Obsessive-Compulsive Disorder (OCD): What it is and how it can be assessed

OCD

1. What is Obsessive-Compulsive Disorder (OCD)?

OCD is a debilitating anxiety disorder comprising of mental obsessions of recurrent, persistent ideas, thoughts, images or impulses (American Psychiatric Association, 2000) followed by repetitive behavioral rituals, called compulsions, which can severely impair a person’s social and occupational functioning. In rare cases OCD can lead to suicide (Alonso et al. 2010). Suffers from OCD are plagued with continuously arising irrational beliefs and are occupied to reduce anxieties produced by these imaginations by performing likewise irrational behavior. OCD is experienced ego-dystonic. This means that sufferers are fully aware of the absurd and senseless nature of the unwanted, intruding patterns. Examples are obsessions about contamination, pathological doubt, symmetry or aggressive and sexually inadequate beliefs. Examples for compulsions are compulsive cleaning, counting, checking or hoarding. In many cases multiple obsessions and compulsions appear simultaneously (Stanford, 2013). COD is diagnosed when a person experiences significant distress, when obsessions must follow compulsions involuntarily and when a person is occupied in excess of one hour a day to ritually reduce anxieties (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 456-457).

2. Framework of assessment, methods, sources and their effectiveness

Most sufferers of OCD do not disclose their condition due to fear of being stigmatized and labeled (Fennel et al., 2007) by admitting to beliefs and behavior which is considered socially deviant, odd, offensive and inappropriate by others. OCD leads to fear of embarrassment but also selfstigmatization of being ‘not normal’ by the sufferer’s very own comparison against societal norms, leading to social withdrawal, concealment and desire to pass as ‘normal’ (Fennel, p.318). A unique trait of OCD is that sufferers cannot find comfort in pointing at OCD as the cause since OCD appears ego-dystonic, prompting sufferers to distinguish between their own thoughts and ‘OCDthoughts’ (Fennel, p.315). This extended understanding has a profound impact on the positioning of the client to the disorder and the formulation of protocol questions. A proposed semi-structured
interview (Groth-Marnat, p.71) consists of a more informal opening to build rapport and
understanding with the client (Turner et al., 2003, p.7) and a structured part for psychometric assessment. Initial open-ended questions might probe the construct of Self-Image and notion of Self-Worth, the availability of social support, the level of unnecessary Self-stigma, dispel misconceptions about ‘mental disorder’ as well as to communicate respect and understanding for the client.

The formal framework consists of applying a reliable instrument for appraisal such as the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS), an extended version of the established Y-BOCS. The instrument demonstrates ‘overall excellent’ results (Pertusa et al., 2012) as well as intercultural validity, ‘excellent’ internal validity and highly inter-correlated results between Self-report and expert ratings (Rosario et al., 2006). For general assessment the Florida Obsessive- Compulsive Inventory/ FOIC (Storch et al., 2007) is a comprehensive choice, a recently developed 25-items self-report questionnaire which demonstrates good results in comparison with Y-BOCS (Mirela et al., 2009). The easy-to-perform FOCI may be more applicable for a first-line, general evaluation. The DY-BOCS by comparison presents a mixed protocol which is partially self-reported and partially interviewer-administered. Featuring 88 items while addressing more specifically subscales and symptoms, the DY-BOCS presents a reliable follow-up, in-depth appraisal tool. A physical examination can rule out biological causes which could be mistaken for OCD. It appears that OCD is a genetic and familial disorder indicated not by categorical, but symptom dimension (e.g., presence of anxieties) and additional information may be obtained via medical family history (Fontenelle et al., 2008).

3. Accommodating Children with OCD and Clients with Varying Severity

OCD appears across ethnic groups and cultures and affects men and women alike. The onset for OCD is often in childhood and adolescence and before 25 years of age with boys reported with a statistically earlier onset (Stanford, 2013). For children between 5-8 years of age the 10-item Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOC) is available. Data suggests that it proves ‘good internal consistency, very good temporal stability, good construct validity, and sensitivity to change.’ (Freeman et al., 2011, p.881). The Children’s Florida Obsessive Compulsive Inventory may be regarded as an alternative (Storch et al., 2009). To help parents deal with OCD-children, March & Benton (2007) have published a useful and accessible book with the title ‘Talking back to OCD’ which can be used collaboratively with parents as a guideline before, during and after therapy.

