Y-BOCS Intake

Date *

Date

Patient Name *

First Name Last Name

Questions 1 - 5 are about your obsessive thoughts

Obsessions are unwanted ideas, images or impulses that intrude on thinking against your wishes and efforts to resist them. They usually involve themes of harm, risk and danger. Common obsessions are excessive fears of contamination; recurring doubts about danger, extreme concern with order, symmetry, or exactness; fear of losing important things.

Please answer each question by selecting the appropriate number.

1. TIME OCCUPIED BY OBSESSIVE THOUGHTS: How much of your time is occupied by obsessive thoughts? *

0 = None 1 = Less than 1 hr/day or occasional occurrence 2 = 1 to 3 hrs/day or frequent 3 = Greater than 3 and up to 8 hrs/day or very frequent occurrence 4 = Greater than 8 hrs/day or nearly constant occurrence

2. INTERFERENCE DUE TO OBSESSIVE THOUGHTS: How much do your obsessive thoughts interfere with your work, school, social, or other important role functioning? Is there anything that you don't do because of them? *

0 = None 1 = Slight interference with social or other activities, but overall performance not impaired 2 = Definite interference with social or occupational performance, but still manageable 3 = Causes substantial impairment in social or occupational performance 4= Incapacitating

3. DISTRESS ASSOCIATED WITH OBSESSIVE THOUGHTS: How much distress do your obsessive thoughts cause you? *

0 = None 1 = Not too disturbing 2 = Disturbing, but still manageable 3 = Very disturbing 4 = Near constant and disabling distress

4. RESISTANCE AGAINST OBSESSIONS: How much of an effort do you make to resist the obsessive thoughts? How often do you try to disregard or turn your attention away from these thoughts as they enter your mind? *

0 = Try to resist all the time 1 = Try to resist most of the time 2 = Make some effort to resist 3 = Yield to all obsessions without attempting to control them, but with some reluctance 4 = Completely and willingly yield to all obsessions

5. DEGREE OF CONTROL OVER OBSESSIVE THOUGHTS: How much control do you have over your obsessive thoughts? How successful are you in stopping or diverting your obsessive thinking? Can you dismiss them? *

0 = Complete control 1 = Usually able to stop or divert obsessions with some effort and concentration 2 = Sometimes able to stop or divert attentino with difficulty 3 = Rarely successful in stopping or dismissing obsessions, can only divert attention with difficulty 4 = Obsessions are completely involuntary, rarely able to even momentarily alter obsessive thinking

Score for Obsessive thoughts (1-5):

Is there anything in this section that you would like to bring to the attention of your provider?

The next several questions are about your compulsive behaviors.

Compulsions are urges that people have to do something to lessen feelings of anxiety or other discomfort. Often they do repetitive, purposeful, intentional behaviors called rituals. the behavior itself may seem appropriate but it becomes a ritual when done to excess. Washing, checking, repeating, straightening, hoarding and many other behaviors can be rituals. Some rituals are mental. For example, thinking or saying things over and over under your breath.

6. TIME SPENT PERFORMING COMPULSIVE BEHAVIORS: How much time do you spend performing compulsive behaviors? How much longer than most people does it take to complete routine activities because of your rituals? How frequently do you do rituals? *

0 = None 1 = Less than 1 hr/day or occasional performance of compulsive behaviors 2 = From 1-3 hrs/day, or frequent performance of compulsive behaviors 3 = More than 3 and up to 8 hrs/day, or very frequent performance of compulsive behaviors 4 = More than 8 hrs/day, or near constant performance of compulsive behaviors (too numerous to count)

7. INTERFERENCE DUE TO COMPULSIVE BEHAVIORS: How much do your compulsive behaviors interfere with your work, school, social, or other important role functioning? Is there anything that you don't do because of the compulsions? *

0 = None 1 = Slight interference with social or other activities, but overall performance not impmaired 2 = Definite interference with social or occupational performance, but still manageable 3 = Causes substantial impairment in social or occupational performance 4 = Incapacitating

8. DISTRESS ASSOCIATED WITH COMPULSIVE BEHAVIOR: How would you feel if prevented from performing your compulsion(s)? How anxious would you become? *

0 = None 1 = Only slightly anxious if compulsions prevented 2 = Anxiety would mount but remain manageable if compulsions prevented 3 = Prominent and very disturbing increase in anxiety if compulsions interrupted 4 = Incapacitating anxiety from any intervention aimed at modifying activity

9. RESISTANCE AGAINST COMPULSIONS: How much of an effort do you make to resist the compulsions? *

0 = Always try to resist 1 = Try to resist most of the time 2 = Make some effort to resist 3 = Yield to almost all compulsions without attempting to control them, but with some reluctance 4 = Completely and willingly yield to all compulsions

10. DEGREE OF CONTROL OVER COMPULSIVE BEHAVIOR: How strong is the drive to perform the compulsive behavior? How much control do you have over the compulsions? *

0 = Complete control 1 = Pressure to per form the behavior but usually able to exercise voluntary control over it 2 = Strong pressure to perform behavior, can control it only with difficulty 3 = Very strong drive to perform behavior, must be carried to completion, can only delay with difficulty 4 = Drive to perform behavior experienced as completely involuntary and over-powering, rarely able to even momentarily delay activity.

