Yale-Brown Obsessive Compulsive Scale - Essay Example

Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) rating scale as described by Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.(1989) in Arch Gen Psychiatry is designed to rate the severity and type of symptoms in patients with obsessive compulsive disorder (OCD) with "particular emphasis on the ability to reflect changes in severity during treatment" and their response to treatment. It was originally designed to "remedy the problems of existing rating scale by providing a specific measure of the severity of symptoms of obsessive-compulsive disorder that is not influenced by the type of obsessions or compulsions present". The scale is a "clinician-rated, 10-item scale, each item rated from 0 (no symptoms) to 4 (extreme symptoms) (total range, 0 to 40), with separate subtotals for severity of obsessions and compulsions." The characteristics of each item during the prior week up until and including the time of the interview is rated where scores reflect the average (mean) occurrence of each item for the entire week. This rating scale is intended for use as a semi-structured interview. The interviewer assesses the items in the listed order and uses the questions provided. However, the interviewer is free to ask additional questions for purposes of clarification. If the patient volunteers information at any time during the interview, that information is considered. Ratings are based primarily on reports and observations gained during the interview. If the information being provided is judged as grossly inaccurate, then the reliability of the patient is in doubt and should be noted accordingly at the cad of the interview (item 19). Additional information supplied by others (e.g., spouse or parent) may be included in a determination of the ratings only if it is judged that (1) such information is essential to adequately assessing symptom severity and (2) consistent week-to-week reporting can be ensured by having the same informant(s) present for each rating session. Before proceeding with the questions, "obsessions" and "compulsions" for the patient is defined as follows: "OBSESSIONS are unwelcome and distressing ideas, thoughts, images or impulses that repeatedly enter your mind. They may seem to occur against your will. They may be repugnant to you, you may recognize them as senseless, and they may not fit your personality." "COMPULSIONS, on the other hand, are behaviors or acts that you feel driven to perform although you may recognize them as senseless or excessive. At times, you may try to resist doing them but this may prove difficult. You may experience anxiety that does not diminish until the behavior is completed." "Let me give you some examples of obsessions and compulsions." "An example of an obsession is: the recurrent thought or impulse to do serious physical harm to your children even though you never would." "An example of a compulsion is: the need to repeatedly check appliances, water faucets, and the lock on the front door before you can leave the house. While most compulsions are observable behaviors, some are unobservable mental acts, such as silent checking or having to recite nonsense phrases to yourself each time you have a bad thought." "Do you have any questions about what these words mean" [If not, proceed.] On repeated testing it is not always necessary to re-read these definitions and examples as long as it can be established that the patient understands them. It may be sufficient to remind the patient that obsessions are the thoughts or concerns and compulsions are the things you feel driven to do, including covert mental acts. The patient is allowed to enumerate current obsessions and compulsions in order to generate a list of target symptoms. The Y-BOCS Symptom Checklist is used as an aid for identifying current symptoms. It is also useful to identify and be aware of past symptoms since they may re-appear during subsequent ratings. Once the current types of obsessions and compulsions are identified, these are then organized and listed on the Target Symptoms form according to clinically convenient distinctions (e.g., divide target compulsions into checking and washing). The salient features of the symptoms is described so that they can be more easily tracked (e.g., in addition to listing checking, specify what the patient checks for). The most prominent symptoms are indicated; i.e., those that will be the major focus of assessment. The rater ascertains that reported behaviors are bona fide symptoms of OCD and not symptoms of another disorder, such as Simple Phobia or a Paraphilia. Separate assessment of tie severity with a tic rating instrument may be necessary in such cases. Some of the items listed on the Y-BOCS Symptom Checklist, such as trichotillomania, are currently classified in DSM-m-R as symptoms of an Impulse Control Disorder. It should be noted that the suitability of the Y-BOCS for use in disorders other than DSM-m-R-defined OCD has yet to be established. However, when using the Y-BOCS to rate severity of symptoms not strictly classified under OCD (e.g., trichotillomania) in a patient who otherwise meets criteria for OCD, it has been a practice to administer the Y-BOCS twice: once for conventional obsessive compulsive symptoms, and a second time for putative OCD-related phenomena. In this fashion separate Y-BOCS scores are generated for severity of OCD and severity of other symptoms in which the relationship to OCD is still unsettled. On repeated testing, review and, if necessary, revise target obsessions prior to rating item I. Do likewise for compulsions prior to rating item 6. All 19 items are rated, but only items 1-10 (excluding items lb and 6b) are used to determine