You are on page 1of 8

Available online at www.sciencedirect.


Comprehensive Psychiatry 51 (2010) 641 – 648

Spanish adaptation of the Dimensional Yale-Brown

Obsessive-Compulsive Scale
Alberto Pertusaa,b , Núria Jaurrietaa , Eva Reala , Pino Alonsoa,c,d , Blanca Buenoa , Cinto Segalàs a ,
Susana Jiménez-Murciaa , David Mataix-Colsb , José M. Menchóna,c,d,⁎
Obsessive-Compulsive Disorder Clinical and Research Unit, Department of Psychiatry, Bellvitge Hospital, Barcelona, Spain
Division of Psychological Medicine. King's College London, Institute of Psychiatry, SE5 8AF London, UK
CIBER Salud Mental (CIBERSAM), Instituto Salud Carlos III, Spain
Department of Clinical Sciences, University of Barcelona, Spain


Background: The Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) is a promising new instrument that allows patient
and clinician ratings of dimension-specific symptom severity, as well as estimates of global symptom severity in patients with obsessive-
compulsive disorder (OCD). The goal of this study was to further explore the psychometric properties of the DY-BOCS in a Spanish sample.
Methods: The internal consistency, reliability, and convergent and divergent validity of the Spanish adaptation of the DY-BOCS were
assessed in a sample of 51 Spanish adult patients with OCD.
Results: All the subscales of the Spanish DY-BOCS showed high internal consistency. The interrater reliability was excellent for all
component scores, and the level of agreement between self-report and expert ratings was high for most symptom dimensions. The subscales
of the DY-BOCS were largely independent from one another and from global OCD severity. The convergent and divergent validities of the
DY-BOCS subscales were adequate.
Conclusions: The Spanish version of the DY-BOCS is a reliable and valid clinical tool for the assessment of obsessive-compulsive
symptom dimensions.
© 2010 Elsevier Inc. All rights reserved.

1. Introduction instrument that possesses excellent psychometric properties

and is consensually acknowledged as being the criterion
A variety of instruments exist for the assessment of the standard for rating the severity of obsessive-compulsive
symptoms of obsessive-compulsive disorder (OCD). Since symptoms [1,2,4].
its introduction in 1989, the Yale-Brown Obsessive- However, although its status in both clinical trials and
Compulsive Scale (Y-BOCS) [1,2] has been increasingly research is undisputed, the Y-BOCS has some important
used in both drug trials and cognitive-behavioral therapy limitations [5]. First, despite the face validity of the initial
studies [3]. The Y-BOCS is a clinician-administered factorial structure of the Y-BOCS (obsessions and compul-
sions subscales), this has not been confirmed by subsequent
research. Specifically, items 4 and 9 (resistance to obses-
⁎ Corresponding author. Deparment of Psychiatry, Bellvitge Hospital,
sions/compulsions) and items 5 and 10 (control over
Feixa Llarga s/n, 08907 Hospitalet de Llobregat, Barcelona, Spain. Tel.: +34 obsessions/compulsions) of the Y-BOCS do not meaning-
93 2607922; fax: +34 93 2607658. fully contribute to the measurement of OCD symptom
E-mail addresses: (A. Pertusa), severity [6,7]. Second, the distinction between obsessions (N. Jaurrieta), (E. Real), and compulsions is controversial because these phenomena (P. Alonso),
are intimately connected and rarely occur in isolation [7,8].
(B. Bueno), (C. Segalàs), (S. Jiménez-Murcia), Third, the Y-BOCS only provides a global measure of OCD (D. Mataix-Cols), severity, regardless of the patients' specific symptom (J.M. Menchón). presentation. Recent research clearly suggests that OCD is
0010-440X/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
642 A. Pertusa et al. / Comprehensive Psychiatry 51 (2010) 641–648

