Constructing A Critical Evaluation Of Cognitive Behavioural Psychotherapy

Opportunities for learning and application

“I am now going to ask several questions about your obsessive thoughts.” [Make specific reference to the patient’s target obsessions.]

1. TIME OCCUPED BY OBSESSIVE THOUGHTS

0 = None.

1 = Mild, less than 1 hr/day or occasional intrusion.

2 = Moderate, 1 to 3 hrs/day or frequent intrusion.

3 = Severe, greater than 3 and up to 8 hrs/day or very frequent intrusion.

4 = Extreme, greater than 8 hrs/day or near constant intrusion.

Q: How much of your time is occupied by obsessive thoughts?
0
[When obsessions occur as brief, intermittent intrusions, it may
1
be difficult to assess time occupied by them in temns of total
2
hours. In such cases, estirnate time by detesmining how
3
frequently they occur. Consider both the number of times the
4
intrusions occur and how many hours of the day are affected.
Ask:1 How frequently do the obsessive thoughts occur? [Be sure
to exclude ruminations and preoccupations which, unlike
obsessions, are ego-syntonic and rational (but exaggerated).]

 

I b. OBSESSION-FREE INTERVAL (not included in total score)

0 = No symptoms.

1 = Long symptom-free interval, more than 8 consecutive hours/day symptom-free.

2 = Moderately long symptom-free interval, more than 3 and up to 8 consecutive hours/day symptom-free.

3 = Short symptom-free interval, from I to 3 consecutive hours/day symptom-free.

4 = Extremely short symptom-free interval, less than I consecutive hour/day symptom-free.

Q: On the average, what is the longest number of consecutive

waking hours per day that you are

completely free of obsessive thoughts? [If necessary, ask:1 What

is the longest block of time in which

obsessive thoughts are absent?

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS

1. INTERFERENCE DUE TO OBSESSIVE THOUGHTS

0 = None.

1 = Mild, slight interference with social or occupational activities, but overall performance not impaired.

2 = Moderate, definite interference with social or occupational performance, but still manageable.

3 = Severe, causes substantial impairment in social or occupational performance.

4 – Extreme, incapacitating.

Q: How much do your obsessive thoughts interfere with your
0
social or work (or role) functioning? Is there anything that you
1
don’t do because of them? [If currently not working determine
2
how much
3
performance would be affected if patient were employed.]
4

1. DISTRESS ASSOCIATED W1TH OBSESSIVE THOUGHT

0 = None

I = Mild, not too disturbing

	2	= 1doderate, disturbing, but still manageable
	3	= Severe, very disturbing
	4	= Extreme, near constant and disabling distress
Q: How much distress do your obsessive thoughts cause you?
0
[In most eases, distress is equated with anxiety; however,	1
patients may report that their obsessions are “disturbing” but	2
deny “anxiety.” Only rate anxiety that seems triggered by	3
obsessions, not generalized anxiety or associated with other	4
conditions.]

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

1. RESISTANCE AGAINST OBSESSIONS

0 = Makes an effort to always resist, or symptoms so minimal doesn’t need to actively resist

1 = Tries to resist most of the time

2 = Makes some effort to resist

3 = Yields to all obsessions without attempting to control them, but does so with some reluctance

4 = Completely and willingly yields to all obsessions

Q: How much of an effort do you make to resist the obsessive
0
thoughts? How often do you try to disregard or turn your anention
1
away from these thoughts as they eater your mind? [Only rate
2
effort made to resist, not success or failure in actually controlling
3
the obsessions. How much the patient resists the obsessions may
4
or may not correlate with his/her abilig to control them. Note that
this item does not direetly measure the severig of the intrusive
thoughts; rather it rates a manifestation of health, i.e., the effort
the patient makes to counteract the obsessions by means other
than avoidance or the performance of compulsions. Thus, the
more the patient tries to resist, the less impaired is this aspect of
his/her functioning. There are “active” and “passive” forms of
resistance. Patients in behavioral therapy may be encouraged to
counteract their obsessive symptoms by not struggling against
them (e.g., “just let the thoughts come; passive opposition) or by
intentionally bringing on the disturbing thoughts. For the purposes
of this item, consider use of these behavioral techniques as forms
of resistance. If the obsessions are minimal, the patieut may not
feel the need to resist them. In such cases, a rating of “0” should
be given.]

1. DEGREE OP CONTROL OVER OBSESSIVE THOUGHTS

0 = Complete control.

1 = Much control, usually able to stop or divert obsessions with some effort and concentration.

2 = Moderate control, sometimes able to stop or divert obsessions.

3 = Little control, rarely successful in stopping or dismissing obsessions, can only divert attention with difficulty.