Milder cases may be treated with Cognitive Behavioral Therapy (CBT) while more severe cases may in addition receive treatment with anti-depressants such as SSRIs (NHS, 2013).

References

Alonso, P., Segalàs, C., Real, E., Pertusa, A., Labad, J., Jiménez-Murcia, S., & Menchón, J. (2010). Suicide in patients treated for obsessive-compulsive disorder: a prospective follow-up study. Journal Of Affective Disorders, 124(3), 300-308.
doi:10.1016/j.jad.2009.12.001

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Fennell, D., & Liberato, A. (2007). Learning to live with OCD: Labeling, the self, and stigma. Deviant Behavior, 28(4), 305-331. doi:10.1080/01639620701233274

Fontenelle, L. F., & Hasler, G. G. (2008). The analytical epidemiology of obsessive-compulsive disorder: risk factors and correlates. Progress In Neuro-Psychopharmacology & Biological Psychiatry, 32(1), 1-15. doi:10.1016/j.pnpbp.2007.06.024

Freeman, J., Flessner, C., & Garcia, A. (2011). The Children’s Yale-Brown Obsessive Compulsive Scale: reliability and validity for use among 5 to 8 year olds with obsessive-compulsive disorder. Journal Of Abnormal Child Psychology, 39(6), 877-883.

Groth-Marnat, G. (2003). Handbook of psychological assessment (4th ed.). New York, NY: Wiley.Pertusa, A., Fernández de la Cruz, L., Mataix-Cols, D., Alonso, P., & Menchón, J. (2012). Independent validation of the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS). European Psychiatry, 27(8), 598 604. doi:10.1016/j.eurpsy.2011.02.010

March, J., & Benton, C. M. (2007). Talking back to OCD [electronic book]: the program that helps kids and teens say “no way”- and parents say “way to go” / John S. March, with Christine M. Benton. New York : Guilford Press, 2007.

Mirela A., A., Gary R., G., Marni L., J., Wayne K., G., & Eric A., S. (2009). Further psychometric analysis of the Florida Obsessive-Compulsive Inventory. Journal Of Anxiety Disorders, 23124-129. doi:10.1016/j.janxdis.2008.05.001

National Health Service (2013). Obsessive compulsive disorder – Treatment. Retrieved from http://www.nhs.uk/Conditions/Obsessive-compulsive-disorder/Pages/Treatment.aspx

Rosario-Campos, M.C., Miguel, E.C., Quatrano, S., Chacon, P., Ferrao Y., Findley, D., Katsovich, L., Scahill, L., King, R.A., Woody, S.R., Tolin, D., Hollander, E., Kano, Y., Leckman, J.F. (2006). The Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS): an instrument for assessing obsessive-compulsive symptom dimensions. Molecular Psychiatry. 2006 May; 11(5):495-504.

Stanford School of Medicine (2013). Symptoms. Clinical Picture. Retrieved from http://ocd.stanford.edu/about/symptoms.html

Stanford School of Medicine (2013). Age at Onset. Retrieved from http://ocd.stanford.edu/about/

Storch, E.A., Stigge-Kaufman, D., Bagner, D., Merlo, L.J., Shapira, N.A., Geffken, G.R. (2007). Florida Obsessive- Compulsive Scale: development, reliability, and validity. Journal of Clinical Psychology, 63, pp. 851–859

Storch, E. A., Khanna, M., Merlo, L. J., Loew, B. A., Franklin, M., Reid, J. M., & Murphy, T. K. (2009). Children’s Florida Obsessive Compulsive Inventory: Psychometric Properties and Feasibility of a Self-Report Measure of Obsessive–Compulsive
Symptoms in Youth. Child Psychiatry & Human Development, 40(3), 467-483. doi:10.1007/s10578-009-0138-9

Turner, S. M., Hersen, M., & Heiser, N. (2003). The interviewing process. In M. Hersen & S. M. Turner (Eds.), Diagnostic interviewing (3rd ed.). New York, NY: Kluwer Academic/Plenum Publishers.

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