"Do not be too timid and squeamish about your actions. All life is an experiment. The more experiments you make the better. What if they are a little coarse and you may get your coat soiled or torn? What if you do fail, and get fairly rolled in the dirt once or twice? Up again, you shall never be so afraid of a tumble. "


A better way to assess & monitor progress with OCD

June 21, 2018

When assessing and monitoring progress with OCD sufferers, originally I used the Y-BOCS questionnaire.  Then some years ago I switched to using the OCI (distress scale).  This is fine ... it's the officially recommended OCD questionnaire by IAPT, the English Increasing Access to Psychological Therapies initiative (see pages 39-41 of their freely downloadable Appendices and helpful resources manual).  But a hassle about the 42-item OCI is that it's time consuming, taking about 12 minutes to complete and a fair amount of time to review & score.  I've now shifted to using the 18-item OCI-R (see Veale et al, 2016 below)

In making this change, I'm reassured by the findings of the 2012 paper "Assessing obsessive-compulsive disorder (OCD): A review of self-report measures" which compared ten different questionnaires.  The authors concluded - "For time efficient measures, the OCI-R is recommended as it has the best psychometric properties of the briefer measures, with numerous external validation studies in English and in other languages".  They estimate that it takes just 3 to 5 minutes to complete the OCI-R.  One can drop down even further to the 3-item OCI-R Main if time is really short.  The very focused OCI-R Main just uses the three questions relevant to the most severely affected OCI-R subscale (washing, checking, ordering, obsessing, hoarding & neutralizing).  If scores for two or more subscales are equally bad, the OCI-R Main score is calculated as the mean of the relevant subscale scores (both pre-, during and post- treatment).  For child and adolescent populations there's the 21-item child version - the OCI-CV.  

Here's a downloadable copy of the 18-item OCI-R (as a Word doc & as a PDF file) and here the 42-item OCI (as a Word doc & as a PDF file).

Each of the OCI questions is answered using a 0 (not at all) to 4 (extremely) distress scale.  IAPT defines 'clinical caseness' on this full 42-item scale as a score of >=40, with 'reliable improvement' involving a change in score of >=32.  Veale et al (see below) recommend that caseness on the OCI-R be defined as >=17 and reliable improvement as a reduction in score of >=13.  Interestingly, in Veale's IAPT outpatient population (not his severe refractory inpatient group), the average length of treatment was 14.8 sessions with a minimum number of sessions of 9 and a maximum of 26.  It was noteworthy that, in this expert specialised service, 65.1% achieved reliable improvement on the OCI-R, 50.8% recovered, and 42.9% achieved both reliable improvement and recovery. 

Veale, D., et al. (2016). "Sensitivity to change in the Obsessive Compulsive Inventory: Comparing the standard and revised versions in two cohorts of different severity"  Journal of Obsessive-Compulsive and Related Disorders 9: 16-23.  The Obsessive Compulsive Inventory (OCI) is often used as a screening instrument for symptoms of Obsessive–Compulsive disorder (OCD) and as an outcome measure for treatment. Three versions of the OCI are available: the original 42-item version, the revised 18-item version (OCI-R) and a shorter version that focuses on the highest subscale (OCI-R Main). Our aim was to determine sensitivity to change and evaluate cut-off scores for caseness in each version of the OCI using the same dataset. Method: We compared the effect size and the number of patients who achieved reliable and clinically significant change after cognitive behavior therapy in two samples of out-patients with OCD. One sample (n=63) had OCD of minor to moderate severity and a second sample (n=73) had severe, treatment refractory OCD. Results: The OCI-R is a valid self-report outcome measure for measuring change and is less burdensome for patients to complete than the OCI. Questions remain about whether the OCI or OCI-R is sufficiently sensitive to change for a service evaluation. We would recommend a slightly higher cut-off score of ≥17 on the OCI-R for the definition of caseness. Discussion: In both samples, the OCI and OCI-R had very similar treatment effect sizes and to a lesser extent in the percentage who achieved reliable improvement and clinically significant change. The OCI-R Main was more sensitive to change than the OCI or OCI-R in both samples. All versions of the OCI were less sensitive to change compared with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).