4 = No control, experienced as completely involuntary, rarely able to even momentarily alter obsessive thinking.

Q: How much control do you have over your obsessive thoughts?
0
How successful are you in stopping or diverting your obsessive
1
thinking? Can you dismiss them? [In contrast to the preceding
2
item on resistance, the ability of the patient to control his
3
obsessions is more closely related to the severity of the intrusive
4
thoughts.]

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

“The next several questions are about your compulsive behaviors.” [Make specific reference to the patient’s target compulsions.]

1. TIME SPENT PERFORM~G COMPULSIVE BEHAVIORS

0 = None

1 = Mild (spends less than I hr/day performing compulsions), or occasional performance of compulsive behaviors.

2 = Moderate (speeds from I to 3 hrs/day performing compulsions), or frequent performance of compulsive behaviors.

3 = Severe (spends more than 3 and up to 8 hrs/day performing compulsions), or very frequent performance of compulsive behaviors.

Demonstrating self-direction and originality

4 = Extreme (spends more than 8 hrs/day performing compulsions), or near constant performance of compulsive behaviors (too numerous to count).

Q: How much time do you spend performing compulsive
0
behaviors? [When rituals involving activities of daily living are
1
chiefly present, ask:] How much longer than most people does it
2
take to complete routine activities because of your rituals? [When
3
compulsions occur as brief, intermittent behaviors, it may difficult
4
to assess time spent performing them in terms of total hours. In
such cases, estimate time by determining how frequently they are
performed. Consider both the number of times compulsions are
performed and how many hours of the day are affected. Count
separate occurrences of compulsive behaviors, not number of
repetitions; e.g., a patient who goes into the bathroom 20
different times a day to wash his hands 5 times very quickly,
performs compulsions 20 times a day, not 5 or 5 x 20 = 100.
Ask:] How frequently do you perform compulsions? 1In most
cases compulsions are observable behaviors(e.g., land washing),
but some compulsions are covert (e.g., silent checking).]

6b. COMPULSION-FREE INTERVAL(not included in total score)

0 = No symptoms.

1 = Long symptom-free interval, more than 8 consecutive hours/day symptom-free.

2 = Moderately long symptom-free interval, more than 3 and up to 8 consecutive hours/day symptom-free.

3 = Short symptom-free interval, from I to 3 consecutive hours/day symptom-free.

4 = Extremely short symptom-free interval, less than I consecutive hour/day symptom-free.

Q: On the average, what is the longest number of consecutive
		0
waking hours per day that you are completely free of compulsive
		1
behavior? [If necessary, ask:] What is the longest block of time in
		2
which compulsions are absent?different times a day to wash his
		3
hands 5 times very quickly, performs compulsions 20 times a day,
		4
not 5 or 5 x 20 = 100. Ask:] How frequently do you perform
compulsions? 1In most cases compulsions are observable
behaviors(e.g., land washing), but some compulsions are covert
(e.g., silent checking).]

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

7 INTERFERIINCE DUE TO COMPULSIVE BEHAVIQRS

0 = None

1 = Mild, slight interference with social or occupational activities, but overall performance not impaired

2 = Moderate, definite interference with social or occupational performance, but still manageable

3 = Severe, causes substantial impaiment in social or occupational performance

4 = Extreme, incapacitating

Q: How much do your compulsive behaviors interfere with your
0
social or work (or role) functioning? Is there anything that you
1
don’t do because of the compulsions? [If currently not working
2
determine how much performance would be affected if patient
3
were employed.]
4

1. DISTRESS ASSOCIATED WITH COMPULSIVE BEHAVIOR

0 = None

I = Mild only slightly anxious if compulsions prevented, or only slight anxiety during performance of compulsions

2 = Moderate, reports that anxioty would mount but remain manageable if compulsions prevented, or that anxiety increases but remains manageable during performance of compulsions

3 = Severe, prominent and very disturbing increase in anxiety if compulsions interrupted, or prorninent and very disturbing increase in anxiety during performance of compulsions

4 = Extreme, incapacitating anxiety from any intervention aimed at modifying activity, or incapacitating anxiety develops during performance of compulsions

Q: How would you feel if prevented from performing your
0
compulsion(s)? [Pause] How anxious would you become? [Rate
1
degree of distress patient would experience if performance of the
2
compulsion were suddenly interrupted without reassurance
3
offered. In most, but not all cases, performing compulsions
4
reduces anxiety. If, in the judgement of the interviewer, anxiety is
actually reduced by preventing compulsions in the manner
described above, then asked: How anxious do you get while
performing compulsions until you are satisfied they are
completed?

