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Screening for Obsessive and Compulsive Symptoms: Validation of the Clark-

Beck Obsessive-Compulsive Inventory.

Article in Psychological Assessment · July 2005

DOI: 10.1037/1040-3590.17.2.132 · Source: PubMed

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Psychological Assessment Copyright 2005 by the American Psychological Association
2005, Vol. 17, No. 2, 132–143 1040-3590/05/$12.00 DOI: 10.1037/1040-3590.17.2.132

Screening for Obsessive and Compulsive Symptoms: Validation of the

Clark–Beck Obsessive–Compulsive Inventory

David A. Clark Martin M. Antony

University of New Brunswick St. Joseph’s Healthcare and McMaster University

Aaron T. Beck Richard P. Swinson

University of Pennsylvania St. Joseph’s Healthcare and McMaster University

Robert A. Steer
University of Medicine and Dentistry of New Jersey

The 25-item Clark–Beck Obsessive–Compulsive Inventory (CBOCI) was developed to assess the
frequency and severity of obsessive and compulsive symptoms. The measure uses a graded-response
format to assess core symptom features of obsessive– compulsive disorder (OCD) based on Diagnostic
and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria
and current cognitive– behavioral formulations. Revisions were made to the CBOCI on the basis of
psychometric and item analyses of an initial pilot study of clinical and nonclinical participants. The
construct validity of the revised CBOCI was supported in a subsequent validation study involving OCD,
nonobsessional clinical, and nonclinical samples. A principal-factor analysis of the 25 items found 2
highly correlated factors of Obsessions and Compulsions. OCD patients scored significantly higher on
the measure than nonobsessional anxious, depressed, and nonclinical samples. The questionnaire had
strong convergent validity with other OCD symptom measures but more modest discriminant validity.

Keywords: obsessive– compulsive disorder, OCD, obsessions, compulsions, assessment of OCD, Clark–
Beck Obsessive–Compulsive Inventory

Obsessive– compulsive disorder (OCD) is a primary anxiety

David A. Clark, Department of Psychology, University of New Bruns-
wick, Fredericton, New Brunswick, Canada; Martin M. Antony and Rich-
ard P. Swinson, Anxiety Treatment and Research Centre, St. Joseph’s
Healthcare, Hamilton, Ontario, Canada, and Department of Psychiatry and
Behavioural Neurosciences, McMaster University, Hamilton, Ontario,
Canada; Aaron T. Beck, Department of Psychiatry, University of Pennsyl-
vania; Robert A. Steer, Department of Psychiatry, School of Osteopathic
Medicine, University of Medicine and Dentistry of New Jersey.
This research was supported by a grant from the Foundation of Cogni-
tive Therapy and Research awarded to David A. Clark. We thank Cory
Newman, Gregory Brown, and Margaret Richter for providing access to
some of the data in the validation study. Michael Kyrios and Thomas
Unger assisted in data collection for the pilot study. We are grateful to
Andrea Liss, Laura Rocca, Noam Lindenboim, Adrienne Wang, Marvin
Claybourn, and Nick Lowther for their assistance with data collection and
entry. Gratitude is expressed to Darcy Santor, who ran the item response
analyses. A copy of the Clark–Beck Obsessive–Compulsive Inventory and
manual can be purchased from the Psychological Corporation, 55 Aca-
demic Court, San Antonio, TX 78204-2498; Web site: www.psychcorp
.com.
David A. Clark and Aaron T. Beck are authors of the Clark-Beck
Obsessive–Compulsive Inventory, which is published by the Psychological
Corporation.
Correspondence concerning this article should be addressed to David A.
Clark, Department of Psychology, University of New Brunswick, Bag
Service #45444, Fredericton, New Brunswick E3B 6E4, Canada. E-mail:
clark@unb.ca
disorder characterized by persistent, recurrent, and uncontrolled
obsessions and compulsions that are time consuming or that cause
marked distress or impairment in daily functioning (American
Psychiatric Association, 1994). Obsessions are intrusive, recurrent,
and persistent unwanted thoughts, images, or impulses that are
experienced as unacceptable, upsetting, and uncontrollable, and
they usually give rise to subjective resistance (Rachman & Hodg-
son, 1980). Compulsions, on the other hand, are repetitive, inten-
tional behavioral or mental responses that are subjectively expe-
rienced as an urge to act, are performed according to certain rules
or in a stereotypic fashion, and are intended to reduce anxiety or
prevent the anticipated negative consequences associated with an
obsession (Hollander & Wong, 2000; Rachman & Shafran, 1998).
OCD has a lifetime prevalence of 1% to 2% in the general
population (Antony, Downie, & Swinson, 1998). Moreover ele-
vated rates of obsessive– compulsive (OC) symptoms and subclin-
ical OCD can be found in the general population as well as in other
clinical disorders such as depression, generalized anxiety disorder,
tic disorders, and OC spectrum disorders (see reviews by D. A.
Clark, 2004; Gibbs, 1996; Hollander & Wong, 2000; Leckman,
1993; O’Connor, 2001). There is also a high comorbid rate of
depression and other anxiety disorders in OCD (Brown, Campbell,
Lehman, Grisham, & Mancill, 2001; Crino & Andrews, 1996) that
complicates the detection and measurement of symptoms. Given
the broad and variable distribution of obsessive and compulsive