not a phenomenologically and etiologically homogeneous aimed to examine the psychometric properties of the
condition and that noting the severity of different symptom Spanish adaptation of the DY-BOCS in a Spanish sample
dimensions may be of great value, both in research and of adult patients with OCD. We predicted that the
clinically [9]. The Y-BOCS contains an ancillary Symptom psychometric properties of the Spanish version DY-
Checklist where clinicians can note the presence or absence BOCS would be similar to those of the original version
of multiple OCD symptoms. However, the Y-BOCS of the instrument.
Symptom Checklist was never designed to be used as a
rating scale and its psychometric properties are relatively
weak [10,11]. 2. Method
In an effort to address these issues, the Dimensional 2.1. Participants
Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) was
recently developed [12]. It consists of a series of scales that Participants were 51 consecutive adult outpatients
assess the presence and severity of the various OCD meeting Diagnostic and Statistical Manual of Mental
symptom dimensions and includes both self-report and Disorder, Fourth Edition, Text Revision (DSM-IV-TR)
clinician-administered versions. The DY-BOCS self-report criteria for OCD recruited from an OCD clinic in Barcelona,
is composed of an 88-item self-report checklist, designed to Spain. All patients were interviewed face-to-face by a
provide a detailed description of obsessions and compul- psychiatrist with clinical and research experience in OCD
sions that are divided into 6 different OC symptom (A.P.), who received training from the developer of the scale
dimensions: (1) obsessions about harm due to aggression/ (M.C. Rosario). Axis I diagnoses were ascertained with the
injury/violence/natural disasters and related compulsions; Mini-International Psychiatric Interview (MINI) [15]. Parti-
(2) obsessions concerning sexual/moral/religious obsessions cipants were excluded if they were younger than 18 years or
and related compulsions; (3) obsessions about symmetry/ older than 65 years or met the criteria for bipolar disorder I or
“just-right” perceptions and compulsions to count or order/ manic episode, psychosis, substance dependence or abuse
arrange; (4) contamination obsessions and cleaning com- (including alcohol), suicidality, or any severe organic
pulsions; (5) obsessions and compulsions related to disturbance. Patients with comorbid Axis I disorders were
hoarding; and (6) miscellaneous obsessions and compul- not excluded, provided that OCD was the primary complaint.
sions that relate to somatic concerns and superstitions, Written informed consent was obtained from all participants.
among other symptoms. In addition to the symptom The study was approved by the Ethics Committee of
checklist, the DY-BOCS self-report also includes items Bellvitge Hospital, Barcelona, Spain.
that ask the patient to assess the overall symptom severity Twenty-two (43.1%) participants were women, and the
in each of the dimensions for the previous week. In the mean (SD) age of the sample was 35.9 (8.6) years (range,
clinician-administered version, the clinician rates the 22-53 years). Eleven (21.6%) patients met the criteria for
severity of each symptom dimension as well as the global other Axis I disorders: social phobia (n = 2, or 4.2%),
OCD symptom severity. generalized anxiety disorder (n = 4, or 7.8%), current (n = 2,
The DY-BOCS offers several improvements compared or 4.2%) or past (n = 8, or 15.7%) major depression,
with its predecessor, the Y-BOCS [1,2]. First, the DY-BOCS dysthymia (n = 2, or 4.2%), eating disorder (n = 2, or 4.2%).
no longer measures obsessions and compulsions separately No patient met the criteria for current chronic tic disorder.
because this distinction has not received consistent support Most participants (94.1%) were on medication at the time of
[7,8]. Second, the DY-BOCS drops the resistance and control the study.
items of the original YBOCS, which were psychometrically
2.2. Measures
weak [7], and focuses on frequency, distress, and interference
as the best estimates of symptom severity within each 2.2.1. Clinician administered
dimension, as well as for all OC symptoms considered in The MINI, Spanish Version 5.0 [15,16], is a structured
aggregate [6,7]. Third, by dividing OC symptoms according interview used to identify the presence of the major Axis I
to the abovementioned 6 dimensions, the DY-BOCS is diagnoses of the DSM-IV. It has 2 to 4 screening questions
capable of inquiring about symptoms that are inherently per disorder. Additional symptom questions are asked only if
ambiguous and that may be present in more than 1 symptom the screen questions are positively endorsed. The MINI has
domain, such as checking and mental rituals—which may be been shown to have good concordance with other diagnostic
performed in response to a variety of obsessions. The focus is measures [17]. The MINI also has good interrater reliability,
on the obsessions motivating the rituals, rather than on the with κ coefficients ranging between 0.88 and 1.0, and good
observable behaviors themselves [13]. test-retest reliability with coefficients ranging between .76
The DY-BOCS is thus a potentially useful tool in and .93 [15].
assessing OC symptom dimensions while continuing to The DY-BOCS [12] consists of an 88-item self-report
provide valid overall estimates of OC symptom severity. checklist of obsessions and compulsions, divided into 6
However, its psychometric properties need to be explored dimensions (contamination obsessions and cleaning compul-
further in other cultural and linguistic contexts [14]. We sions; collecting and hoarding obsessions and compulsions;
A. Pertusa et al. / Comprehensive Psychiatry 51 (2010) 641–648 643

