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

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.

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

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
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
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.

"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.

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.

Clinically significant change benchmarks with common instruments and mood rating scales
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