Jonathan S.; Deacon, Brett J.; Olatunji, Bunmi O.; Wheaton, Michael G.; Berman, Noah C.; Losardo, Diane; Timpano, Kiara R.; McGrath, Patrick B. et al.. "Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the Dimensional Obsessive-Compulsive Scale.". Psychological Assessment 22 (1): 180–198. doi:10.1037/a0018260. http://dx.doi.org/10.1037/a0018260. 
  16. ↑ Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis, P. M. (2002). The Obsessive-Compulsive Inventory: development and validation of a short version. Psychological assessment, 14(4), 485.
  17. ↑ "Development and initial validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory". Behaviour Research and Therapy 39 (8): 987–1006. doi:10.1016/s0005-7967(00)00085-1. https://doi.org/10.1016/S0005-7967(00)00085-1. 
  18. ↑ 18.0 18.1 Youngstrom, E. A. (2013). Future directions in psychological assessment: Combining evidence-based medicine innovations with psychology's historical strengths to enhance utility. Journal of Clinical Child and Adolescent Psychology, 42(1), 139-159.
  19. ↑ Strauss, S. E., Glasziou, P., Richardson, W. S., & Haynes, R. B. (2011). Evidence-based medicine: How to practice and teach EBM (4th ed.). New York, NY: Churchill Livingstone.
  20. ↑ Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM. Edinburgh: Churchill Livingstone.
  21. ↑ Steketee, G; Frost, R; Bogart, K (August 1996). "The Yale-Brown Obsessive Compulsive Scale: interview versus self-report.". Behaviour research and therapy 34 (8): 675-84. PMID 8870295. 
  22. ↑ 22.0 22.1 Foa, EB; Huppert, JD; Leiberg, S; Langner, R; Kichic, R; Hajcak, G; Salkovskis, PM (December 2002). "The Obsessive-Compulsive Inventory: development and validation of a short version.". Psychological assessment 14 (4): 485-96. PMID 12501574. 
  23. ↑ Abramowitz, JS; Deacon, BJ; Olatunji, BO; Wheaton, MG; Berman, NC; Losardo, D; Timpano, KR; McGrath, PB et al. (March 2010). "Assessment of obsessive-compulsive symptom dimensions: development and evaluation of the Dimensional Obsessive-Compulsive Scale.". Psychological assessment 22 (1): 180-98. PMID 20230164. 
  24. ↑ Whittal M.L., McLean P.D., Söchting I., Koch W.J., Taylor S., Anderson K., Paterson R.OCD treatment outcome using behavioral and cognitive approaches Paper presented at the meeting of the Association for Advancement of Behavior Therapy, Miami Beach, FL (1997)
  25. ↑ Foa, Edna B.; Kozak, Michael J.. "Beyond the efficacy ceiling? Cognitive behavior therapy in search of theory". Behavior Therapy 28 (4): 601–611. doi:10.1016/s0005-7894(97)80019-6. https://doi.org/10.1016/S0005-7894(97)80019-6. 
  26. ↑ E. Foa, M. Kozak Mastery of obsessive–compulsive disorder: A cognitive-behavioral approach Graywind Publications (1997)
  27. ↑ S., Abramowitz, Jonathan (2006). Obsessive compulsive disorder. Cambridge, MA: Hogrefe & Huber Publishers. ISBN 9780889373167. OCLC 70659789. https://www.worldcat.org/oclc/70659789. 
  28. ↑ Keeley, M. L., Geffken, G. R., Ricketts, E., McNamara, J. P., & Storch, E. A. (2011). The therapeutic alliance in the cognitive behavioral treatment of pediatric obsessive–compulsive disorder. Journal of Anxiety Disorders, 25(7), 855-863.
  29. ↑ Sheehan DV, Harnett-Sheehan K, Raj BA. 1996. The measurement of disability. Int Clin Psychopharmacol 11(Suppl 3): 89–95.
  30. ↑ McHorney, C., Ware, J., & Raczek, A. (1993). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and Clinical Tests of Validity in Measuring Physical and Mental Health Constructs. Medical Care, 31(3), 247-263. Retrieved from http://www.jstor.org/stable/3765819

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