symmetry, ordering, counting, and arranging obsessions and 2.3. Data analyses
compulsions; aggressive obsessions and compulsions; sexu-
al/religious obsessions and compulsions; miscellaneous The internal consistency of the DY-BOCS was deter-
obsessions and compulsions), and a series of clinician- mined by using Cronbach α to assess the 3 severity items
administered scales which can be used to assess the presence (time, distress, and interference) in each of the dimensions.
and severity of each of the above symptom dimensions. Each Convergent validity was assessed with Pearson product-
of these scales consists of 3 items (frequency, distress, and moment or Spearman ρ correlations—depending on whether
interference) measured on a 0 to 5 scale, yielding a total score the assumption of normality was met—between the DY-
ranging from 0 to 15 (0 = no symptoms, 15 = extremely BOCS, Y-BOCS, and OCI-R subscales. To assess the
severe symptoms). In addition to the symptom severity divergent validity of the Spanish version of the DY-BOCS,
ratings for each dimension, it contains a Global symptom we calculated correlations between the DY-BOCS subscales
severity scale using the same 3 ordinal scales (frequency, and depression (HAM-D) and anxiety (HAM-A). Following
distress, and interference; score range, 0-15) and an Cohen's classification [26], large correlations will be defined
Impairment score to assess the overall level of current as .50 or greater, medium correlations between .30 and .49,
impairment due to OC symptoms on a scale that ranges from and small correlations from .10 to .29. Interrater reliability
“none” (0 points) to “severe” (15 points). The total global was determined for a subset of 15 (29.4%) patients using
score is obtained by combining the sum of the global severity intraclass correlation coefficients. The interviews were audio
scores and the impairment score, yielding a maximum total recorded, and 4 raters (none of whom was the rater who
global severity score of 3. In its original validation study, the performed the initial interview) scored them independently.
DY-BOCS proved to be reliable and showed good construct Correlation coefficients were used to evaluate the association
and divergent validity in both child and adult populations between the patient self-report and the clinician measures of
[12]. The self- and clinician-administered versions of the DY- severity for each dimension on 38 (74.5%) patients. Thirteen
BOCS are highly intercorrelated [12]. The original version of patients were excluded from this analysis because they did
the DY-BOCS was translated into Spanish by 2 of us (N.J. not fill out the questions assessing symptoms severity in the
and A.P.) and back-translated into English by D.M.C. The self-report. Sample size differs in some variables as a result
back-translated version was then reviewed by the authors of of missing data.
the original scale to verify the accuracy of the translation. The All analyses were conducted with SPSS (version 17;
Spanish DY-BOCS is available from the corresponding SPSS, Chicago, Ill). Due to the risk of false positives due to
author upon request. multiple testing, the P value was conservatively set at less
The Y-BOCS [1,2] is a 10-item scale that rates the than .01. Correlations significant at the .05 level were
severity of obsessions (items 1-5) and compulsions (items 6- considered trends. All statistical tests are 2 tailed.
10). Each item is rated from 0 (none) to 4 (extreme); thus,
scores on the Y-BOCS range from 0 to 4. The psychometric
3. Results
properties of the English and Spanish versions of Y-BOCS
have been well documented [7,18].
A preliminary analysis of the DY-BOCS scores showed
The Hamilton Scale for Depression (HAM-D) [19,20] is a
that all obsessive-compulsive symptom dimensions were
17-item scale that evaluates depressed mood, vegetative and
generally well represented in our sample. Twenty two
cognitive symptoms of depression, and comorbid anxiety
(43.1%) patients endorsed symptoms in the Contamination
symptoms. The Hamilton Scale for Anxiety (HAM-A)
subscale (mean severity score, 9.6), 9 (17.6%) patients
[21,22] consists of 14 items, each defined by a series of
endorsed symptoms in the Hoarding subscale (mean severity
symptoms. Similar to the HAM-D, each item is rated on a
score, 4.8), 25 (49.0%) patients endorsed symptoms in the
5-point scale, ranging from 0 (not present) to 4 (severe). The
Symmetry subscale (mean severity score, 8.0), 30 (58.8%)
highest score of the scale is 56. The psychometric properties
patients endorsed symptoms in the Aggressive subscale
of the English and Spanish versions of the HAM-D and
(mean severity, 8.5), 23 (45.1%) patients endorsed symp-
HAM-A have been well documented.
toms in the Sexual/Religious subscale (mean severity score,
8.4), and 31 (60.8%) patients endorsed symptoms in the
2.2.2. Self-administered
Miscellaneous subscale (mean severity score, 8.4). The mean
The Obsessive-Compulsive Inventory–Revised (OCI-R)
global severity score was 10.8.
[23] is an 18-item self-report questionnaire designed to
assess the severity of OCD symptoms. Each item is scored 3.1. Internal consistency
on a 0 to 4 scale (0 = not at all; 4 = extremely). Each of its
factor analysis-derived subscales (Washing, Checking, The internal consistency across the domains of time,
Hoarding, Ordering, Obsessing and Neutralizing) consists distress, and interference for each dimension was excellent.
of 3 items (score range, 0-12) and its total score ranges from Cronbach αs were .99 for Contamination, .98 for Hoarding,
0 to 72. The psychometric properties of the English and .98 for Symmetry, .97 for Aggressive, .97 for Sexual/
Spanish versions of the OCI-R are excellent [23-25]. Religious, and .98 for Miscellaneous dimensions. Cronbach
644 A. Pertusa et al. / Comprehensive Psychiatry 51 (2010) 641–648