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

1. RESISTANCE AGAINST COMPULSIONS

0 = Malces an effort to always resist, or symptoms so minimal doesn’t need to actively resist

I = Tries to resist most of the time

2 = Makes some effort to resist

3 = Yields to almost all compulsions without attempting to control them, but does so with somreluetance

4 = Completely and willingly yields to all compulsions

Q: How much of an effort do you make to resist the compulsions?
0
I Only rate effort made to resist, not success or failure in actually
1
controlling the compulsions. How much the patient resists the
2
compulsions may or may not correlate with his ability to control
3
them. Note that this item does not directly measure the severity
4
of the compulsions; rather it rates a manifestation of health, i.e.,
the effort the patient makes to counteract the compulsions. Thus,
the more the patient tries to resist, the less impaired is this
aspect of his functioning. If the compulsions are minimal, the
patient may not feel the need to resist them. In such cases, a
rating of “0” should be given.]

1. DEGREE OF CONTROL OVER COMULSIVE BEHAVIOR

I = Much control, experiences pressure to perform the behavior but usually able to exercise voluntary control over it.

2 = Moderate control, strong pressure to perform behavior, can control it only with difficulty

3 = Little control, very strong drive to perform behavior, must be carried to completion, can only delay with difficulty

4 = No control. drive to perform behavior expericoced as completely involuntary and overpowering, rarely able to even momentarily delay activity

Q: How strong is the drive to perform the compulsive behavior?
0
[Pause] How much control do you have over the compulsions? [In
1
contrast to the preceding item on resistance, the ability of the
2
patient to control his compulsions is more closely related to the
3
severity of the compulsions.]
4

“The remaining questions are about both obsessions and compulsions. Some ask about related problems.” These are investigational items not included in total Y-BOCS score but may be useful in assessing these symptoms

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

1. INSIGHT INTO OBSESSIONS AND COMPULSIONS

Justifying and critically evaluating cognitive behavioural interventions

0 = Excellent insight, fully rational

1 = Good insight. Readily acknowledges absurdity or excessiveness of thoughts or behaviors but does not seem completely convinced that there isn’t something besides anxiety to be concerned about (i.e., has lingering doubts).

2 = Fair insight. Reluctantly admits thoughts or behavior seem unreasonable or excessive, but wavers.

May have some unrealistic fears, but no fixed convictions.

3 = Poor insight. Maintains that thoughts or behaviors are not unreasonable or excessive, but acknowledges validity of contrary evidence (i.e., overvalued ideas present).

4 = Lacks insight, delusional. Definitely convinced that concerns and behavior are reasonable, unresponsive to contrary evidence.

Q: Do you think your concerns or behaviors are reasonable?
0
[Pause] What do you think would happen if you did not perform
1
the compulsion(s)? Are you convinced something would really
2
happen? 1Ratc patient’s insight into the senselessness or
3
excessiveness of his obsession(s) based on beliefs expressed at
4
the time of the interview.]

1. AVOIDANCE

0 = No deliberate avoidance

1 = Mild, minimal avoidance

2 = Modrate, some avoidance; clearly present

3 = Severe, much avoidance; avoidance prominent

4 = Extreme, very extensive avoidance; patient does almost everything he/she can to avoid triggering symptoms

Q: Have you been avoiding doing anything, going any place, or
0
being with anyone because of your obsessional thoughts or out of
1
concern you will perform compulsions? [If yes, then ask:] Elow
2
much do you avoid? [Rate degree to which patient deliberately
3
tries to avoid things. Sometimes compulsions are designed to
4
“avoid” contact with something that the patient fears. For
example, clothes washing rituals would be designated as
compulsions, not as avoidant behavior. If the patient stopped
doing the laundry then this would constitute avoidance.]

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

1. DEGEE OF INDECISIVENESS

0 = None

1 = Mild, some trouble making decisions about minor things

2 = Moderate, freely reports significant trouble making decisions that others would not think twice

about

	3	= Severe, continual weighing of pros and cons about nonessentials.
	4	= Extreme, unable to make any decisions. Disabling.
Q: Do you have trouble making decisions about little things that	0
other people might not think twice about (e.g., which clothes to	1
put on in the morning; which brand of cereal to buy)? [Exclude	2
difficulty making decisions which reflect ruminative thinking.	3
Ambivalence concerning rationally-based difficult choices should	4
also be excluded.]