132
 CLARK–BECK OBSESSIVE–COMPULSIVE INVENTORY
symptoms in both clinical and nonclinical populations, a brief
symptom-screening instrument would be a useful clinical tool for
providing the initial detection of OC symptoms.
At present, various instruments are available to assist in the
diagnosis and measurement of OCD. The most widely accepted
measure is the Yale–Brown Obsessive–Compulsive Inventory
(YBOCS), which consists of a 64-item checklist of past and
current obsessions and compulsions followed by a 10-item clini-
cian rating scale that assesses the severity of obsessions and
compulsions independent of the content or number of symptoms
(Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989;
Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989).
The YBOCS has high interrater reliability for the 10 core severity
items (Goodman, Price, Rasmussen, Mazure, Fleischmann, et al.,
1989; Nakagawa, Marks, Takei, De Araujo, & Ito, 1996; Woody,
Steketee, & Chambless, 1995), although support for the internal
consistency of the YBOCS Obsessions and Compulsions subscales
has been mixed (Amir, Foa, & Coles, 1997; Goodman, Price,
Rasmussen, Mazure, Fleischmann, et al., 1989; Richter, Cox, &
Direnfeld, 1994; Steketee, Frost, & Bogart, 1996; Woody et al.,
1995). It has good convergent validity and sensitivity to treatment
effects, but discriminant validity may be weaker (see reviews by
Antony, 2001; Feske & Chambless, 2000; Taylor, 1995, 1998;
Taylor, Thordarson, & Söchting, 2002).
Although the YBOCS is considered the “gold standard” for
measuring OC symptoms (Steketee, 1994), it has a number of
significant limitations. The instrument is time-consuming to ad-
minister and requires trained interviewers (Taylor, 1995). The
factorial validity of the YBOCS has not been clearly supported
(Amir et al., 1997), it has weak discriminant validity as evidenced
by significant correlations with depression measures, and at times
its correlations with other standardized self-report OCD measures
have been unexpectedly low (e.g., Goodman, Price, Rasmussen,
Mazure, Delgado, et al., 1989; Obsessive Compulsive Cognitions
Working Group, 2003; Woody et al., 1995). For these reasons,
other measures of OC symptoms are needed to supplement the
YBOCS.
A number of self-report symptom measures have also been
developed to assess the frequency and severity of obsessions and
compulsions (for a comprehensive review, see Antony, 2001;
D. A. Clark, 2004; Feske & Chambless, 2000; Steketee, 1993,
1994; Taylor, 1995, 1998; Taylor et al., 2002). Three of these
instruments are of particular relevance to the development of the
current measure.
Hodgson and Rachman (1977) constructed the 30-item Mauds-
ley Obsessional Compulsive Inventory (MOCI) to assess the pres-
ence of different types of obsessive and compulsive complaints.
The MOCI is actually a symptom checklist (Taylor, 1998) con-
sisting of total score and four factorially derived subscales: Check-
ing, Washing, Slowness/Repetition, and Doubting/Conscientious-
ness. It has strong convergent and factorial validity (e.g.,
Emmelkamp, Kraaijkamp, & van den Hout, 1999). Positive find-
ings have supported the discriminant and criterion-related validity
of the MOCI (see reviews by Feske & Chambless, 2000; Taylor,
1998). The questionnaire, however, has several serious shortcom-
ings including (a) some items that do not directly assess OC
symptoms, (b) a dichotomous response format that limits its ability
to quantify symptom severity, and (c) an overrepresentation of
washing and checking compulsions coupled with too few items on
133
obsessional rumination (Taylor, 1995). A 52-item revision of the
MOCI was undertaken to address many of these criticisms (Thor-
darson et al., 2004).
Another self-report questionnaire that is frequently used to
measure obsessive and compulsive symptoms is the 60-item Padua
Inventory (PI) developed by Sanavio (1988). The questionnaire
consists of four factorially derived subscales and a total score:
Impaired Control Over Mental Activities, Contamination, Check-
ing, and Urges and Worries of Losing Control of Motor Behavior.
The PI, however, is highly correlated with measures of worry
(Freeston et al., 1994), so a 41-item (van Oppen, Hoekstra, &
Emmelkamp, 1995) and a 39-item (Burns, Keortge, Formea, &
Sternberger, 1996) version were proposed that eliminated items
that overlapped with worry. Good reliability and validity have
been reported for these revisions, especially the Washington State
University Revision developed by Burns et al. (1996; for reviews,
see Antony, 2001; Feske & Chambless, 2000). However the PI and
its revisions have low discriminate validity, and they fail to assess
important characteristics of OCD such as symptom duration, in-
terference, resistance, and uncontrollability. As well, certain types
of obsessions and compulsions (e.g., mental rituals, sexual intru-
sive thoughts, neutralizing responses) are not well represented
(Feske & Chambless, 2000; Foa, Kozak, Salkovskis, Coles, &
Amir, 1998).
Foa et al. (1998) developed a 42-item questionnaire, the
Obsessive–Compulsive Inventory (OCI), to assess a broader range
of obsessive and compulsive symptom content in both clinical and
nonclinical samples. The OCI scales have good internal consis-
tency and test–retest reliability, and OCD patients score signifi-
cantly higher on all subscales except Hoarding than other anxiety
disorders and nonclinical controls (Foa et al., 1998). It has strong
correlations with the MOCI and the Compulsive Activity Sched-
ule, but the correlation coefficients with the YBOCS are low. A
brief 18-item version of the OCI (OCI–R) was recently published,
and the authors recommend that clinicians use the OCI–R rather
than the OCI (Foa et al., 2002). However, the OCI–R may not
provide an adequate assessment of obsessions, given that only 3
items deal with obsessional symptoms. As well, the instrument has
a very high correlation with the MOCI (r ⫽ .85).
Diagnosis and assessment of OCD presents special challenges
because the assessment process can activate incapacitating obses-
sional symptoms such as indecision, perfectionism, and doubting
that heighten the respondent’s anxiousness. This can lead to non-
compliance or even to outright refusal to participate in the assess-
ment process. Thus, brief OC measures are needed that can be
included in a broad, integrated assessment battery of psychopa-
thology that strikes a balance between increased administrative
efficiency and diagnostic accuracy. In addition, a new OC symp-
tom screener might have greater clinical utility if it more equally
represented obsessive and compulsive content and severity across
the primary Diagnostic and Statistical Manual of Mental Disor-
ders (4th ed.; DSM–IV; American Psychiatric Association, 1994)
symptom domains and incorporated recent cognitive– behavioral
concepts of OCD.
A new 25-item questionnaire called the Clark–Beck Obsessive–
Compulsive Inventory (CBOCI) was developed (a) to provide a
brief screener for the frequency and severity of obsessive and
compulsive symptoms; (b) to complement the Beck Depression
Inventory–II (BDI-II; Beck, Steer, & Brown, 1996) and Beck
134 CLARK, ANTONY, BECK, SWINSON, AND STEER
Anxiety Inventory (BAI), so that a battery of highly compatible but
discriminating symptom measures can be assembled; (c) to assess
the core symptom features of OCD as indicated in DSM–IV and
current cognitive– behavioral theories of OCD; and (d) to assess
obsessive and compulsive frequency, severity, and content in a
manner that is relevant to both clinical and nonclinical population.
The psychometric properties of the instrument were investigated in
a pilot study, then in a larger validation study consisting of both
clinical and nonclinical samples that completed standard measures
of OC symptoms, anxiety, depression, and worry.
Study 1: Questionnaire Development and Revision
Development of the CBOCI began with a 27-item version of the
questionnaire. Item construction was based on a review of pub-
lished theoretical, diagnostic, and assessment literature on OCD; a
survey of existing measurement instruments; and the consensus of
an expert panel. The 27-item CBOCI was administered to four
samples, and psychometric analyses led to further revisions that
resulted in the final 25-item version. A brief summary of the pilot
study results is presented below. For more details of the pilot study
and item development, see the published manual (D. A. Clark &
Beck, 2002).
Method
Participants
The pilot study sample consisted of 56 individuals with a DSM–IV Axis
I principal diagnosis of OCD, 38 nonobsessional psychiatric outpatients, 35
nonclinical community adults, and 403 undergraduate students. Individuals
in the OCD group were drawn from a variety of sites: the Anxiety
Treatment and Research Centre at St. Joseph’s Healthcare (Hamilton,
Canada; n ⫽ 37), the Royal Melbourne Hospital (Melbourne, Australia;
n ⫽ 7), the Center for Cognitive Therapy at the University of Pennsylvania
(n ⫽ 2), and independent practice settings (n ⫽ 10). The 38 nonobsessional
depressed or anxious patients were obtained from the Center for Cognitive
Therapy, University of Pennsylvania. Individuals were excluded if they
had a primary, secondary, or tertiary OCD diagnosis. Diagnosis for most of
the clinical participants was based on the Structured Clinical Interview for
DSM–III–R (SCID; Spitzer, Williams, & Gibbon, 1987), DSM–IV
(SCID–IV; First, Gibbon, Spitzer, & Williams, 1996), or the Anxiety
Disorders Interview Schedule for DSM–IV (Brown, Di Nardo, & Barlow,
1994). The 35 nonclinical community adults were drawn from community
and church groups and from acquaintances of graduate students under
David A. Clark’s supervision. The 403 students were primarily first-year
undergraduates of the University of New Brunswick enrolled in an intro-
ductory psychology class.
Development of the CBOCI
David A. Clark developed an initial 28-item pool based on a review of
current research on diagnosis and symptom presentation in OCD as well as
on DSM–IV diagnostic criteria (American Psychiatric Association, 1994).
Items assessing each symptom construct were written with four response
statements (0 –3) reflecting increasing levels of symptom frequency or
severity. The item response format was modeled after the BDI-II. In
addition, a definition and examples of obsessions and compulsions were
provided based on the DSM–IV and the YBOCS. The instructions were
similar to the BDI-II, with respondents requested to select “the one state-
ment in each group that best describes your thoughts, feelings or behavior
during the past two weeks including today.”
The 28 items were sent to an expert panel of 10 internationally recog-
nized OCD researchers, who provided quantitative and qualitative feed-
back on the items. This resulted in a 27-item pilot version of the question-
naire that assessed 15 features of obsessions and 12 characteristics of
compulsions. The first 15 items were summed to yield an Obsessions score,
the next 12 items were summed to yield a Compulsions score, and a Total
Score was derived from the sum of the two subscales.
Measures
The BDI-II is a 21-item self-report measure designed to assess the
frequency of depressive symptoms (Beck et al., 1996). Numerous studies
have supported the reliability and validity of the BDI in clinical and
nonclinical samples (Beck, Steer, & Garbin, 1988). The more recent
version of the questionnaire (BDI-II) shares many of the same psychomet-
ric properties of the BDI and correlates .93 with the older measure (Dozois,
Dobson, & Ahnberg, 1998).
The BAI is a 21-item self-report questionnaire that assesses the severity
of anxious symptoms (Beck & Steer, 1993). The psychometric properties
of the BAI have been supported in clinical and nonclinical samples (D. A.
Clark, Steer, & Beck, 1994; Hewitt & Norton, 1993; Steer, Ranieri, Beck,
& Clark, 1993). Steer et al. (1993) reported a moderately high correlation
between the BAI and BDI (r ⫽ .61).
The Penn State Worry Questionnaire (PSWQ) is a 16-item questionnaire
that assesses a general tendency to worry independent of the content of
worry (Meyer, Miller, Metzger, & Borkovec, 1990). The PSWQ has been
used extensively in clinical and nonclinical samples, and its construct
validity has been supported (see Molina & Borkovec, 1994, for review).
However the PSWQ Total Score is moderately correlated with self-report
measures of OCD like the PI (Freeston et al., 1994) and the MOCI (Brown,
Moras, Zinbarg, & Barlow, 1993).
Two self-report questionnaires of obsessive and compulsive symptoms
were also included in the assessment battery. The Padua Inventory—
Washington State University Revision (PI–WSUR) and the self-report
version of the YBOCS were discussed in the introduction.
Procedure
Most of the OCD participants completed a battery of questionnaires at
home that included the CBOCI, BDI-II, BAI, PSWQ, and self-report
YBOCS, whereas a few participants also completed either the 60-item PI
or the PI–WSUR. The OCD patients were at various stages of treatment
when they completed the questionnaire battery. Analysis revealed that
generally the OCD patients from different sites were quite similar on the
main dependent variables of the pilot study, with the exception of those
measured on the BAI. Therefore, we felt justified in combining the OCD
patients into a single diagnostic group (n ⫽ 56).
The CBOCI was administered to the 38 nonobsessional psychiatric
patients within the first or second session of treatment. Scores on the
BDI-II and BAI were also available from the pretreatment intake assess-
ment. The 35 nonclinical community adults completed a packet of ques-
tionnaires anonymously at home that included a demographic sheet, the
CBOCI, BDI-II, BAI, PSWQ, PI–WSUR, and self-report YBOCS. There
was no screen for past or present psychiatric disorders. Some of the
participants in the student sample also completed self-report YBOCS (n ⫽
159) and the 60-item PI (n ⫽ 161) in addition to the CBOCI, BDI-II, and
BAI. PI–WSUR scores were calculated from the 39 items that correspond
to that revision of the instrument.
Results
Internal Consistency
The CBOCI subscales had satisfactory internal consistency. For
the 15-item CBOCI Obsessions subscale, ␣ ⫽ .85 for the OCD
 CLARK–BECK OBSESSIVE–COMPULSIVE INVENTORY
sample (n ⫽ 51) and ␣ ⫽ .89 for the total sample (n ⫽ 494). For
the 12-item CBOCI Compulsions subscale, ␣ ⫽ .84 for the OCD
sample (n ⫽ 54) and ␣ ⫽ .89 for the total sample (n ⫽ 499).
Group Differences
A one-way multivariate analysis of variance (MANOVA) with
the four samples and gender as between-groups factors was per-
formed on CBOCI Obsessions, Compulsions, BDI-II, and BAI.
Only the main effect of group was significant, Wilk’s ␭ ⫽ .58, F(4,
12) ⫽ 22.97, p ⬍ .01, ␩2 ⫽ .17. Follow-up F tests revealed
significant group differences on all four scales, CBOCI Obses-
sions, F(3, 460) ⫽ 53.81, p ⬍ .01, ␩2 ⫽ .26; CBOCI Compulsions,
F(3, 460) ⫽ 59.99, p ⬍ .01, ␩2 ⫽ .28; BDI-II, F(3, 460) ⫽ 39.93,
p ⬍ .01, ␩2 ⫽ .21; BAI, F(3, 460) ⫽ 17.57, p ⬍ .01, ␩2 ⫽ .10.
Student Newman–Keuls post hoc comparisons indicated that the
OCD patients scored significantly higher than all other groups on
CBOCI Obsessions and Compulsions.
A series of one-way analyses of variance (ANOVAs) revealed
significant between-groups differences on CBOCI Total Score,
F(3, 514) ⫽ 77.64, p ⬍ .01, ␩2 ⫽ .31; YBOCS Total Score, F(2,
234) ⫽ 95.32, p ⬍ .01, ␩2 ⫽ .45; and PI–WSUR Total Score, F(2,
239) ⫽ 37.67, p ⬍ .01, ␩2 ⫽ .24. As expected, post hoc compar-
isons indicated that the OCD sample scored significantly higher
than the community adults and students on the total scores of the
CBOCI, YBOCS, and PI–WSUR. Furthermore, the OCD group
was significantly higher than the nonobsessional psychiatric pa-
tients on CBOCI Total Score. The group differences on the CBOCI
are in the predicted direction and therefore provide support for the
criterion-related validity of the measure.
Correlations With Other Measures
The CBOCI Obsessions and Compulsions subscales were highly
correlated in the OCD (r ⫽ .67, p ⬍ .01) and nonclinical (r ⫽ .61,
p ⬍ .01) samples. Support for the concurrent validity of the
CBOCI was evident as all three scales (CBOCI Obsessions, Com-
pulsions, and Total Score) were highly correlated with the self-
report YBOCS and PI–WSUR Total Scores in both OCD and
nonclinical samples (rs ranged from .48 to .80). However the
CBOCI scales were also moderately correlated with the BDI-II and
BAI (rs of .26 to .54). The CBOCI Total Score and PSWQ Total
Score were significantly correlated in the OCD (r ⫽ .68, p ⬍ .01)
and nonclinical (r ⫽ .38, p ⬍ .05) samples.
Item Analysis
To assess the discriminability of individual questionnaire items,
we conducted three types of item analyses. A series of one-way
ANOVAs performed on the 27 CBOCI items indicated that the
OCD patients scored significantly higher than the nonobsessional
psychiatric patients on all items except obsessional impulses,
doubting, perfectionism, and indecision. As well, the OCD patients
did not score significantly higher than the nonclinical samples on
the obsessional impulse item. A principal-components analysis
with varimax rotation performed on the total sample (N ⫽ 478)
revealed that all but 5 CBOCI items loaded ⱖ .40 on a single factor
(frequency of moral/religious obsessions: .33, obsessional im-
135
pulses: .19, frequency of washing compulsions: .32, frequency of
precision/symmetry: .39, and hoarding: .32).
The third set of analyses involved calculating response-
characteristic curves to determine how well each item discrimi-
nated at varying levels of symptom severity as a function of the
probability of endorsing an item option statement (Santor, Ram-
say, & Zuroff, 1994). If the probability of endorsing higher item
response levels changes as a function of OC symptom severity,
then the item is a good discriminator (Ramsay, 1993; Santor,
Zuroff, Ramsay, Cervantes, & Palacios, 1995). Response charac-
teristic curves were calculated first for the OCD sample (n ⫽ 56)
and then for the student sample (n ⫽ 403). A second item response
analysis plotted the expected item score against the CBOCI Total
Score for the OCD, nonobsessional psychiatric, community adult,
and student samples.
Inspection of the response-characteristic curves revealed that 18
CBOCI items did not show optimal discrimination at increasing
levels of symptom severity because the OCD patients and students
rarely endorsed the fourth option. This indicates that the threshold
for these items may have been set too high. Analysis of the
expected item score also indicated that 4 items (frequency of
harm/aggression obsessions, frequency of moral/religious obses-
sions, obsessional impulses, and hoarding) had even more serious
problems because the “0” option was more likely endorsed at all
levels of severity.
Overall, the findings from the pilot study suggested that the
CBOCI Obsessions and Compulsive subscales and Total Score had
acceptable internal consistency as well as good convergent and
criterion-related validity. However, it was also clear that discrimi-
nant validity was weaker and that many of the items should be
rewritten to improve their ability to more accurately discriminate
at varying levels of OC symptom severity. Thus, an extensive
revision of the questionnaire was conducted on the basis of these
findings. Two items were deleted, obsessional impulse and hoard-
ing, because they consistently failed to differentiate OC symptoms.
In addition, 13 items were rewritten to improve their sensitivity to
symptom severity and their ability to discriminate OCD patients.
The revised 25-item CBOCI consists of a 14-item Obsessions
subscale and an 11-item Compulsions subscale.
Study 2: Validation of the Revised Measure
A second study was undertaken to determine the psychometric
properties of the revised CBOCI. This also provided an opportu-
nity to improve on the research design of the pilot study. A larger
sample of OCD patients was recruited from a single treatment
setting, an expanded sample of nonobsessional psychiatric patients
was obtained that allowed direct comparisons with specific diag-
nostic groups, and a subset of the student sample was retested to
investigate the test–retest reliability of the CBOCI.
Method
Participants
The sample consisted of 83 OCD patients, 43 non-OCD patients with
other anxiety disorders, 32 nonobsessional depressed patients, 26 nonclini-
cal community adults, and 308 undergraduate students. None of the indi-
viduals in this sample participated in the pilot study. The OCD group was
drawn from the Anxiety Treatment and Research Centre at St. Joseph’s
136 CLARK, ANTONY, BECK, SWINSON, AND STEER