α for the 3 domains (time, distress, and interference) of the BOCS, and OCI-R. Correlations between the DY-BOCS
Global score was .89. Global Severity scale and the Y-BOCS obsessions, compul-
sions, and total score were large and highly significant (r =
3.2. Interrater reliability 0.82, r = 0.79, and r = 0.84, respectively; all P b .01). As
The interrater reliability between the expert raters on the predicted, the largest correlations were between the
DY-BOCS was very strong. Intraclass correlation coeffi- corresponding symptom subscales, whereas the correlations
cients were .92 for Contamination, .93 for Hoarding, .85 for between noncorresponding subscales were generally non-
Symmetry, .90 for Aggressive, .95 for Sexual/Religious, and significant or medium. The Contamination/Washing sub-
.81 for Miscellaneous dimensions. scale of the DY-BOCS was most strongly correlated with the
Washing subscale of the OCI-R (r = 0.84, P b .01). The
3.3. Level of agreement between self-report and Aggressive subscale of the DY-BOCS showed the largest
expert ratings correlation with the Checking and Neutralizing subscales of
the OCI-R (r = 0.53, P b .01, and r = .34, P b .05,
The correlations between the self-report and clinician
respectively). The Symmetry/Order subscale of the DY-
measures of severity (n = 38) were large and statistically
BOCS strongly correlated with the Order and the Checking
significant for most symptom dimensions. Correlation
subscales of the OCI-R (r = 0.42, P b .01, and r = 0.42, P b
coefficients were .91 for Contamination, .76 for Hoarding,
.01, respectively). The Sexual/Religious subscale of the DY-
.55 for Symmetry, .77 for Aggressive, .83 for Sexual/
BOCS was most strongly correlated with the Obsessing
Religious, and .66 for Miscellaneous dimensions (P b .01 for
subscale of the OCI-R (r = 0.33, P b .05). The Miscellaneous
all dimensions).
subscale of the DY-BOCS moderately correlated with the
3.4. Intercorrelations between the DY-BOCS subscales Washing and Neutralizing subscales of the OCI-R. The
Global Severity subscale of the DY-BOCS correlated most
Table 1 shows the intercorrelations (Pearson or Spear- strongly with the OCI-R Total (r = 0.45, P b .01) and
man, as appropriate) between the various subscales of the showed also significant correlations with the Washing (r =
DY-BOCS. Like in the original validation study [12], the 0.45, P b .01) and Order (r = .43, P b .01) subscales of the
symptom dimension subscales of the DY-BOCS were OCI-R. The Impairment scale of the DY-BOCS showed
largely uncorrelated with one another, with the exception medium correlations with the same OCI-R scales. The
of the Symmetry/Order subscale, which correlated moder- Hoarding subscale of the DY-BOCS was most strongly
ately with the Contamination/Washing and the Miscella- correlated with the Ordering and Hoarding subscales of the
neous subscales. The Miscellaneous subscale was also OCI-R (r = 0.45, P b .01, and r = 0.36, P b .05).
moderately correlated with the Contamination subscale.
The correlations between the symptom dimension subscales
and the Global Severity and Impairment scales were 3.6. Divergent validity
nonsignificant for most dimensions. The Global Severity Table 3 shows the correlations between the subscales of
and Impairment scales seemed to be largely equivalent (r = the DY-BOCS and measures of depression (HAM-D) and
0.89, P b .01). Anxiety (HAM-A). As expected, the correlations ranged
3.5. Convergent validity from small and nonsignificant to moderate. The Sexual/
Religious subscale of the DY-BOCS showed medium
Table 2 shows the intercorrelations (Pearson or Spear- correlations with the HAM-D and the Aggressive subscale
man, as appropriate) between subscales of the DY-BOCS, Y- with the HAM-A.

Table 1
Intercorrelations between the subscales of the DY-BOCS in a sample of 51 OCD patients
DY-BOCS subscale
Contamination/washing Aggressive Hoarding Symmetry/ Sexual/Religious Miscellaneous Global Severity Impairment
Contamination/Washing – −.020 .266 .398⁎⁎ −.198 .362⁎⁎ .275 .116
Aggressive – .042 −.059 .099 .053 .308⁎ .335⁎
Hoarding – .034 −.158 .256 .089 −.048
Symmetry/Ordering – −.215 .366⁎⁎ .126 .173
Sexual/Religious – −.210 .073 .061
Miscellaneous – .365⁎⁎ .253
Global severity – .893⁎⁎
⁎ Correlation is significant at the .05 level (2-tailed).
⁎⁎ Correlation is significant at the .01 level (2-tailed).
A. Pertusa et al. / Comprehensive Psychiatry 51 (2010) 641–648 645

Table 2
Convergent validity of the DY-BOCS in a sample of 51 OCD patients
DY-BOCS subscale
Contamination/ Aggressive Hoarding Symmetry/ Sexual/Religious Miscellaneous Global Impairment
Washing Ordering Severity
OCI-R Washing .841⁎⁎ −.046 .286 .357⁎ −.236 .363⁎ .447⁎⁎ .330⁎
OCI-R Checking .236 .526⁎⁎ .157 .417⁎⁎ −.017 .270 .288 .315
OCI-R Hoarding .382 −.115 .363⁎ .270 −.055 -.029 .029 .253
OCI-R Ordering .743⁎⁎ .079 .455⁎⁎ .419⁎⁎ −.175 .262 .262 .179
OCI-R Obsessing .300 .231 −.064 −.393⁎ .334⁎ .052 .190 .216
OCI-R Neutralizing .312 .339⁎ .160 .256 −.005 .334⁎ .431⁎⁎ .371⁎
OCI-R Total score .579⁎⁎ .248 .359⁎ .267 −.028 .380⁎ .454⁎⁎ .358⁎
Y-BOCS Obsessions −.006 .026 .016 −.081 −.325⁎ .129 .815⁎⁎ .673⁎⁎
Y-BOCS Compulsions .168 .036 .148 .092 .163 .403⁎ .789⁎⁎ .601⁎⁎
Y-BOCS Total .089 −.017 .089 −.013 .242 .308 .838⁎⁎ .682⁎⁎
⁎ Correlation is significant at the .05 level (2-tailed).
⁎⁎ Correlation is significant at the .01 level (2-tailed).