the total score. The total Y-BOCS score is the sum of items 1-10 (excluding lb and 6b), whereas the obsession and compulsion subtotals are the sums of items 1-5 (excluding lb) and 10 (excluding 6b3; respectively. Items lb (obsession-free interval), 6b (compulsion-free interval), and 12 (avoidance) may provide information that has bearing on the severity of obsessive-compulsive symptoms. Item 11 (insight) may also furnish useful clinical information. Items 17 (global severity) and 18 (global improvement) have been adapted from the Clinical Global Impression Seale (Guy W, 1976 qtd in www.cnsforum.com, nd.) to provide measures of overall functional impairment associated with, but not restricted to, the presence of obsessive-compulsive symptoms. Disability produced by secondary depressive symptoms would also be considered when rating these items. Item 19, which estimates the reliability of the information reported by the patient, may assist in the interpretation of scores on other Y-BOCS items in some cases of OCD. Its being independent of the number and type of OCD symptoms and since it minimizes confounding with other types of symptoms, YBOCS has become the standard for assessing the outcome of behavioral and pharmacological treatments. Several studies were done to further validate the YBOCS in relation to self-report measures of obsessive compulsive phenomena in a nonclinical population. One such research was done among a group of 45 female college students (Frost, et al., 1995). The three primary YBOCS measures (obsessions, compulsions, and total score) were found to be "internally consistent and correlated moderately to strongly with self-report measures of obsessive compulsive phenomena that have been used in previous research". Furthermore, "the compulsive subscale of the YBOCS showed the lowest correlation with self-report measures sharing only 25% of the common variance", a measure "appropriate for use with nonclinical samples and may prove superior to other instruments for detecting the presence and severity of obsessive and compulsive symptoms." Another study, which establishes the facility of the YBOCS, was done. Lochner, et al (2005) have interviewed two hundred and seventy eight OCD patients (n = 278: 148 male; 130 female) and 54 TTM patients (n = 54; 5 male; 49 female) of all ages to compare Obsessive-compulsive disorder and trichotillomania. Female patients were compared on select demographic and clinical variables, including comorbid axis I and II disorders, and temperament/character profiles. The Yale-Brown Obsessive-Compulsive Severity Scale (Y-BOCS) was implemented to assess the severity of OCD symptoms among the interviewees. The results were assessed with other instruments. The data gathered from the instrument suggest that "despite some overlap, TTM differs from OCD in terms of demographics (gender distribution), associated clinical variables (e.g. comorbidity, cognitive schemas, temperament/character profiles and disability), precipitating factors (trauma history) and treatment response." It has been suggested that although TTM is not the same as OCD, it lies on a compulsive-impulsive spectrum of disorders. However, it is notable that "impulsivity may be an important component of OCD, and rather than viewing OCD and TTM on a single dimension, compulsivity and impulsivity should arguably therefore be seen as lying on orthogonal dimensions. Although TTM patients had more novelty seeking, OCD patients were more likely to have intermittent explosive disorder; such data support a view that TTM should not be classified as an impulse control disorder. Indeed, TTM may have more in common with conditions characterized by stereotypical self-injurious symptoms, such as skin-picking. Differences between OCD and TTM may reflect contrasts in underlying psychobiology, and may necessitate contrasting treatment approaches." The results hereby support that YBOCS is appropriate tool for its intended use. Bystritsky et al (1999) conducted a study to evaluate whether the YBOC scale was adaptable for use with the patient population with obsessive-compulsive disorder and whether patients' score on the QOL changed as measurements of the severity of obsessive-compulsive symptoms improved. Thirty treatment-resistant patients with a primary DSM-IV diagnosis of obsessive-compulsive disorder were assessed at admission to and discharge from a partial hospitalization program to determine whether improvement in symptoms of the disorder was associated with improvements in patients' quality of life. Symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (YBOCS). Quality of life was measured using Lehman's Quality of Life (QOL) scale, which includes several objective and subjective indexes. YBOCS scores significantly improved with treatment, as did scores on the majority of the QOL subjective indexes and on the objective social, health, and activity indexes. No significant association between changes in YBOCS scores and QOL scores was found. Changes in YBOCS scores were not associated with changes in the QOL subscales, suggesting that the outcome measures used in this study may be changing independently. These findings are similar to those of Koran and associates (qtd in Bystritsky, 1999), who found minimal association between YBOCS scores and QOL scores. These findings suggest clinicians should carefully observe changes in the objective parameters of the QOL scale while treating patients' primary symptoms and should target improvements in these parameters in further therapeutic interventions. YBOCS therefore is independent and can therefore be used to assess severity of obsessive-compulsive behavior among OCD patients. In contrast to previous cited researches, a study on heavy drinking with mild to moderately dependent alcohol abusers (Federoff, et al., 1999) which used a self-administered version of the YBOCS-hd to evaluate the severity of drinking-related obsessive compulsive symptoms with mild to moderately dependent alcohol abusers (problem drinkers), and determine whether end-of-treatment changes in YBOCS-hd scores would be related to within-treatment functioning have put the utility of modified YBOCS in question. Evaluation of the YBOCS-hd has been limited to more severely dependent alcohol abusers. Results indicated that problem drinkers have lower alcohol-related Obsessive and Compulsive subscale scores than did more severely dependent drinkers, but higher scores than did non-problem drinkers, supporting the construct validity of the YBOCS-hd. In addition, at the end of treatment, the YBOCS-hd scores of alcohol abusers who drank at low-risk levels during treatment were significantly lower than the scores of those who drank at high-risk levels. Lastly, exploratory factor analysis did not provide support for the two YBOCS-hd subscales (Obsessive, Compulsive). Instead, the analysis yielded a single general factor and a second factor that contained two questions measuring heavy drinking. The study found that total YBOCS-hd scores is covaried with drinking, but neither the total YBOCS-hd pretreatment score nor the two subscale scores predicted functioning at the end of treatment. This questions the utility of the YBOCS-hd, because a single item measuring the heaviness of drinking was as useful as the total YBOCS-hd and its two subscales in relating changes during treatment to end-of-treatment functioning for problem drinkers. The YBOCS-hd however may have value as an indirect measure of drinking in situations where direct measurement of alcohol consumption is undesirable (i.e., direct measurement might be reactive). Because the present findings are derived from problem drinkers, further research is needed to confirm the factor structure of the YBOCS-hd with clients who represent a broader range of alcohol problem severity. From these researches, despite of a few concerns on the capacity of some modified YBOCS to assess severity of specific obsessive-compulsive behavior among OCD patients, YBOCS in general is an adequate measure of the said disorder. It can stand independently among other instruments to assess the severity of obsessive-compulsive behavior of OCD patients as established repeatedly by researches and studies. YBOCS as originally designed was set as standard for assessing intended disorder. Any modifications for specific obsessive-compulsive behavior therefore should also be designed and tested by researches rigidly to come up with the standard the original YBOCS had set and measured. Ethical considerations associated with YBOCS include treatments specifically drugs administration based on the analysis of YBOCS results should be reviewed carefully. However due to the ability of the instrument to assess wide range of obsessive-compulsive behaviors, information gathered from statistical analysis of the instrument is reliable enough for consideration. Another ethical consideration is that the instrument is a clinician-rated. Though the items depend on the patient's report, the final rating is based on the clinical judgment of the interviewer. The judgment of the clinician therefore should be clinically reviewed before any statistics should be derived from the data gathered by the clinician. Obsessive-compulsive disorder is a psychiatric behavior, like neurological disorders, is grounded in brain dysfunction. The effectiveness of any clinical medication and procedures to treat said disorders are crucial to the patient's welfare. The premise underlying the effectiveness of these procedures is that "altering brain structure will change mental functioning" (Park, et al, 2006). The brain-based interventions should be highly considered specially the biological states of complex mental phenomena. "Psychiatric disorders are increasingly conceptualized as an alteration of brain processing and treatments are designed to intervene on a neurobiological level." (Park, et al, 2006). Understanding brain-based interventions as it affects mental functioning is recommended. References Bystritsky, A., S. Saxena, K. Maidment, T. Vapnik, G. Tarlow, and R. Rosen. (1999). Quality-of-life changes among patients with obsessive-compulsive disorder in a partial hospitalization program. American Psychiatric Association Psychiatr Serv 50:412-414, March 1999 Fedoroff, Ingrid, Linda C. Sobell, Sangeeta Agrawal, Mark B. Sobell, Douglas R. Gavin (1999). Evaluation of the Yale-Brown Obsessive Compulsive Scale (YBOCS-hd) for heavy drinking with mild to moderately dependent alcohol abusers. Alcoholism: Clinical and Experimental Research 23 (9) , 1477-1483 doi:10.1111/j.1530-0277.1999.tb04670.x Frost, Randy O., Gail Steketee, Meredith S. Krause, Kristin L. Trepanier (1995). The relationship of the Yale-Brown Obsessive Compulsive Scale (YBOCS) to other measures of obsessive compulsive symptoms in a nonclinical population. Journal of Personality Assessment 65(1); 158 - 168 doi: 10.1207/s15327752jpa6501_12 Goodman, W.K., Price, L.H., Rasmussen, S.A. et al. (1089). "The Yale-Brown Obsessive Compulsive Scale." Arch Gen Psychiatry 46:1006-1011 Lochner, C., S. Seedat, P. L du Toit, D. G Nel, D. JH Niehaus, R. Sandler and D. J Stein. (2005). Obsessive-compulsive disorder and trichotillomania: a phenomenological comparison. BMC Psychiatry 2005, 5:2 doi:10.1186/1471-244X-5-2 Park, L. T., D.D.Dougherty and S.L.Rauch (2007). Neurosurgical treatments for psychiatric indications. Current Clinical Neurology. Humana Press. SpringerLink 339-361 doi:10.1007/978-1-59259-960-8_26 Read More