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

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## What is a "portfolio"?

* For background information on what assessment portfolios are, click the link in the heading above.
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### Introduction

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

   ICD-11 Criteria
   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

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 sample (n=2073) | World Health Organization Composite International Diagnostic Interview (CIDI 3.0) |
| Epidemiological Catchment Area (ECA) Program | 1.9-3.3% | U.S. household sample (n=18572) | Diagnostic Interview Schedule (DIS) |
| Iranian population-based study | 1.8% | Iranian adults (n=25180) | DIS |
| African-American and Caribbean Households (U.S.) | 1.6% | NSAL adult study (n=5191) | CIDI Short Form |
| Singapore Mental Health Study | 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
### Diagnosis

   ICD-11 Criteria
   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

| 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 | Diagnostic Measures | Diagnostic Measures | Diagnostic Measures | Diagnostic Measures | Diagnostic Measures | Diagnostic Measures | Diagnostic Measures | Diagnostic Measures | |
| 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 | Assessment Center Online Version |
| 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 | | | RCADS homepage Assessment Center Online Child Report Version Assessment Center Online Parent Report Version PDFs for RCADS RCADS Child Self-reported (8-18 years) RCADS Parent-reported Child Scoring Aid Parent Scoring Aid Subscales OCD Self-reported OCD Parent-reported Translations User Guide |
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)

## Prescription phase
### Recommended self-report questionnaires

* Dimensional Obsessive Compulsive Scale (DOCS)
* Obsessive Compulsive Inventory – Revised
* Interpretation of Intrusions Inventory

### Interpreting obsessive compulsive disorder screening measure scores

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. 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. 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 |
| Y-BOCS-SR | 0.75 (N=162) | 5.50 (7) | 0.50 | Moderate: OCD among pregnant and postpartum women | Y-BOCS-SR |
| OCI-R Total | 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 | 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 | 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 | (N=50) | | | | BABS |

## Process phase
### Treatments
#### 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:
** The therapist guide: Mastery of Obsessive-Compulsive Disorder: A Cognitive Behavioral Approach
** Cognitive Therapy of Obsessive-Compulsive Disorder: A Guide for Professionals (Wilhelm & Steketee)
** Obsessive Compulsive Disorder: Advances in Psychotherapy
* 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.

#### Medication

* Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat OCD.
* These antidepressants include:
** fluvoxamine
** fluoxetine
** sertraline
** paroxetine
** citalopram
** clomipramine
** escitalopram
** venlafaxine
* 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 | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Benchmarks Based on Published Norms ||||||||
| | | A | B | C | 95% | 90% | SE$_{difference}$ |
| Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR) | Total | 10.6 | 14.4 | 12.6 | 4.7 | 3.9 | 2.4 |
| Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR) | Obsessions | 6.6 | 7.6 | 7.0 | 2.5 | 2.1 | 1.3 |
| Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR) | 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 |
| Obsessive-Compulsive Inventory – Revised (OCI-R) | Washing | n/a | 7.4 | 3.1 | 3.4 | 2.9 | 1.7 |
| Obsessive-Compulsive Inventory – Revised (OCI-R) | Checking | n/a | 8.0 | 3.7 | 3.0 | 2.5 | 1.5 |
| Obsessive-Compulsive Inventory – Revised (OCI-R) | Ordering | n/a | 10.5 | 4.6 | 3.1 | 2.6 | 1.6 |
| Obsessive-Compulsive Inventory – Revised (OCI-R) | Obsessing | n/a | 8.3 | 4.7 | 3.8 | 3.2 | 1.9 |
| Obsessive-Compulsive Inventory – Revised (OCI-R) | Hoarding | n/a | 9.8 | 4.1 | 2.8 | 2.4 | 1.4 |
| Obsessive-Compulsive Inventory – Revised (OCI-R) | 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 |
| Dimensional Obsessive Compulsive Scale (DOCS) | Contamination | n/a | 7.8 | 3.4 | 2.4 | 2.0 | 1.2 |
| Dimensional Obsessive Compulsive Scale (DOCS) | Responsibility for Harm | n/a | 8.7 | 4.4 | 2.4 | 2.0 | 1.2 |
| Dimensional Obsessive Compulsive Scale (DOCS) | Unacceptable Thoughts | n/a | 9.6 | 5.4 | 2.5 | 2.1 | 1.3 |
| Dimensional Obsessive Compulsive Scale (DOCS) | 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

* Quality of Life
** Sheehan Disability Scale
** Medical Outcomes Study (MOS) 36-Item Short Form (SF-36) Health Survey
* Compulsions scale of YBOCS
* SUDS Ratings

## External Links

* 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