Healthcare (Hamilton, Canada). The patient edition of the SCID–IV Re-
search Version (First et al., 1996) was used to establish the principal
DSM–IV Axis I diagnosis. Eighty-two individuals in the OCD group had a
principal diagnosis of OCD, and 1 was diagnosed with an anxiety disorder
(OCD) in partial remission. Sixty-eight OCD patients (81.9%) had one or
more additional diagnoses primarily consisting of depression and/or other
anxiety disorders.
Half (n ⫽ 21) of the nonobsessional anxious group was drawn from the
Hamilton site and the remainder (n ⫽ 22) was recruited from the Center for
Cognitive Therapy, University of Pennsylvania, Philadelphia. Participants
drawn from the Philadelphia site were diagnosed with the Outpatient
Version of the SCID–IV (First et al., 1996). The diagnostic composition of
the sample consisted of panic disorder with or without agoraphobic avoid-
ance (n ⫽ 20, 46.5%), social phobia (n ⫽ 10, 23.3%), specific phobia (n ⫽
2, 4.7%), generalized anxiety disorder (n ⫽ 8, 18.6%), and other anxiety
disorder (n ⫽ 3, 7%). Twenty-eight (65.1%) participants had one or more
additional diagnoses. Individuals with a secondary or tertiary diagnosis of
OCD were excluded from the study.
The depressed sample consisted of 31 participants from the Philadelphia
site and 1 patient with major depression from the Hamilton setting who did
not have a comorbid diagnosis of OCD. The principal Axis I diagnosis of
the sample included major depression (n ⫽ 22, 68.7%); dysthymic disorder
(n ⫽ 4, 12.5%); bipolar disorder, with depressed mood the most recent
episode (n ⫽ 5, 15.6%); and depressed mood due to a general medical
condition (n ⫽ 1, 3.1%). Eighteen (56.3%) had one or more additional
diagnoses.
Eleven (42.3%) of the nonclinical community adult sample came from
the Hamilton setting, and 15 (57.7%) were recruited in Fredericton, Can-
ada. The Hamilton controls were screened for disorders via telephone
interview based on the SCID–IV screening questions, whereas a written
version of this screener was included in the questionnaire packet given to
the Fredericton sample.
The questionnaire battery was completed by 359 introductory psychol-
ogy undergraduates at the University of New Brunswick, Canada. Students
who indicated they received psychiatric or psychological treatment were
excluded from further analysis (except for the confirmatory factor analysis
[CFA]), leaving a final student sample of 308.
Table 1 presents the demographic characteristics across the four sam-
ples. Chi-square analyses of gender, ␹2(4, N ⫽ 488) ⫽ 6.05, ns, and
ethnicity ␹2(4, N ⫽ 478) ⫽ 7.19, ns, were not significant, although the
groups did differ in relationship (married vs. single) status, ␹2(4, N ⫽
485) ⫽ 131.71, p ⬍ .01, ␩2 ⫽ .38, and age, F(4, 484) ⫽ 178.19, p ⬍ .01,
␩2 ⫽ .60. A significantly greater proportion of the students were single,
whereas a higher percentage of the community adults were married. The
students were significantly younger than all other groups, whereas the
OCD group was significantly younger than the two clinical controls and the
community adult group. There was no significant difference between the
OCD, anxious, depressed, or community adult groups in proportion with or
without exposure to postsecondary education, ␹2(3, N ⫽ 165) ⫽ 5.50, ns.
Measures
The same measures that are described in the pilot study were used in the
present investigation.
Procedure
Individuals in the OCD group completed the CBOCI, self-report
YBOCS, BDI-II, BAI, PI–WSUR, and the PSWQ at intake after the
diagnostic interview. Participation was on a voluntary basis, with the
assessment packet completed at home and returned to the clinic on a
subsequent visit. Participants from the Center for Cognitive Therapy in
Philadelphia also completed the CBOCI, BDI-II, and BAI at intake. Inde-
pendent t tests indicated that individuals with an anxiety diagnosis from the
Hamilton site were significantly older, t(41) ⫽ 2.2, p ⬍ .05, and had a
higher BAI score, t(40) ⫽ 2.8, p ⬍ .01, than the Philadelphia patients.
There were no significant differences on the CBOCI or BDI-II. The
university student sample completed the entire questionnaire battery in
large groups for course credit.
The 11 individuals from the Hamilton site who were included in the
nonclinical community adult sample were recruited from the community
via advertisements and word-of-mouth for another research project con-
ducted at the Anxiety Treatment and Research Centre, whereas the 15
Fredericton community adults were drawn from friends and family of

Table 1
Demographic Characteristics of the Validation Sample

OCD Anxious Depressed Adult Student

Variable n % n % n % n % n %

Gender
Women 51 61 30 70 14 44 19 73 197 64
Men 32 39 12 28 16 50 7 27 110 36
Ethnicity
White 69 83 38 88 25 78 23 89 291 95
Other 8 10 3 7 4 13 3 11 14 5
Marital status
Single 43 52 21 49 14 44 6 23 294 96
Married 34 41 18 42 8 25 17 65 11 4
Separated 5 6 3 7 7 22 3 12 1
Education
Less than HS 9 11 4 9
HS diploma 29 35 19 44 7 22 10 39
University 34 41 12 28 15 47 8 31 289 94
Graduate level 9 11 6 14 7 22 8 31 10 3

Note. Sample age, in years, means (and standard deviations) are as follows: obsessive– compulsive disorder
(OCD), 34 (10); anxious, 39 (14); depressed, 40 (12); adult, 40 (11); student, 19 (3). Percentages do not sum to
100 because of missing data. Married includes cohabiting, separated includes divorced or widowed. Education
is the highest educational attainment; university includes trade or technical school education, graduate level
refers to any postgraduate education. HS ⫽ high school.
 CLARK–BECK OBSESSIVE–COMPULSIVE INVENTORY 137

Table 2
Promax-Rotated Principal-Factor Pattern Standardized Regression and Orthogonalized Schmid–
Leiman Coefficients of the Clark-Beck Obsessive–Compulsive Inventory (CBOCI) Items Based on
the Combined Clinical Sample

Principal factor analysis Schmid–Leiman analysis

General
CBOCI items Obsessions Compulsions factor Obsessions Compulsions h2

Obsessions subscale
1. Dirt/contamination .06 .68 .61 .04 .39 .53
2. Aggression/harm .60 ⫺.10 .41 .35 ⫺.06 .29
3. Religious/moral/sexual .37 ⫺.01 .29 .21 .00 .13
4. Distress .76 .00 .62 .44 .00 .58
5. Uncontrollability .87 ⫺.04 .68 .50 ⫺.02 .71
6. Salience .91 ⫺.03 .72 .52 ⫺.02 .79
7. Inflated responsibility .61 ⫺.04 .47 .35 ⫺.02 .34
8. Doubting .43 .28 .58 .25 .16 .42
9. Effort to control .88 ⫺.11 .71 .51 ⫺.01 .77
10. Pathological perfectionism .48 .22 .57 .27 .13 .41
11. Indecision .43 .27 .57 .24 .16 .41
12. Social/occupation interference .63 .24 .72 .36 .14 .66
13. Insight and fixity .88 ⫺.15 .60 .51 ⫺.08 .62
14. Cognitive avoidance .81 ⫺.11 .57 .47 ⫺.06 .55
Compulsive subscale
15. Cleaning ⫺.29 .96 .55 ⫺.17 .55 .63
16. Checking .09 .68 .63 .05 .39 .56
17. Repeating .08 .66 .60 .05 .38 .51
18. Precision, symmetry, routine ⫺.24 .90 .54 ⫺.14 .52 .58
19. Internal neutralizing .27 .48 .61 .16 .28 .48
20. Slowness ⫺.14 .93 .64 ⫺.08 .53 .70
21. Distress From Prevention .08 .73 .66 .05 .42 .62
22. Social/Occupational interference .27 .63 .74 .16 .36 .70
23. Avoidance .42 .35 .63 .24 .20 .50
24. Uncontrollability .27 .61 .72 .15 .35 .68
25. Distress of compulsions .34 .52 .70 .20 .30 .62
Total % 29 27 39 9 8 56
Common % 52 48 68 17 15 100

Note. N ⫽ 160. Salient factor loadings ⱖ .35 appear in boldface. h2 ⫽ communality estimates after extraction.

students taught by David A. Clark. Independent t tests failed to reveal
significant differences between the two sets of nonclinical community
groups on any of the questionnaires or demographic variables, with the
exception that the Fredericton adults were significantly older than the
Hamilton respondents, t(24) ⫽ 4.23, p ⬍ .01.
Results
Factorial Validity
The factor structure of the CBOCI was first investigated in a
combined clinical group that included the OCD, anxious, and
depressed samples (n ⫽ 160 after listwise deletion). The subject:
variable ratio was too low to base the analysis only on the OCD
sample, and the subject:variable ratio in the combined sample was
also too low to conduct a CFA. However, the inclusion of nonob-
sessional anxious and depressed participants increased the scoring
range, which is more conducive to factor analysis.
An initial principal-components analysis was performed to de-
termine the number of factors to extract. On the basis of Cattell’s
(1966) scree test and Kaiser’s coefficient alpha of generalizability
(Kline & Barrett, 1983), it was decided that two factors should be
retained. The first five consecutive eigenvalues were 12.19, 2.40,
1.25, 1.20, and 0.95, and the coefficient alphas of generalizability
were .96, .61, and .21 for the first three components. Clearly, the
third component did not attain an adequate level of internal con-
sistency to warrant retention.
On the basis of the combined clinical sample, we next per-
formed an iterated principal-factor analysis using the squared
multiple correlations of the items as the initial communality esti-
mates, and the two extracted factors were rotated to a Promax (k ⫽
4) oblique criterion. Kaiser’s Measure of Sampling Adequacy was
.94 (Dziuban & Shirkey, 1974), a value that Kaiser and Rice
(1974) described as “marvelous” for factor analytic purposes. A
common factor model was appropriate because there were many
very small values in the anti-image correlation matrix.1
Table 2 presents the Promax-rotated principal-factor pattern for
the 25 CBOCI items. Based on the pattern of salient (ⱖ .35)
standardized-regression coefficients, two highly correlated (r ⫽
.67, p ⬍ .01) dimensions were identifiable; the first represented
Obsessions and the second described Compulsions. All but one of
the CBOCI Obsessions items (dirt/contamination) and one of the
1
Copies of the CBOCI item intercorrelation matrix for both the com-
bined patient and student samples can be found in D. A. Clark and Beck
(2002).
138 CLARK, ANTONY, BECK, SWINSON, AND STEER

Table 3
Homogeneity and Internal Consistency Estimates for the Three CBOCI Scale Scores by Type of
Sample

OCD Combined clinical Student

(n ⫽ 75) (n ⫽ 160) (n ⫽ 343)

Scale ␻ ␣ rtot ␻ ␣ rtot ␻ ␣ rtot

Obsessions .90 .60 .93 .65 .79 .42

Compulsions .87 .59 .93 .72 .81 .47
Total Score .65 .93 .57 .77 .95 .66 .60 .86 .43

Note. ␻ ⫽ McDonald’s omega; ␣ ⫽ Cronbach’s coefficient alpha; rtot ⫽ mean corrected item-total correlation.
Sample sizes varied because of listwise deletion of missing values. Clark–Beck Obsessive–Compulsive Inven-
tory (CBOCI) total score statistics are M ⫽ 43.27, SD ⫽ 43.26, variance ⫽ 252.93 for obsessive– compulsive
disorder (OCD) sample; M ⫽ 29.53, SD ⫽ 18.99, variance ⫽ 360.53 for combined sample; M ⫽ 17.14, SD ⫽
8.74, variance ⫽ 76.34 for students.

Compulsions items (avoidance) loaded specifically on their re-
spective factor. Overall, the factor pattern provided empirical
support for the rationally determined item composition of the
Obsessions and Compulsions subscales.
Schmid–Leiman analysis. The high positive correlation be-
tween the two factors indicated that the Obsessions and Compul-
sions dimensions might be measuring a common second-order
factor of symptom distress. To investigate this possibility, we
performed a Schmid–Leiman transformation (Gorsuch, 1983;
Loehlin, 1987) to assess the common and specific dimensions of
the CBOCI. The same type of principal-factor analysis that was
performed with the 25 CBOCI items was now performed with the
two first-order factor loadings constrained to be equal. The stan-
dardized regression coefficient for both of these first-order factors
on the second-order factor was .82, with a squared-communality
estimate of .67 for each factor.
The Schmid–Leiman-transformed coefficients of the 25 CBOCI
items on the orthogonalized second-order factor and the two first-
order factors are also displayed in Table 2. The second-order factor
explained approximately 39% of the total and 68% of the common
or shared variance after the Schmid–Leiman transformation. The
percentages of orthogonalized or unique variance contributed by
the Obsessions and Compulsions factors were, respectively, 17%
and 15%. As Table 2 indicates, only Item 3 (religious/moral/
sexual) was not salient (ⱖ .35) on the second-order factor or either
of the first-order factors. Nine of the obsessions items (64%) were
salient on the orthogonalized Obsessions factor, and 8 of the
Compulsions items (73%) were salient on the orthogonalized
Compulsions factor. Three obsessions items (doubting, perfection-
ism, and indecision) and 3 compulsion items (internal neutralizing,
avoidance, and distress of compulsions) were shared variance
items exclusively. One obsessions item (dirt/contamination) con-
tinued to show specificity with the Compulsions rather than the
Obsessions orthogonalized factors.
CFA. Because there was a unselected sample of 343 under-
graduates (after listwise deletion), the ratio of the number of
participants to the number of structural equation parameters (343/
51 ⫽ 6.7) was considered acceptable. Thus, a CFA was performed
to determine whether the present scoring scheme for the Obses-
sions and Compulsions subscales would be appropriate for under-
graduate students. The first 14 CBOCI items used in scoring the
Obsessions scale were hypothesized to load on one factor, and the
remaining 11 items were hypothesized to load on a second factor.
The two factors were permitted to be correlated with each other.
All of the error and uniqueness terms for the two factors and the 25
CBOCI items were assumed to be random. The CFA was per-
formed with the SAS CALIS procedure.
The chi-square test for the CFA model was significant, ␹2(274,
N ⫽ 343) ⫽ 698.02, p ⬍ .001, indicating there was residual
variance that still remained to be explained. Bentler’s comparative
fit index, the adjusted goodness-of-fit index, and Tucker–Lewis
index were, respectively, .80, .81, and .78. These values are ⬍ .90,
which according to Hatcher (1994), suggests that the two-factor
model is an inadequate fit for this data set. However, the root-
mean-square error of approximation was .07 and ⬍ .08, suggesting
an acceptable error of approximation. We conclude that for re-
search purposes, the first 14 CBOCI items can be summed to
derive the Obsessions subscale and the last 11 items can be
summed to produce the Compulsions subscale in college student
samples.
Reliability Analyses
Internal consistency. Table 3 presents Cronbach’s alpha coef-
ficients and the mean corrected item-total correlations of the three
CBOCI scale scores for the OCD, combined clinical, and student
samples as well as McDonald’s (1999) omega coefficient for the
Total Score. McDonald’s omega coefficient is the ratio of the
variance that is explained by the common construct assumed to be
underlying a scale to the total amount of variance that is explained
by the scale. Omega is an index that may be used to evaluate
whether a set of items is sufficiently homogeneous to warrant
summing its item ratings to yield a total score.2 Because omega is
only relevant for estimating the homogeneity of a total scale,
omega coefficients were not calculated for the CBOCI subscales.
Generally the omega coefficients support the homogeneity of the
CBOCI Total Score in all three samples, although the coefficient
is somewhat lower in the OCD and student samples. This suggests
that the homogeneity of the CBOCI Total Score may be lower in
samples with a more restricted scoring range such as the OCD or
nonclinical sample. On the other hand, the mean corrected-item
2
A copy of the item means and standard deviations for each of the three
samples reported in Table 3 is available from David A. Clark.
 CLARK–BECK OBSESSIVE–COMPULSIVE INVENTORY 139

Table 4
Means, Standard Deviations, and Sample Size of the Dependent Measures for the Five Samples

OCD Depressed Anxious Community Student

Measure n M SD n M SD n M SD n M SD n M SD

CBOCI
Obsessions 83 22.07 9.81 32 13.94 8.14 43 9.40 8.12 26 3.31 3.03 303 8.69 4.62
Compulsions 83 20.07 7.85 32 8.03 6.06 43 6.19 6.54 26 1.85 2.57 303 7.66 4.89
Total Score 83 42.14 16.07 32 21.97 12.42 43 15.58 13.00 26 5.15 5.03 306 16.30 8.34
YBOCS 78 21.92 8.40 — — 20 6.80 10.24 11 1.09 2.77 290 4.04 5.18
PI–WSUR 70 46.54 30.15 — — 21 13.19 16.23 26 7.31 6.70 307 19.78 14.93
PSWQ 83 64.77 12.45 — — 21 55.86 16.59 26 38.31 16.29 299 46.47 14.05
BDI-II 80 25.61 14.44 31 23.61 11.90 42 15.45 12.48 26 3.69 4.61 297 9.42 7.02
BAI 80 19.51 14.26 31 12.52 12.79 42 17.93 15.52 26 3.08 3.17 297 9.61 7.22

Note. Dash indicates data are not available. CBOCI ⫽ Clark–Beck Obsessive–Compulsive Inventory; YBOCS ⫽ self-report Yale–Brown Obsessive–
Compulsive Scales Total Score; PI–WSUR ⫽ Padua Inventory Washington State University Revision Total Score; PSWQ ⫽ Penn State Worry
Questionnaire Total Score; BDI-II ⫽ Beck Depression Inventory–II Total Score; BAI ⫽ Beck Anxiety Inventory Total Score.

total correlations for the OCD and combined clinical samples are
well above .30, and the alpha coefficients are in the mid-.80s or
above .90. The range of the latter alpha coefficients is considered
by Cicchetti (1994) to reflect good to excellent internal consis-
tency for clinical purposes. The students’ alpha coefficients are
lower, especially for the CBOCI Obsessions subscale.
Test–retest stability. Sixty-seven students completed the same
questionnaire battery a second time after a 1 month interval (M ⫽
31.5 days, range 10 – 45 days). After deletion of missing data, the
final sample consisted of 55 students. The CBOCI Obsessions (r ⫽
.69, p ⬍ .001), Compulsions (r ⫽ .79, p ⬍ .001), and Total Score
(r ⫽ .77, p ⬍ .001) showed a moderate level of temporal stability.
There was a significant decline in the mean CBOCI Obsessions,
t(54) ⫽ 4.66, p ⬍ .001, Compulsions, t(54) ⫽ 3.79, p ⬍ .001, and
Total, t(54) ⫽ 5.01, p ⬍ .001, scores. The average CBOCI Ob-
sessions score decreased by 2.22 (SD ⫽ 3.64), Compulsions de-
creased by 1.70 (SD ⫽ 3.34), and the Total Score declined by 3.93
(SD ⫽ 5.83). However, length of time between test administrations
did not correlate with magnitude of decrease in CBOCI scoring.
The CBOCI stability coefficients were comparable to those
achieved by other measures in the questionnaire battery such as the
BDI-II (r ⫽ .81, p ⬍ .001), PSWQ (r ⫽ .74, p ⬍ .001), and BAI
(r ⫽ .65, p ⬍ .001). However, in comparison to CBOCI Total
Score, the PI–WSUR Total Score achieved an unusually high
test–retest correlation (r ⫽ .93, p ⬍ .001), whereas the YBOCS
Total Score produced a much lower test–retest coefficient (r ⫽ .52,
p ⬍ .001).
remaining samples, the anxious and student groups followed with
similar scores, and the community adults were significantly lower
than all other participants. On the CBOCI Compulsions subscale,
the depressed, anxious, and student groups were not significantly
different from each other, whereas the community adults were
again significantly lower than all groups. A one-way ANOVA on
the CBOCI Total Score was highly significant, F(4, 485) ⫽
113.73, p ⬍ .001, ␩2 ⫽ .48, with the OCD group scoring signif-
icantly higher than all other groups; the depressed, anxious, and
student groups scoring at a similar level; and the community adults
responding significantly lower than any other participants.4
As expected, significant group differences were evident on the
YBOCS Total Score, F(3, 395) ⫽ 174.04, p ⬍ .001, ␩2 ⫽ .57;
PI–WSUR Total Score, F(3, 420) ⫽ 51.39, p ⬍ .001, ␩2 ⫽ .27;
PSWQ, F(3, 425) ⫽ 42.59, p ⬍ .001, ␩2 ⫽ .23; BDI-II, F(4,
477) ⫽ 63.56, p ⬍ .001, ␩2 ⫽ .35; and the BAI, F(4, 477) ⫽ 25.87,
p ⬍ .001, ␩2 ⫽ .18. The OCD sample scored significantly higher
than all other participants on the YBOCS, PI–WSUR, and PSWQ.
Together, the depressed and OCD groups were significantly higher
on BDI-II, whereas the anxious and OCD groups had significantly
elevated scores on the BAI. Once again, the expected pattern of
group differences on the CBOCI scales supports the criterion-
related validity of the measure. Moreover, the CBOCI and YBOCS
total scores clearly accounted for more between-groups variance
than the PI–WSUR, PSWQ, BAI, and BDI-II.

Criterion-Related Validity: Group Comparisons 3

Table 4 presents means and standard deviations for the five
samples on the CBOCI scales and other questionnaire measures
included in the study.3 A one-way MANOVA performed on
CBOCI Obsessions and Compulsions was significant, Wilk’s ␭ ⫽
.49; F(8, 962) ⫽ 51.88, p ⬍ .001, ␩2 ⫽ .30, for both Obsessions,
F(4, 482) ⫽ 85.29, p ⬍ .001, ␩2 ⫽ .41, and Compulsions, F(4,
482) ⫽ 96.84, p ⬍ .001, ␩2 ⫽ .45. Scheffé’s post hoc comparisons
indicated that the OCD group scored significantly higher than all
other groups on both CBOCI subscales. On the Obsessions sub-
scale, the depressed group scored significantly higher than the
A series of t tests investigated gender differences on the dependent
measures within each sample. In the OCD sample, women scored signif-
icantly higher on CBOCI Compulsion, PI–WSUR, BDI-II, and BAI. There
were no significant gender differences in the anxious or community adult
samples. Women scored significantly higher than men on PSWQ in the
student sample and significantly higher on BDI-II in the depressed group.
Because no consistent gender differences emerged across samples, analy-
ses were conducted on the total sample.
4
Because the depressed sample did not complete the PI–WSUR or the
YBOCS, and part of the community adult group did not have YBOCS
scores, the CBOCI Total Score, PI—WSUR, and YBOCS were analyzed
separately.
140 CLARK, ANTONY, BECK, SWINSON, AND STEER

Convergent and Discriminant Validity
Table 5 presents the zero-order correlation matrix for the
CBOCI and other symptom measures. Correlation coefficients for
the OCD sample (n ⫽ 64 after listwise deletion) are presented
above the diagonal, whereas correlations for the nonclinical sam-
ple (adults and students combined) are found below the diagonal
(n ⫽ 282 after listwise deletion). Correlations for the nonobses-
sional depressed and anxious samples were not calculated because
of an insufficient sample size (n ⫽ 19 after listwise deletion).
The CBOCI subscales and Total Score were highly correlated
with the YBOCS subscales and PI–WSUR Total Score in both the
OCD and nonclinical samples, thus supporting the instrument’s
concurrent validity. However a z test comparison of correlated
correlation coefficients (Meng, Rosenthal, & Rubin, 1992) indi-
cated that the CBOCI Total Score correlation with the YBOCS
Total Score was not significantly greater than the PI–WSUR
correlation with the YBOCS in both the OCD (z ⫽ 0.18, ns) and
nonclinical (z ⫽ 1.20, ns) samples.
The CBOCI scales were also moderately correlated with self-
report measures of depression and anxiety. However, z test com-
parisons indicated that the CBOCI Total Score was significantly
more correlated with the PI–WSUR Total Score than with the BAI
Total Score in both the OCD (z ⫽ 2.21, p ⬍ .05, zdiff ⫽ .31) and
nonclinical (z ⫽ 3.30, p ⬍ .001, zdiff ⫽ .24) samples. Both of these
effect sizes are considered medium (Cohen, 1992). The YBOCS
Total Score, on the other hand, was significantly more correlated
with the PI–WSUR Total Score than with the BAI Total Score in
the OCD sample (z ⫽ 2.95, p ⬍ .01, zdiff ⫽ .38) but not in the
nonclinical group (z ⫽ 1.87, p ⫽ .06, zdiff ⫽ .13). The PI–WSUR
and CBOCI did not differ significantly in their correlation with the
BAI Total Score in the OCD (z ⫽ 0.15, p ⫽ .88, zdiff ⫽ .02) or the
nonclinical (z ⫽ 1.38, p ⫽ .17, zdiff ⫽ .08) samples. These findings
indicate that the CBOCI is more closely related to OC symptoms
than it is to general anxiety symptoms, thus supporting its dis-
criminant validity. There is also evidence that the CBOCI might
have slightly better discriminant validity than the YBOCS but not
than the PI–WSUR in nonclinical samples. However, the CBOCI
correlations with the BDI-II were as high as its correlations with
the YBOCS or PI–WSUR.
Another aspect of discriminant validity concerns the relation-
ship between the CBOCI and PSWQ. Previous OCD measures
have had difficulty distinguishing worry from obsessions (Freeston
et al., 1994; Turner, Beidel, & Stanley, 1992). Partial correlations
were calculated between the CBOCI scales, other measures of OC
symptoms (PI–WSUR and YBOCS Total Scores), and worry
(PSWQ). For the OCD sample, CBOCI Total Score continued to
have a high correlation with PI–WSUR Total Score (r ⫽ .78, pr ⫽
.67, p ⬍ .001) and YBOCS Total Score (r ⫽ .78, pr ⫽ .71, p ⬍
.001) after covarying PSWQ. Partialing out the YBOCS Total
Score resulted in a substantial reduction in the relationship of the
CBOCI Total Score with the PSWQ (r ⫽ .60, pr ⫽ .45, p ⬍ .001).
These findings were replicated in the student sample. Together,
these results indicate that the CBOCI has a closer relationship with
OC symptom measures than with measures of worry (see D. A.
Clark & Beck, 2002, for additional partial correlations), although
these results also confirm a close continuing relationship between
worry and obsessionality.
General Discussion
The present study reported on the development and initial val-
idation of a 25-item self-report measure of obsessive and compul-
sive symptoms intended to provide an accurate and reliable brief
assessment that could be included in a more comprehensive diag-
nostic assessment of OCD. The reliability and validity of the
CBOCI equals, or surpasses, lengthier OC symptom measures. The
integrity of the questionnaire’s two-dimensional structure was
supported by factor analysis, and the measure distinguishes indi-
viduals with OCD from those with major depression, other anxiety
disorders, and nonclinical controls. It correlates with other symp-
tom measures like the YBOCS and PI–WSUR. The similar pattern
of relations between the CBOCI and other measures in the non-
clinical samples indicates that it has relevance for clinical and
nonclinical populations, although more caution is needed when
interpreting nonclinical scores. As a 25-item questionnaire that
correlates moderately with the BDI-II and BAI, it clearly can be
used along with these other measures. The more cognitive–
behavioral items in the questionnaire, such as controllability and
fixity of belief, also had high loadings on their respective dimen-

Table 5
Zero-Order Correlation Matrix Based on the OCD Group and Combined Nonclinical Samples in the Validation Study

Measure 1 2 3 4 5 6 7 8 9 10

1. CBOCI Obsessions — .75 .95 .80 .59 .75 .69 .60 .60 .73
2. CBOCI Compulsions .56 — .92 .65 .66 .71 .77 .60 .54 .65
3. CBOCI Total Score .87 .89 — .78 .66 .78 .77 .64 .61 .75
4. YBOCS Obsessions .55 .42 .55 — .72 .93 .63 .48 .42 .59
5. YBOCS Compulsions .49 .52 .57 .72 — .92 .64 .41 .37 .44
6. YBOCS Total Score .56 .51 .60 .93 .93 — .68 .48 .42 .56
7. PI–WSUR Total Score .45 .70 .65 .46 .52 .53 — .56 .62 .70
8. PSWQ Total Score .49 .45 .53 .37 .37 .40 .44 — .51 .64
9. BAI Total Score .46 .40 .49 .39 .41 .43 .43 .56 — .80
10. BDI-II Total Score .53 .48 .57 .44 .42 .47 .45 .51 .62 —

