Volume 10, Issue 4 (Autumn 2022)                   PCP 2022, 10(4): 275-278 | Back to browse issues page


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Abbasi Jondani J. COVID-19 Pandemic and the Questionable Validity of Obsessive-Compulsive Questionnaires. PCP 2022; 10 (4) :275-278
URL: http://jpcp.uswr.ac.ir/article-1-794-en.html
Department of Psychology, Faculty of Education and Psychology, University of Isfahan, Isfahan, Iran. , j.abbasi70@edu.ui.ac.ir
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The world is currently coping with the COVID-19 pandemic. Until now, approximately 521 million people have been afflicted, and about 6.3 million people have died because of this disease worldwide (Worldometer, 2021). COVID-19 has impacted all aspects of our lives, resulting in a high mental health burden (Steardo & Verkhratsky, 2020). 
The World Health Organization (WHO) has recommended several effective preventative strategies to slow down the spread of COVID-19. Some of these strategies include basic hygiene, such as washing hands thoroughly and regularly, cleaning and disinfecting the surfaces touched frequently, and avoiding contact with bodily secretions as the primary source of COVID-19 transmission between people (World Health Organization, 2021). These recommendations are similar to the concerns of people with obsessive-compulsive disorder (OCD), particularly patients with contamination fears and cleaning/washing compulsions. Therefore, it is not surprising that the prevalence rates and severity of OCD have increased during this ongoing pandemic (Wheaton et al., 2021). Additionally, COVID-19 anxiety is a widespread problem during this pandemic, mainly because of the unpredictable and life-threatening nature of this disease (Sher, 2020). Those with high COVID-19 anxiety may feel more urge to adhere to the COVID-19 preventative strategies. This is particularly true in individuals with OCD because they have beliefs, such as the intolerance of uncertainty and the overestimation of threat (Obsessive Compulsive Cognitions Working Group, 2005). The heightened vulnerability of OCD patients to COVID-19 anxiety and the similarity of their concerns with the COVID-19 preventative strategies pose some challenges for the assessment of the actual OCD severity using the self-report OC questionnaires. 
Using questionnaires has a very long history in psychology (Gault, 1907). Nowadays, questionnaires are used in clinical psychology and psychiatry for many reasons, such as screening psychiatric disorders, assessing their symptoms’ severity, estimating their prevalence rates, and measuring other constructs related to these disorders (Demetriou et al., 2014).

OCD is among the most prevalent mental disorders (American Psychiatric Association, 2013), and there are many questionnaires developed to assess its symptom severity. The most popular self-report OC questionnaires include Maudsley obsessive-compulsive inventory (MOCI) (Hodgson & Rachman, 1977), Padua inventory-Washington State University revision (PI-WSUR) (Burns et al., 1996), obsessive-compulsive inventory-revised (OCI-R) (Foa et al., 2002), Vancouver obsessional compulsive inventory (VOCI) (Thordarson et al., 2004); Florida obsessive-compulsive inventory (FOCI) (Storch et al., 2007), and dimensional obsessive-compulsive scale (DOCS) (Abramowitz et al., 2010). These self-report questionnaires are commonly utilized in OCD research and treatment settings. A questionnaire should have some characteristics to be considered a psychometrically sound instrument. One of these crucial characteristics is validity. Validity can be described as whether an instrument actually measures what it is supposed to measure (Moerdyk, 2015). For instance, a questionnaire measuring OCD severity is valid when it actually measures OCD severity, not any other construct. 
All well-known self-report OC questionnaires mentioned above have several items about basic hygienic behaviors, such as contamination, cleaning, and washing. Some of these items are similar to the highly recommended preventative strategies for COVID-19 (Table 1 for examples of these items).



This overlap between OCD rituals and COVID-19 preventative strategies raises concerns about the validity of these instruments. For example, if a person rates the prototypical item “I wash my hands frequently” as very high, the assessor cannot maintain with certainty to what extent this answer is indicative of the OCD severity, COVID-19 recommendations’ adherence, and or simply COVID-19 anxiety. Therefore, it is logical for the researchers to doubt the validity of such self-report questionnaires, particularly the contamination/cleaning/washing subscales. However, despite the questionable validity of OC self-report questionnaires, they are widely used in current OCD research without any modification.
Nevertheless, some remedies exist for this problem. In addition to the self-report questionnaires, there are several clinician-rated instruments to diagnose OCD and rate its severity. These include the structured clinical interview for the diagnostic and statistical manual of mental disorders, 5th edition (DSM-5; SCID) (First, 2014), the anxiety and related disorders interview schedule for DSM-5 (ADIS) Brown & Barlow, 2014), and the Yale-Brown obsessive-compulsive scale (YBOCS) (Goodman et al., 1989) that is specifically developed for OCD. Although the clinician-rated OC instruments are time-consuming compared to the self-report OC questionnaires, they can provide much more valid results during the COVID-19 pandemic. This is because the examiners can inspect the main motivation of the examinees (actual OCD severity, adherence to COVID-19 recommendations, or simply COVID-19 anxiety). Clinicians should rely on their clinical judgments to determine whether patients’ cleaning behaviors are more than what is expected based on the healthcare guidelines. OCD is a chronic disorder (American Psychiatric Association, 2013); thus, its course during the pandemic can be retrospectively inspected. Since the COVID-19 pandemic started, its intensity has fluctuated a lot. If an OCD patient has had a relatively stable symptom severity, the clinician may consider the assessment more valid. A considerable increase in symptom severity during COVID-19 peaks poses a need for more careful assessment. The COVID-19 pandemic may also change the symptom presentations of OCD patients (Jassi et al., 2020). Therefore, clinicians need to assess the new potential obsessions induced by the COVID-19 pandemic, such as being contaminated by the coronavirus and harming others by unintentionally transmitting the virus to them. In addition to interviews, clinicians can use behavioral measures, such as behavioral avoidance tasks (BATs) (Abramowitz et al., 2017). In the BATs, the patients are faced with their feared stimuli and the clinicians observe their actual responses. Since BATs rely on in vivo observations, they are more valid than self-report OC questionnaires. 
The assessment of the actual OC severity (i.e., ensuring the validity) is much harder in research settings. Researchers mainly use self-report OC questionnaires, not interviews or BATs. Therefore, inspecting the actual respondents’ motivations for cleaning behaviors is difficult, if not impossible. Typically, research in mental health involves comparing groups on some variables (e.g. OC severity) or testing some kinds of correlations between variables (e.g. the correlation between OC severity and meta-cognitive beliefs). One potential solution for increasing the validity of OC self-report questionnaires is to control confounding variables statistically. Researchers can incorporate some questions about COVID-19 (e.g. the amount of compliance with the healthcare protocols) and some measures of COVID-19 anxiety (e.g. Lee, 2020) in their questionnaire package. After collecting the data, they can statistically control the effects of COVID-19-related variables on OC measures using the analysis of covariance or partial correlation. Researchers can also compare the means of their OC questionnaires with the norms provided for both clinical and non-clinical populations before the COVID-19 pandemic (e.g. Ghassemzadeh et al., 2016). The more comparable their means to the norms, the more confidence they can have about the validity of their questionnaires. A better solution is to encourage researchers to provide new norms for the OC self-report questionnaires during the COVID-19 pandemic. 
In summary, despite the widespread use of self-report OC questionnaires, there is an issue that has been ignored in OCD research. It seems that the validity of these instruments is questionable because of the similarities between some of their items and the COVID-19 preventative recommendations. I hope this call to action can alert the researchers and clinicians regarding the appropriate assessment in OCD research and treatment. 


Ethical Considerations
Compliance with ethical guidelines

There were no ethical considerations to be considered in this research.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 
Conflict of interest
The authors declared no conflict of interest.


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Type of Study: Applicable | Subject: Psychometric
Received: 2021/11/11 | Accepted: 2022/09/10 | Published: 2022/10/1

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