4. Discussion symmetry obsessions/compulsions in the self-report version

due to lack of attribution of obsessive-compulsive symptoms
The DY-BOCS is a promising new instrument that allows related to “just right” feelings (ie, the need to do or repeat
patient and clinician ratings of dimension-specific symptom things because it does not feel “just right”). Therefore, the
severity, as well as estimates of global OCD symptom clinician should screen for this symptoms even if the patient
severity. The current study provides the first analysis of its has not endorsed them in the self-report scale. In their
psychometric properties by an independent group of original report, the authors state that “the DY-BOCS is a
researchers in a Spanish population. valid and reliable tool for assessing OC symptom dimensions
The psychometric properties of the Spanish version of the using either expert clinicians or relying solely on self-
DY-BOCS in our sample were very similar to those reported reports.” However, given that the level of agreement between
by Rosario-Campos et al [12] in their original validation self-report and expert ratings may vary widely on an
study. The internal consistency across the domains of time, individual basis, our results suggest caution with the use of
distress, and interference for all 6 dimensions of and for the the DY-BOCS self-report subscales as a reliable substitute
Global score was excellent, and the interrater reliability was for their clinician-administered counterparts, at least for the
very high. One of the reasons that may account for the higher symmetry and miscellaneous subscales. This is in agreement
reliability of the DY-BOCS as compared with the Y-BOCS with our experience with other self-report measures of OCD
is the removal of the resistance and control items [7]. symptoms, which often do not correlate as highly as
With the exception of the Symmetry and Miscellaneous expected with the corresponding clinician-administered
subscales, the level of agreement between self-report and version in our patient population [10].
expert ratings was overall good and similar to that reported in Like in the initial validation study [12], the subscales of
the original study [12]. The correlation coefficient between the DY-BOCS were largely independent from one another
the self-report and clinician measure of severity was .55 (P b and correlated only moderately with the DY-BOCS Global
.01) for the Symmetry subscale of the DY-BOCS. Although Severity score. This suggests that the Spanish version of the
it is still a large correlation, we did not expect to find a DY-BOCS is also capable of measuring the different
weaker level of agreement between self- and clinician- symptom dimensions of OCD without being confounded
administered measures in this dimension compared with the by other co-occurring symptoms. These results also confirm
other dimensions assessed by the DY-BOCS. A review of the relative independence of the various symptom dimen-
the rater's notes taken during the interviews revealed that 5 sions of OCD [9]. The Global Severity and Interference
patients (20% of the 25 patients who endorsed symptoms in scales of the DY-BOCS were very highly intercorrelated,
the Symmetry dimension) failed to endorse the presence of suggesting that they are possibly redundant and one of them

Table 3
Divergent validity of the DY-BOCS in a sample of 51 OCD patients
Contamination/Washing Aggressive Hoarding Symmetry/Ordering Sexual/Religious Miscellaneous
HAM-D .135 .255 −.047 .115 .424⁎⁎ .053
HAM-A .033 .373⁎ −.071 .017 .245 .108
⁎ Correlation is significant at the .05 level (2-tailed).
⁎⁎ Correlation is significant at the .01 level (2-tailed).
646 A. Pertusa et al. / Comprehensive Psychiatry 51 (2010) 641–648

could be eliminated without losing valuable information and considered as a standalone disorder [29]. In this study, all
therefore shortening the administration time. participants were screened for the presence of clinically
The DY-BOCS Global Severity scale correlated strongly significant hoarding symptoms (in conjunction with another
with the clinician-administered Y-BOCS obsessions, com- project undertaken by the research team) that would meet
pulsions, and total scores, suggesting that the DY-BOCS Frost and Hartl's criteria for pathologic hoarding behavior,
continues to provide valid overall estimates of global OCD sometimes referred to as “Compulsive Hoarding Syndrome”
symptom severity [12]. One strength of our study is that we [30] or, more recently, “Hoarding Disorder” [31]. Because
assessed the convergent validity of every specific dimen- none of the participants in our sample endorsed hoarding
sion of the DY-BOCS with another instrument capable of symptoms severe enough to meet these criteria, the hoarding
quantitatively assessing the severity of OC symptom obsessions/compulsions captured by the DY-BOCS and the
dimensions—the OCI-R. The convergent validity of the OCI-R are likely to be either subclinical presentations of the
DY-BOCS component scores with their corresponding Compulsive Hoarding Syndrome, or symptoms related to
subscales in the OCI-R was overall good. However, as other obsessive-compulsive dimensions. Previous studies
expected, some subscales of the DY-BOCS were signifi- have reported higher prevalence of symmetry/order obses-
cantly correlated with more than 1 subscale of the OCI (eg, sions and compulsions among OCD patients who scored
the Contamination/Washing subscale of the DY-BOCS high on hoarding [28,32-34].
significantly correlated both with the Washing and the The divergent validity of the DY-BOCS was adequate.
Ordering subscales of the OCI-R). According to the As expected, the correlations between the DY-BOCS
multidimensional model of OCD [9], obsessive-compulsive subscales and the HAM-D and HAM-A ranged from small
symptom dimensions are “a spectrum of potentially over- to moderate and were generally smaller than the correlations
lapping syndromes that may coexist in any patient.” For among OCD scales. The DY-BOCS Sexual/Religious and
example, a patient who feels compelled to repeatedly wash Aggressive scores showed moderate correlations with the
her hands in order to feel “just right” (and not because of HAM-D and HAM-A, respectively. These results are
fear of contamination) would score both in the Contami- partially in agreement with those reported in the original
nation subscale of the OCI-R (item #17 reads “I wash my validation study [12], where the authors found that the
hands more often and longer than necessary”) and in the Aggressive subscale had the strongest correlations with the
Symmetry subscale of the DY-BOCS (ie, “doing and re- HAM-D and HAM-A scores.
doing and the need for things to be just-right”). Thus, these The Miscellaneous dimension comprises several different
“hybrid” symptom combinations (ie, the combination of an obsessive-compulsive symptoms (eg, about disease, super-
obsession from one dimension with a compulsion from stitious fears/behaviors, obsessions about food, and patho-
another) may at least partially account for cross-dimension- logic grooming behaviors such as skin picking or
al correlations. There is an ongoing debate on whether the trichotillomania). This dimension showed moderate correla-
classification of obsessive-compulsive symptoms into a tions with the Contamination/Washing and the Symmetry/
specific dimension (ie, Washing, Symmetry, etc) should be Ordering dimensions of the DY-BOCS, suggesting that
primarily based on the nature of the obsessive thought or some of the symptoms included in the Miscellaneous
sensation, or rather on the type of compulsive behavior dimension might be associated with these dimensions. It is
performed by the patient. As Summerfeldt et al [13,27] unclear whether some symptoms included in the miscella-
have rightly pointed out, a classification system that neous dimension may constitute 1 or more independent
exclusively relies on overt symptoms (eg, checking) can dimensions. Large-scale item-level principal component
be problematic because the same behaviors can have analyses of each individual item of the DY-BOCS will be
different underlying causes and motivations. The DY- required to answer this question. With the data at hand,
BOCS addresses this important issue by including compul- however, it seems clear that some of the symptoms now
sions, such as checking and mental rituals (both of which included in the miscellaneous dimension are likely to
tend to appear in response to a variety of motivations), in become part of the other already existing subscales.
each symptom dimension, so that the emphasis is now on This study is not without limitations. First, the sample size
the main motivation behind the symptom. (n = 51) is smaller than the sample used in the original
In our sample, the Hoarding subscale of the DY-BOCS validation study (n = 137). However, all obsessive-
showed significant correlation with the Ordering subscale of compulsive symptom dimensions (except for possibly the
the OCI-R, but not with the Symmetry subscale of the DY- hoarding dimension) were well represented in our sample.
BOCS. A possible explanation is the fact that 2 of the 3 OCI- On the other hand, the fact that we have been able to replicate
R symmetry items (“I get upset if objects are not arranged the psychometric properties found in the original validation
properly” and “I need things to be arranged in a particular study in a smaller sample speaks for the robustness of the
order”) address worries that are frequently common in psychometric properties DY-BOCS. Second, our sample was
individuals with hoarding. In recent years, the status of entirely an adult one, so our results cannot be generalized to
hoarding as a symptom of OCD has been called into question the pediatric OCD population. Third, although interrater
[28], and some authors have proposed that hoarding be reliability was determined for a subset of 15 (21.2%) patients
A. Pertusa et al. / Comprehensive Psychiatry 51 (2010) 641–648 647

of the sample, ideally the number of interviews used to rate Because the ordinal scales used for assessing the 3
the interrater reliability would have been larger. Fourth, like severity domains have been expanded from 5 anchor points
in the original validation study, we did not evaluate test- in the Y-BOCS to 6 anchor points in the DY-BOCS, the
retest reliability, nor did we assess the sensitiveness to latter should be more capable of measuring subclinical OC
change of the DY-BOCS. Therefore, our results should be symptoms in people who do not fulfill OCD criteria
interpreted with caution when using the DY-BOCS as the according to the current classifications [4]. In this study,
outcome measure in treatment studies. Future studies should the DY-BOCS was only administered to patients with a
address this issue. confirmed OCD diagnosis. The refinement of the assessment
of subjects with subclinical presentations of OCD might help
4.1. Shortcomings of the DY-BOCS and suggestions assess more accurately family members presenting with OC
for improvement symptoms below the threshold for a DSM-IV diagnosis in
genetic studies [35], as well as OC behaviors and mental
As mentioned in the original validation paper, one states that otherwise healthy individuals may experience in
limitation of the DY-BOCS is the time required to certain periods of life (ie, childbirth), in which a diagnosis of
administer it. According to the original validation study, OCD would be inappropriate. Thus, the psychometric
an average patient needs approximately 40 minutes to properties of the DY-BOCS in nonclinical populations
complete the self-administered version, and the expert rater remain to be studied.
requires approximately 49 minutes to administer the Although the use of the DY-BOCS in clinical settings
clinician version [12]. In our sample, patients took an may provide the clinician with a valuable perspective on the
average of 46 minutes (range, 9-180 minutes) to complete dimensional landscape of their patients' obsessive-compul-
the self-administered version, and raters required approxi- sive symptoms, its use in research studies may or may not
mately 54 minutes to administer the clinician version. outweigh the time cost associated with their use. Nonethe-
However, it should be noted that the administration time can less, given that a dimensional approach to OC symptoms
be shortened if the rater was interested only in the scores for may have heuristic value in genetic, neurobiologic, comor-
every dimension plus the global score, rather than having to bidity, and treatment response studies [9,36], the use of the
enquire about the presence of every individual item. In our DY-BOCS in research studies is likely to provide new and
experience, the time required by the patients to complete the relevant information about the multidimensionality of OCD
self-report version may be an issue especially for certain and therefore contribute to these areas of knowledge in the
patients with reading-related symptoms (eg, checking or field of OCD.
rereading compulsions).
Interestingly, after completing the self-administered 4.2. Conclusions
version and reviewing it with the expert rater, a number of The results of the present study confirm that the
participants reported that their knowledge about their psychometric properties of the Spanish version of the
disorder had significantly increased (ie, they were able to DY-BOCS are excellent. Therefore, it can be used to
identify obsessions/compulsions that they previously con- assess obsessive-compulsive symptom within the Spanish-
sidered normal behaviors and vice versa), as did their speaking world.
awareness on the severity and impact of the disease on their
lives. On the other hand, reviewing the comprehensive Acknowledgment
checklist with the patient might provide the clinician with
valuable information on obsessions/compulsions that had not We would like to thank J.F. Leckman and M.C. Rosario
been previously self-reported by the patient. This might be for their help in reviewing the back-translated version of the
especially relevant in psychotherapy settings where the DY-BOCS, for training the authors to administer the DY-
identification of all significant obsessive-compulsive symp- BOCS, and for their valuable comments on the manuscript.
toms is desirable. We would also like to thank Ana López for helping with
When completing the self-administered version, a number the ratings.
of patients endorsed items that were subsequently not
regarded as disabling obsessions/compulsions by the expert
rater. Likewise, some patients misinterpreted or under-
reported some of their symptoms. The clinician should [1] Goodman WK, Price LH, Rasmussen SA, Mazure C, Delgado P,
therefore check for the presence of every item, regardless of Heninger GR, et al. The Yale-Brown Obsessive-Compulsive Scale. II.
whether or not it has been previously endorsed by the patient Validity. Arch Gen Psychiatry 1989;46(11):1012-6.
in the self-report version. According to our experience in [2] Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL,
administering the DY-BOCS, rewording some of its items Hill CL, et al. The Yale-Brown Obsessive-Compulsive Scale. I.
Development, use, and reliability. Arch Gen Psychiatry 1989;46(11):
and adding more examples may result in a better compre- 1006-11.
hension by the patient, leading to less incorrect attributions [3] Hohagen F, Winkelmann G, Rasche-Ruchle H, Hand I, Konig A,
or lack of endorsement of relevant items. Munchau N, et al. Combination of behaviour therapy with fluvoxamine
648 A. Pertusa et al. / Comprehensive Psychiatry 51 (2010) 641–648

in comparison with behaviour therapy and placebo. Results of a [19] Hamilton M. A rating scale for depression. J Neurol Neurosurg
multicentre study. Br J Psychiatry Suppl 1998(35):71-8. Psychiatry 1960;23:56-62.
[4] Frost RO, Steketee G, Krause MS, Trepanier KL. The relationship of [20] Ramos-Brieva JA, Cordero-Villafafila A. A new validation of the
the Yale-Brown Obsessive-Compulsive Scale (YBOCS) to other Hamilton Rating Scale for Depression. J Psychiatr Res 1988;22(1):
measures of obsessive-compulsive symptoms in a nonclinical 21-8.
population. J Pers Assess 1995;65(1):158-68. [21] Maier W, Buller R, Philipp M, Heuser I. The Hamilton Anxiety Scale:
[5] Moritz S, Meier B, Kloss M, Jacobsen D, Wein C, Fricke S, et al. reliability, validity and sensitivity to change in anxiety and depressive
Dimensional structure of the Yale-Brown Obsessive-Compulsive Scale disorders. J Affect Disord 1988;14(1):61-8.
(Y-BOCS). Psychiatry Res 2002;109(2):193-9. [22] Lobo A, Chamorro L, Luque A, Dal-Re R, Badia X, Baro E.
[6] Woody SR, Steketee G, Chambless DL. Reliability and validity of the Validation of the Spanish versions of the Montgomery-Asberg depres-
Yale-Brown Obsessive-Compulsive Scale. Behav Res Ther 1995;33 sion and Hamilton anxiety rating scales. Med Clin (Barc) 2002;118
(5):597-605. (13):493-9.
[7] Deacon BJ, Abramowitz JS. The Yale-Brown Obsessive-Compulsive [23] Foa EB, Huppert JD, Leiberg S, Langner R, Kichic R, Hajcak G, et al.
Scale: factor analysis, construct validity, and suggestions for The Obsessive-Compulsive Inventory: development and validation of
refinement. J Anxiety Disord 2005;19(5):573-85. a short version. Psychol Assess 2002;14(4):485-96.
[8] Amir N, Foa EB, Coles M. Factor Structure of the Yale-Brown [24] Fullana MA, Tortella-Feliu M, Caseras X, Andion O, Torrubia R,
Obsessive-Compulsive Scale (YBOCS). Psychol Assess 1997;9: Mataix-Cols D. Psychometric properties of the Spanish version of the
312-6. Obsessive-Compulsive Inventory–Revised in a non-clinical sample.
[9] Mataix-Cols D, Rosario-Campos MC, Leckman JF. A multidimen- J Anxiety Disord 2005;19(8):893-903.
sional model of obsessive-compulsive disorder. Am J Psychiatry 2005; [25] Abramowitz JS, Deacon BJ. Psychometric properties and construct
162(2):228-38. validity of the Obsessive-Compulsive Inventory–Revised: replication
[10] Mataix-Cols D, Fullana MA, Alonso P, Menchon JM, Vallejo J. and extension with a clinical sample. J Anxiety Disord 2006.
Convergent and discriminant validity of the Yale-Brown Obsessive- [26] Cohen J. Statistical power analysis for the behavioral sciences. Revised
Compulsive Scale Symptom Checklist. Psychother Psychosom 2004; edition. New York: Academic Press; 1977.
73(3):190-6. [27] Summerfeldt LJ. Understanding and treating incompleteness in
[11] Sulkowski ML, Storch EA, Geffken GR, Ricketts E, Murphy TK, obsessive-compulsive disorder. J Clin Psychol 2004;60(11):1155-68.
Goodman WK. Concurrent validity of the Yale-Brown Obsessive- [28] Pertusa A, Fullana MA, Singh S, Alonso P, Menchon JM, Mataix-Cols
Compulsive Scale-Symptom Checklist. J Clin Psychol 2008;64(12): D. Compulsive hoarding: OCD symptom, distinct clinical syndrome,
1338-51. or both? Am J Psychiatry 2008;165(10):1289-98.
[12] Rosario-Campos MC, Miguel EC, Quatrano S, Chacon P, Ferrao Y, [29] Pertusa A, Frost R, Fullana MA, Samuels J, Steketee G, Tolin D, et al.
Findley D, et al. The Dimensional Yale-Brown Obsessive-Compulsive Refining the diagnostic boundaries of compulsive hoarding: a critical
Scale (DY-BOCS): an instrument for assessing obsessive-compulsive review. Clin Psychol Rev 2010. doi:10.1016/j.cpr.2010.01.007.
symptom dimensions. Mol Psychiatry 2006;11(5):495-504. [30] Frost RO, Hartl TL. A cognitive-behavioral model of compulsive
[13] Summerfeldt LJ, Richter MA, Antony MM, Swinson RP. Symptom hoarding. Behav Res Ther 1996;34(4):341-50.
structure in obsessive-compulsive disorder: a confirmatory factor- [31] Mataix-Cols D, Frost RO, Pertusa A, Clark LA, Leckman JF, Saxena
analytic study. Behav Res Ther 1999;37(4):297-311. S, et al. Hoarding disorder: a new diagnosis for DSM-V? Depres
[14] Harsanyi A, Csigo K, Demeter G, Rajnai C, Nemeth A, Racsmany M. Anxiety 2010. (In Press)
Hungarian translation of the Dimensional Yale-Brown Obsessive- [32] Samuels JF, Bienvenu 3rd OJ, Pinto A, Fyer AJ, McCracken JT, Rauch
Compulsive Scale and our first experiences with the test. Psychiatr SL, et al. Hoarding in obsessive-compulsive disorder: results from the
Hung 2009;24(1):18-59. OCD Collaborative Genetics Study. Behav Res Ther 2007;45(4):
[15] Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller 673-86.
E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): [33] Baer L. Factor analysis of symptom subtypes of obsessive-compulsive
the development and validation of a structured diagnostic psychiatric disorder and their relation to personality and tic disorders. J Clin
interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59(Suppl Psychiatry 1994;55(Suppl):18-23.
20):22-33 [quiz 4-57]. [34] Bloch MH, Landeros-Weisenberger A, Rosario MC, Pittenger C,
[16] Bobes J. A Spanish validation study of the mini international Leckman JF. Meta-analysis of the symptom structure of obsessive-
neuropsychiatric interview. Eur Psychiatry 1998;13(4):198s-9s. compulsive disorder. Am J Psychiatry 2008;165(12):1532-42.
[17] Lecrubier Y, Sheehan DV, Weiller E, Amorim P, Bonora I, Sheehan [35] Miguel EC, Leckman JF, Rauch S, do Rosario-Campos MC, Hounie
KH, et al. The Mini International Neuropsychiatric Interview (MINI). AG, Mercadante MT, et al. Obsessive-compulsive disorder pheno-
A short diagnostic structured interview: reliability and validity types: implications for genetic studies. Mol Psychiatry 2005;10(3):
according to the CIDI. Eur Psychiatry 1997;12(5):224-31. 258-75.
[18] Vega-Dienstmaier JM, Sal YRHJ, Mazzotti Suarez G, Vidal H, [36] Miguel EC, Leckman JF, Rauch S, do Rosario-Campos MC, Hounie
Guimas B, Adrianzen C, et al. Validation of a version in Spanish of the AG, Mercadante MT, et al. Obsessive-compulsive disorder pheno-
Yale-Brown Obsessive-Compulsive Scale. Actas Esp Psiquiatr 2002; types: implications for genetic studies. Mol Psychiatry 2004;10(3):
30(1):30-5. 258-75.