Score for Compulsive behaviors (6-10):

Total Score:

Is there anything in this section that you would like to bring to the attention of your provider?

Y-BOCS Symptom Checklist

Instructions: Generate a Target Symptoms List from the Y-BOCS Symptom Checklist by asking the patient about specific obsessions and compulsions. Select all that apply. Distinguish between current and past symptoms and mark principal symptoms. These will form the basis of the Target Symptoms List. Items marked may* or may not be an OCD phenomena.

AGGRESSIVE OBSESSIONS:

	Current	Past	Principle
Fear might harm self
Fear might harm others
Violent or horrific images
Fear of blurting out obscenities or insults
Fear of doing something else embarrassing*
Fear will act on unwanted impulses (e.g. to stab friend)
Fear will steal things
Fear will harm others because not careful enough (e.g. hit/run motor vehicle accident)
Fear will be responible for something else terrible happening (e.g. fire, burglary)
Other

If other please specify here:

SOMATIC OBSESSIONS:

	Current	Past	Principle
Concern with illness or disease*
Excessive concern with body part or aspect of appearance (e.g. dysmorphophobia)*
Other

If other please specify here:

CONTAMINATION OBSESSIONS:

	Current	Past	Principle
Concerns or disgust w/bodily waste or secretions (e.g. urine, feces, saliva)
Concern with dirt or germs
Excessive concern with environmental contaminants (e.g. asbestos, radiation toxic waste)
Excessive concern with household items (e.g. cleansers, solvents)
Excessive concern with animals (e.g. insects)
Bothered by sticky substances or residues
Concerned will get ill because of contaminant
Concerned will get others ill by spreading contaminant (Agressive)
No concern with consequences of contamination other than how it might feel

CLEANING/WASHING COMPULSIONS:

	Current	Past	Principle
Excessive or ritualized handwashing
Excessive or ritualized showering, bathing, toothbrushing grooming, or toilet routine involves cleaning of household items or other inanimate objects
Other measures to prevent or remove contact with contaminants
Other

If other please specify here:

CHECKING COMPULSIONS:

	Current	Past	Principle
Checking locks, stove, appliances etc.
Checking that did not/will not harm others
Checking that did not/will not harm self
Checking that nothing terrible did/will happen
Checking that did not make mistake
Checking tied to somatic obsessions
Other

If other please specify here:

REPEATING RITUALS:

	Current	Past	Principle
Rereading or rewriting
Need to repeat routine activities (e.g. job, in/out door, up/down from chair)
Other

If other please specify here:

COUNTING COMPULSIONS:

	Current	Past	Principle
Counting compulsions

Please specify counting compulsions if any:

ORDERING/ARRANGING COMPULSIONS:

	Current	Past	Principle
Ordering/arranging compulsions

Please specify ordering/arranging compulsions if any:

SEXUAL OBSESSIONS:

	Current	Past	Principle
Forbidden or perverse sexual thoughts, images, or impulses
Content involves children or incest
Content involves homosexuality*
Sexual behavior towards others (Agressive)*
Other

If other please specify here:

HOARDING/SAVING OBSESSIONS:

	Current	Past	Principle
Distinguish from hobbies and concern with objects of monetary or sentimental value

Specify if necessary:

HOARDING/COLLECTING COMPULSIONS:

	Current	Past	Principle
Distinguish from hobbies and concern with objects of monetary or sentimental value (e.g. carefully reads junk mail, piles up old newspapers, sorts through garbage, collects useless objects)

Specify if necessary:

RELIGIOUS OBSESSIONS (Scrupulosity)

	Current	Past	Principle
Concerned with sacrilege and blasphemy
Excess concern with right/wrong, morality
Other

If other please specify here:

OBSESSION WITH NEED FOR SYMMETRY OR EXACTNESS:

	Current	Past	Principle
Accompanied by magical thinking (e.g. concerned that another will have accident unless things are in the right place)
Not accompanied by magical thinking

MISCELLANEOUS OBSESSIONS:

	Current	Past	Principle
Need to know or remember
Fear of saying certain things
Fear of not saying just the right thing
Fear of losing things
Intrusive (nonviolent) images
Intrusive nonsense sounds, words, or music
Bothered by certain sounds/noises*
Lucky/unlucky numbers
Colors with special significance
3 supersitious fears
Other:

If other please specify here:

MISCELLANEOUS COMPULSIONS:

	Current	Past	Principle
Mental rituals (other than checking/counting)
Excessive listmaking
Need to tell, ask, or confess
Need to touch, tap or rub*
Rituals involving blinking or staring*
Measures (not checking) to preent: harm to self/harm to others terrible consequences
Ritualized eating behaviors*
Superstitious behaviors
Trichotillomania*
Other self-damaging or self-mutilating behaviors*
Other

If other please specify here:

Is there anything in this section that you would like to bring to the attention of your provider?

Adapted from Goodman, W.K. Price, L.H. Rasmussen, S.A. et al:

"The Yale-Brown Obsessive Compulsive Scale"

Arch Gen Psychiatry 46:1006-1011, 1989

Provider Notes: