The Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS): an instrument for assessing obsessive-compulsive symptom dimensions.

Obsessive-compulsive disorder (OCD) encompasses a broad range of symptoms representing multiple domains. This complex phenotype can be summarized using a few consistent and temporally stable symptom dimensions. The objective of this study was to assess the psychometric properties of the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS). This scale measures the presence and severity of obsessive-compulsive (OC) symptoms within six distinct dimensions that combine thematically related obsessions and compulsions. The DY-BOCS includes portions to be used as a self-report instrument and portions to be used by expert raters, including global ratings of OC symptom severity and overall impairment. We assessed 137 patients with a Diagnostic and Statistical Manual-IV diagnosis of OCD, aged 6-69 years, from sites in the USA, Canada and Brazil. Estimates of the reliability and validity of both the expert and self-report versions of the DY-BOCS were calculated and stratified according to age (pediatric vs. adult subjects). The internal consistency of each of the six symptom dimensions and the global severity score were excellent. The inter-rater agreement was also excellent for all component scores. Self-report and expert ratings were highly intercorrelated. The global DY-BOCS score was highly correlated with the total Yale-Brown Obsessive-Compulsive Scale score (Pearson r = 0.82, P<0.0001). Severity scores for individual symptom dimensions were largely independent of one another, only modestly correlated with the global ratings, and were also differentially related to ratings of depression, anxiety and tic severity. No major differences were observed when the results were stratified by age. These results indicate that the DY-BOCS is a reliable and valid instrument for assessing multiple aspects of OCD symptom severity in natural history, neuroimaging, treatment response and genetic studies when administered by expert clinicians or their highly trained staff.

Memory for facial expressions in social phobia.

Memory biases toward threat have been documented in several anxiety disorders, but contradictory findings have recently been reported in social phobics' recognition of facial expressions. The present study examined recognition memory in clients with social phobia, in an effort to clarify previous inconsistent results. Just before giving a speech to a live audience, social phobia clients and normal controls viewed photographs of people with reassuring and threatening facial expressions. The stimuli were later presented again alongside photographs of the same person with a different facial expression, and participants chose which face they had seen before. Individuals with social phobia were less accurate at recognizing previously seen photographs than controls, apparently due to state anxiety. In contrast, social phobics did not show a memory bias toward threatening facial expressions. Theoretical and treatment implications are discussed.

Implicit associations for fear-relevant stimuli among individuals with snake and spider fears.

This study investigated an implicit measure of cognitive processing, the Implicit Association Test (IAT; A. G. Greenwald, D. E. McGhee, & J. L. K. Schwartz, 1998), as a measure of fear-related automatic associations. Sixty-seven students with snake or spider fears completed 4 IAT tasks in which they classified pictures of snakes and spiders along with descriptive words indicating valence, fear, danger, or disgust. Results indicated that all 4 tasks discriminated between fear groups in terms of their implicit associations, and fear-specific effects were significant even after controlling for the impact of valence evaluation. Findings are discussed in terms of applications of the IAT methodology to examine cognitive processing and schemata in anxiety and potential uses for assessing anxiety disorders.

Self-focused attention in the treatment of social phobia.

For those with social phobia self-focused attention has been linked with impairment in social performance increased social anxiety, and a higher frequency of self-critical thoughts during social situations. The purpose of this investigation was to assess correlates of changes in situational self-focus over the course of cognitive-behavioral treatment (CBT). Focus of attention was assessed after in-session role-plays and after in vivo homework assignments during group CBT for social phobia. Analyses revealed a significant decrease in self-focused attention over time; focus on events and stimuli outside of the self remained unchanged. Treatment gains on anxiety during dyadic interactions, on negative self-judgments, and on personalized social fears were related to reduction in self-focused attention. Those with public speaking phobias showed a strong relationship between decreased self-focus and speech anxiety. These findings suggest that changes in self-focused attention during the course of CBT are related to important therapeutic gains Specific interventions aimed at decreasing self-focus may be a useful treatment strategy.

Effects of focus of attention on anxiety levels and social performance of individuals with social phobia.

Self-focused attention has been linked to social anxiety and poor social performance, but the causal direction of this relationship has not been established. For this study, focus of attention was manipulated during a speech task, conducted in pairs for 38 individuals with generalized social phobia. Results indicated that intensifying self-focused attention increased anticipated anxiety and anxious appearance, regardless of whether the individual was giving a speech or passively standing before the audience. The self-focus manipulation also increased self-reported anxiety during the task, but only for individuals assigned to a passive role. Contrary to expectation, self-focused attention did not affect any measure of social performance. These results indicate that self-focused attention may play a causal role in exacerbating social anxiety.

Perceived responsibility: structure and significance.

Given the postulated significance of inflated responsibility in obsessive compulsive disorder (OCD), there is a need for clarification of the concept itself and a means for measuring such responsibility. Two psychometric studies were conducted in order to develop a reliable self-report scale. In the first study 291 students completed the specially constructed Responsibility Appraisal Questionnaire (RAQ). Four factors emerged: responsibility for harm, responsibility in social contexts, a positive outlook towards responsibility, and thought-action fusion (TAF). In the second study, 234 students completed a revised RAQ. Four comparable factors emerged, and the TAF subscale correlated significantly with measures of obsessionality, guilt, and depression. The correlations between TAF and obsessionality and guilt remained significant even after BDI scores were controlled. It is concluded that the broad concept of inflated responsibility needs to be qualified; the connection between inflated responsibility and OCD appears to be situation-specific and idiosyncratic. There is more inflated responsibility than there is OCD. The measured concept of inflated responsibility is multifactorial (harm, social, positive, and TAF), not unitary. The TAF factor appears to be particularly significant in OCD.

Reliability and validity of the Yale-Brown Obsessive-Compulsive Scale.

The reliability and validity of the Yale-Brown Obsessive-Compulsive Scale were examined according to a multi-trait multi-method approach in a sample of 54 outpatients with obsessive-compulsive disorder (OCD). Internal consistency was acceptable but was improved by deletion of items concerning resistance to obsessions and compulsions. Inter-rater reliability was excellent, but test-retest reliability over an average interval of 48.5 days was lower than desirable. The YBOCS demonstrated good convergent validity with most other measures of OCD, but divergent validity vis à vis depression was poor. Analyses of new items assessing avoidance and the duration of obsession-free and compulsion-free intervals indicated that only the avoidance rating added meaningfully to the full scale score. In future research the authors recommend deletion of the resistance items and inclusion of the avoidance item to yield a revised 9-item YBOCS total score.

The usefulness of the Obsessive Compulsive Scale of the Symptom Checklist-90-Revised.

The reliability and validity of the SCL-90-R Obsessive Compulsive Scale were examined using a multi-trait multi-method approach in a sample of 54 outpatients with obsessive-compulsive disorder (OCD). The OC scale proved to be internally consistent. Evidence for convergent validity was mixed, and the results suggest poor divergent and criterion-related validities. The scale demonstrated sensitivity to changes with behavioral treatment. Overall, the SCL-90-R proved to be a poor measure of OCD symptoms.

A multicomponent behavioral treatment for social phobia: social effectiveness therapy.

The development of a new, comprehensive and multicomponent treatment for social phobia is described. Initial results of a pilot study with the new treatment also are reported. The treatment was found to be effective with severe (generalized) social phobics, most of whom had co-occurring Axis I and/or II conditions. In addition to significant change on a host of outcome variables, a normative-based endstate functioning index was used to determine treatment efficacy. The results are discussed with respect to the implementation of the treatment and in terms of the need for a comprehensive approach to treating social phobia.

Is agoraphobia harder to treat? A comparison of agoraphobics' and simple phobics' response to treatment.

Agoraphobia is reputed to be more difficult to treat than simple phobia. In a test of this supposition, 38 agoraphobics and 19 simple phobics were each given 10 sessions of graduated in vivo exposure. They were assessed before and after therapy using a behavioral avoidance test, behavioral diaries, and self-report measures. Analysis of covariance revealed unequivocal posttest differences only on self-assessed disability level; agoraphobics had changed less in their report of global disability immediately following treatment but not at follow-up. Sixty-eight percent of the simple phobics showed clinically significant improvement on avoidance of the Main Phobia, compared with 34% of the agoraphobics. On three other outcome measures, including more precise behavioral measures of phobia, agoraphobics and simple phobics responded equivalently to treatment. Given clinicians' impression about the comparative difficulty in treating agoraphobic clients, fewer differences in treatment response were obtained than were expected. Several possible explanations for this discrepancy are discussed.