Assessing OCD

OCD often goes undiagnosed, especially if a provider is not nuanced in some of the more subtle ways OCD presents itself. Some may be familiar with the DSM-5, which details the following when diagnosing OCD: the presence of recurrent, unwanted, and intrusive thoughts (ie, obsessions) and/or repetitive behaviors or rituals (ie, compulsions) intended to relieve the fear, anxiety, and/or distress associated with obsessions. 

When assessing for OCD in a session, a common measure that is more in depth is The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and its counterpart for children, the Children’s Yale- Brown Obsessive- Compulsive Scale. There is a screening checklist that lists various common obsessions and compulsions that the patient fills out. The Symptom Checklist includes 54 common obsessions and compulsive behaviors, which are grouped according to thematic content (i.e., contamination and aggression) or behavioral expression (i.e, checking and washing). From there, it is often helpful to gather more information about the items they endorsed. Good questions to ask are how often the obsessions compulsions occur, whether or not they interfere with daily living, and how distressing they are. Symptoms that are endorsed over the past week are then globally rated by the clinician using a five-point scale ranging from 0 (none) to 4 (extreme) across five dimensions: (1) time/frequency, (2) interference, (3) distress, (4) resistance, and (5) degree of control. From there, the clinician tallies the score and the severity categorized into none, mild, moderate, severe, or extreme. The following score clusters approximately map onto symptom severity: mild symptoms (0–13), moderate symptoms (14–25), moderate–severe symptoms (26–34), and severe symptoms (35–40).

There are some other commonly used measures to assess OCD: the Florida Obsessive Compulsive Inventory (FOCI) and the Obsessive Compulsive Inventory-Revised (OCI-R) for self-reporting of symptoms. The FOCI is a symptom checklist that assesses symptom severity and impairment. In the checklist, the individual marks the presence or absence of 20 common obsessions and compulsions (ten each). On the severity items, the individual rates the cumulative severity of endorsed symptoms on five items, time occupied, interference, distress, resistance, and degree of control. The OCI-R is an 18-item self-report questionnaire based on the earlier 84-item OCI. Participants rate the degree to which they are bothered or distressed by specific OCD symptoms in the past month.

Some commonly overlooked categories that often don’t get properly diagnosed as OCD are intrusive thoughts about harm to oneself or others. These thoughts are unwanted, very distressing to the person, and they typically do everything they can to get rid of these thoughts. This type of thought is known as ego-dystonic. This type of OCD is very different than actual suicidal/homicidal ideation, where the person feels the thoughts fit with their beliefs and are not distressed by them (ego-syntonic). One key way to get at whether these thoughts are OCD, is to ask about the feelings that arise when this thought happens, does it cause distress and do you want to avoid the actions associated with them? 

When working with children, it is also useful to get an idea of much the family is involved in the OCD. The Family Accommodation Scale (FAS) assesses how much others accommodated the patient’s obsessions and compulsions by providing reassurance or the help necessary for completion of compulsions, decreasing behavioral expectations, modifying family activities or routines, and/or helping the child avoid objects, places, or experiences that may cause him or her distress.

In sum, when assessing for OCD, it is very important to get at how much it is impairing the patient’s life, how distressing it is for them, and how much time it takes up. It is also very helpful to get as much detail about the obsessions and compulsions, as this will help when coming up with exposure ideas in the future.