Note. Correlations in italics above the diagonal are based on the OCD sample (n ⫽ 64 after listwise deletion; all rs are significant at p ⬍ .001).
Correlations below the diagonal are based on the combined adult and student samples (n ⫽ 282 after listwise deletion; all rs are significant at p ⬍ .001).
Note. CBOCI ⫽ Clark–Beck Obsessive–Compulsive Inventory; YBOCS ⫽ self-report Yale–Brown Obsessive–Compulsive Scales; PI-WSUR ⫽ Padua
Inventory Washington State University Revision Total Score; PSWQ ⫽ Penn State Worry Questionnaire Total Score; BDI-II ⫽ Beck Depression
Inventory–II Total Score; BAI ⫽ Beck Anxiety Inventory Total Score.
 CLARK–BECK OBSESSIVE–COMPULSIVE INVENTORY
sions. Thus, the strong cognitive– behavioral orientation to the
questionnaire was empirically supported in the psychometric
analyses.
An initial exploratory factor analysis of the 25 CBOCI items
resulted in two highly correlated dimensions that corresponded
very closely to the rationally derived Obsessions and Compulsions
subscales. A subsequent factor analysis based on a Schmid–
Leiman transformation revealed that two thirds of the variance in
the CBOCI represented a second-order general factor, whereas the
remaining one third of the variance was accounted for by specific
first-order Obsessions and Compulsions factors. It is noteworthy
that a significant amount of CBOCI variance is specific to OC
symptoms and that the item loadings on the two first-order factors
generally supports the 14-item Obsessions and 11-item Compul-
sions subscales. However the two-factor structure of the question-
naire had less support from a CFA performed on the student
sample in which only one out of four indices suggested adequate
fit.
The two-factor structure of the CBOCI gained further support
from the reliability analyses summarized in Table 3. Cronbach’s
alpha indicated that the CBOCI Obsessions and Compulsions
subscales were homogeneous in both clinical and nonclinical sam-
ples. However, the CBOCI Total Score omega coefficient was low
in the student sample. Although there is no convention on what is
an acceptable omega value, it is clear that caution must be exer-
cised in using the CBOCI Total Score with a nonclinical sample.
Given that OCD is defined by the presence of distinct obsessive
and compulsive symptoms, it is likely that researchers and prac-
titioners will find the two CBOCI subscales more clinically useful
than the Total Score. The lower reliability of the CBOCI scales in
the student sample and weak support from the CFA also suggest
that a symptom measure like the CBOCI must be used cautiously
in nonclinical samples that have a restricted scoring range.
It is clear from the Schmid–Leiman analysis that some CBOCI
items are more specific to obsessions and compulsions, whereas
others are more general in nature. Doubting, perfectionism, inde-
cision, mental compulsions (internal neutralizing), avoidance of
stimuli that trigger compulsions, and distress associated with com-
pulsions had significant loadings only on the second-order factor.
Although these items may assess more general phenomena, they
should not be eliminated from the measure because they do assess
important features of the obsessional state. However, other ques-
tionnaire items such as uncontrollability of obsessions, salience,
effort to control, degree of insight, presence of cleaning or preci-
sion/symmetry rituals, and slowness had substantial loadings on
the OC unique factors. In circumstances in which differentiating
OC symptoms from other clinical presentations may be difficult,
the clinician could examine how the patient responds to the OC-
specific items to determine whether an obsessional state might be
present.
Although the CBOCI has fewer items, its concurrent and dis-
criminant validity is comparable to the YBOCS and PI–WSUR. In
fact, the squared eta values associated with the ANOVAs indicated
that the CBOCI and YBOCS total scores were able to differentiate
OCD from nonclinical status better than the PI–WSUR or the
nonobsessional symptom measures. The partial correlations indi-
cate that the CBOCI is more relevant to OC symptoms than to
worry. Nevertheless the CBOCI also appears to be sensitive to
general anxiety, worry, and depression. It may be that obsessions,
141
compulsions, depression, anxiety, and worry co-occur at such a
high frequency that a sharp discrimination is impossible. Also, all
of these symptom states have overlapping features that will inflate
their interrelation, and all are likely linked to a common higher
order construct such as negative affect or neuroticism (D. A. Clark
et al., 1994; Watson & Clark, 1992). Thus, like the attempt to
distinguish anxiety and depression, there may be a lower boundary
to the discriminant validity of OC symptom measures (for discus-
sion of the discriminability of anxiety and depression measures,
see L. A. Clark & Watson, 1991).
The CBOCI was developed as a relatively quick self-report
screener for obsessive and compulsive symptoms. It is one of the
first self-report OCD questionnaires to have equally represented
and empirically verified specific obsession and compulsion sub-
scales. Moreover the cognitive– behavioral orientation to the
CBOCI and its closer approximation to DSM–IV diagnostic criteria
distinguish it from other OCD measures such as the PI–WSUR.
The inclusion of symptom content items as well as more
cognitive– behavioral items is a departure from the YBOCS. As a
symptom screener, the 18-item OCI–R is more similar to the
CBOCI than other OC questionnaires. Although it is difficult to
assess the relative performance of these two measures without a
direct comparison, the item content of the OCI–R and CBOCI is
very different, with 17% of OCI–R items assessing obsessions
compared with 56% of the CBOCI items. It would be interesting
to compare the performance of these two brief OCD measures in
a future study. In the meantime there are a number of features to
the CBOCI that distinguish it from existing OCD symptom
measures.
In terms of a clinical assessment strategy, the CBOCI could be
administered as part of an initial suite of depression and anxiety
symptom measures. Individuals who obtain a high score on the
CBOCI should then be given a structured clinical interview to
determine whether the diagnostic criteria for OCD are met. As
with all self-report symptom measures, the CBOCI is not a diag-
nostic instrument but rather a measure of the frequency and se-
verity of symptoms. The clinical utility of self-report symptom
measures like the CBOCI can only be fully realized within the
context of individual clinical interviews.
There are limitations to the current studies that should be ad-
dressed in any further research on the CBOCI. A larger OCD
sample would be helpful so that exploratory and CFA can be
conducted on an OCD-only sample. Test–retest reliability data are
also needed on an OCD sample and the sensitivity of the instru-
ment to treatment effects remains to be determined. Whether the
CBOCI is equally sensitive to all subtypes of OCD should be
addressed. Like most clinical instruments, a larger nonstudent
community adult sample is needed to provide normative data on
the CBOCI. Also, it would be important to determine the diagnos-
tic sensitivity and specificity of the questionnaire in a large mixed
clinical sample drawn from a single treatment setting. Finally, the
current studies relied exclusively on self-report questionnaires.
The relation of the CBOCI to interviewer-based instruments such
as the standard YBOCS or the Compulsive Activity Checklist is
unknown. Further research is also needed on OCD symptoms in
depression. Although the depressed sample had elevated CBOCI
scores, the failure to administer the full assessment protocol to the
depressed sample limits the conclusions that can be drawn about
142 CLARK, ANTONY, BECK, SWINSON, AND STEER
the differentiation of obsessions and compulsions from major
depression.
Despite these areas for further investigation, we believe the
current findings provide strong support for the construct validity of
the CBOCI. The present analyses indicated that a highly focused
25-item symptom screener can be used to assess symptom severity
in a complex clinical condition like OCD with as much discrim-
inability as longer, more time-consuming measures. Only further
research can establish whether the CBOCI is a significant im-
provement over existing OCD symptom measures.
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Received March 3, 2003
Revision received October 19, 2004
Accepted February 8, 2005 䡲