1. OVERVALUED SENSE OF RESPONSIBILY

0 = None I = Mild, only mentioned on questioning, slight sense of over-responsibility

2 = Moderate, ideas stated spontaneously, clearly present; patient experiences significant sense of over-responsibility for events outside his/her reasonable control

3 = Severe, ideas prominent and pervasive; deeply concerned he/she is responsible for events clearly outside his control. Self-blaming farfetched and nearly irrational

4 = Extreme, delusional sense of responsibility (e.g., if an earthquake occurs 3,000 miles away patient blames herself because she didn’t perform her compulsions)

Q: Do you feel very responsible for the consequences of your
0
actions? Do you blame yourself for the outcome of events not
1
completely in your control? [Distinguish from normal feelings of
2
responsibility, feelings of worthlessness, and pathological guilt. A
3
guilt-ridden person experiences himself or his actions as bad or
4
evil.]

1. PERVASIVE SLOWNESS/ DISTURBANCE OF INERTIA

0 = None.

I = Mild, occasional delay in starting or finishing.

2 = Moderate, frequent prolongation of routine activities but tasks usually completed. Frequently late.

3 = Severe, pervasive and marked difficulty initiating and completing routine tasks. Usually late.

4 = Extreme, unable to start or complete routine tasks without full assistance.

Q: Do you have difficulty starting or finishing tasks? Do many
0
routine activities take longer than they should? [Distinguish from
1
psychomotor retardation secondary to depression. Rate increased
2
time spent performing routine activities even when specific
3
obsessions cannot be identified.]
4

1. PATHOLOGICAL DOUBTING

0 = None.

1 = Mild, only mentioned on questioning, slight pathological doubt. Examples given may be within normal range.

2 = Moderate, ideas stated spontaneously, clearly present and apparent in some of patient’s behaviors, patient bothered by significant pathological doubt. Some effect on performance but still manageable.

3 = Severe, uncertainty about perceptions or ,memory prominent; pathological doubt frequently affects performance.

4 = Extreme uncertainty about perceptions constantly present; pathological doubt substantially affects almost all activities. Incapacitating (e.g., patient states “my mind doesn’t trust what my eyes see”).

Q: After you complete an activity do you doubt whether you
0
performed it correctly? Do you doubt whether you did it at all?
1
When carrying out routine activities do you find that you don’t
2
trust your senses (i.e., what you see, hear, or touch)?
3

[Items 17 and 18 refer to global illness severity. The rater is required to consider global function, not just the severity of obssive-compulsive symptoms.]

1. GLOBAL SEVERITY:

	1	= Illness slight, doubtful, transient; no functional impairment
	2	= Mild symptoms, little functional impairment
	3	= Moderate symptoms, functions with effort
	4	= Moderate – Severe symptoms, limited functioning
	5	= Severe symptoms, functions mainly with assistance
	6	= Extremely Severe symptoms, completely nonfunctional
Interviewer’s judgement of the overall severity of the patient’s
0
illness. Rated from O (no illness) to 6-(most severe patient seen).	1
[Consider the degree of distress reported by the patient, the	2
symptoms observed, and the functional impairment reported.	3
weighing the reliability or accuracy of the data obtained. This	5

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

1. GLOBAL IMPROVEMENT:

0	= Very much worse
1	= Much worse
2	= Minimal worse
3	= No change
4	= Minimally improved
5	= Much improved
6	= Very much improved
Rate total overall improvement present SINCE THE INITIAL
0
RATING whether or not, in your judgement, it is due to drug	1
treatment.	2

1. RELIABILITY:

= Excellent, no reason to suspect data unreliable  . .
= Good, factor(s) present that may adversely affect reliability
= Fair, factorts) present that definitely reduce reliability
= Poor, very low reliability
obsessive-compulsive symptoms present may interfere with the	3
patient’s concentration, attention, or freedom to speak
spontaneously (e.g., the content of some obsessions may cause
the patient to choose his words very carefully).

 

References

Items 17 and 18 arc adapted from the Clinical Global Impression Scale (Guy W: ECDEU Assessment Manual for Psychopharrnacology: Publication 76-338. Washington, D.C., U.S. Department of Health, Education, and Welfare (1976)).

Additional infomnation regarding the development, use, and psychometric properties of the Y-BOCS can be found in Goodman WK, Price LH, Rasmussen SA, et al.: The Yale-Brown Obsessive Compulsive Scaie (YBOCS): Part I. Development, use, and reliability. Arch Gen Psvchiaty (46:1006~1011, 1989). and Goodman WK, Price LH, Rasmussen SA, ct al.: The Yale-Brown Obsessive Compulsive Scale (Y-BOCS): Part II. Validity. Arch Gen Psvchiatry (46:1012-1016, 1989).

Copies of a version of the Y-BOCS modified for usc in children, the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (Goodman WK, Rasmussen SA, Price LH, Mazure C, Rapoport JL, Heninger GR, Charney DS), is available from Dr. Goodman on request.