Measuring self-report obsessionality in anorexia nervosa: Maudsley obsessive–compulsive inventory...

RESEARCH ARTICLE

Measuring Self-Report Obsessionality in AnorexiaNervosa: Maudsley Obsessive–Compulsive Inventory(MOCI) or Obsessive–Compulsive Inventory-Revised(OCI-R)?Marion Roberts1, Anna Lavender2 & Kate Tchanturia1*

1Institute of Psychiatry, Department of Psychological Medicine, King’s College London, UK

2Institute of Psychiatry, Department of Psychology, King’s College London, UK

Abstract

Self-report measures are often used in research and clinical practise as they efficiently gather a large amount of

information. With growing numbers of self-report measures available to target single constructs, it is important to

revisit one’s choice of instrument to be sure that the most valid and reliable measure is employed. The Maudsley

Obsessive–Compulsive Inventory (MOCI) and the Obsessive–Compulsive Inventory-Revised (OCI-R) were admi-

nistered to 223 female participants: 30 inpatients with anorexia nervosa (AN), 62 community cases with AN, 69

community cases weight restored from AN and 62 healthy controls. Both measures distinguished between clinical

and healthy groups; however, the OCI-R showed superior internal reliability. Additionally, the OCI-R measures six

(to the MOCI’s four) obsessive–compulsive constructs, and uses a more sensitive response format (likert scale vs.

categorical). It is recommended that the OCI-R be employed as the self-report instrument of choice for assessing

obsessive–compulsive pathology in those with AN. Copyright# 2010 John Wiley & Sons, Ltd and Eating Disorders

Association.

Keywords

anorexia nervosa; obsessive–compulsive disorder; MOCI; OCI-R; psychometrics

*Correspondence

Dr Kate Tchanturia, PhD, Eating Disorders Unit PO59, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF,

UK. Tel: 0044 207 848 0134. Fax: 0044 207 848 0181.

Email: [email protected]

Published online 28 December 2010 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.1072

Introduction

The high level of comorbidity and symptomalogical

overlap between anorexia nervosa (AN) and obsessive–

compulsive disorder (OCD) has long been acknowl-

edged. Co-morbidity estimates of the proportion of AN

sufferers with co-morbid OCD vary widely, from 17.5%

(Godart et al., 2003) to 66% (Fornari, Kaplan,

Sandberg, Matthews, Skolnick, & Katz, 1992). This

considerable variation may in part be due to the wide

range of measurement instruments employed to

measure comorbid OCD in the AN literature.

Clinically, high obsessive–compulsive symptomatology

has been associated with poor treatment outcome

(Rastam, Gillberg, &Wentz, 2003; Thomsen, 1994) and

increased severity of eating disorder psychopathology

(Jimenez-Murcia et al., 2007).

The complexity of this picture underlines the need

to be able to assess obsessive–compulsive symptoms

in eating disorder patients quickly and easily in

routine clinical practice (e.g. Davies, Liao, Campbell,

& Tchanturia, 2009). In brief, reliable measurement

Eur. Eat. Disorders Rev. 19 (2011) 501–508 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association. 501

of obsessive–compulsive symptoms in patients with an

eating disorder enables more comprehensive and

individualised assessment and treatment planning,

enhancing outcome assessment. Such a measure is also

of use as a research tool, allowing efficient gathering of

data with minimal researcher input. With growing

numbers of self-report measures available to target

single constructs, it is important to revisit one’s

choice of instrument in order to be sure that the most

valid and reliable measure is employed.

The Maudsley Obsessive–Compulsive Inventory

(MOCI; Hodgson & Rachman, 1977) is a 30-item

self-report scale with a yes/no response format. It

produces a total score in addition to scores for its four

subscales: Checking, washing, doubting and slowness. It

is a well-validated instrument (Dent & Salkovskis, 1986;

Sternberger & Burns, 1990) and has been used in

numerous studies of obsessionality in various popu-

lations (Alegret, Junque, Valldeoriola, Vendrell, Marti,

& Tolosa, 2001; Kano, Ohta, Nagai, Pauls, & Leckman,

2004; Li & Chen, 2007). However, use of the MOCI

within the eating disorder population has produced

equivocal results. While some papers report favourable

discriminant validity between eating disorder and

OCD/anxiety participants (Emmelkamp, Kraaijkamp,

& van den Hout, 1999; Jimenez-Murcia et al., 2007),

others have reported no difference in MOCI score

between these populations (Fahy, 1991).

The Obsessive–Compulsive Inventory-Revised

[OCI-R; (Foa et al., 2002)] is an 18-item self-report

scale with a five-point likert scale format. Like the

MOCI, it yields both a total score and individual

scores for each of its six subscales: Checking, washing,

obsessing, neutralising, ordering and hoarding.

The OCI-R has exhibited good-to-excellent internal

reliability among clinically anxious (total scale

0.81–0.93; Foa et al., 2002) and non-anxious control

participants for all subscales but neutralising (total scale

a¼ 0.88; Hajcak, Huppert, Simons, & Foa, 2004).

Hajcak and colleagues (2004) provide strong support

for good test–retest reliability (r¼ .70), and convergent

and divergent validity of the OCI-R in a college sample.

The OCI-R has been further validated in both clinical

and subclinical populations (Abramowitz & Deacon,

2006; Huppert et al., 2007; Roberts & Wilson, 2008).

As the OCI-R appeared in the anxiety literature only

8 years ago (compared to the MOCI’s 30-year

presence), research using the OCI-R in the eating

disorder field is just beginning to emerge. Recent

studies have reported effect sizes of up to 1.9 (very large

effect) when comparing OCI-R scores of AN and

healthy control (HC) groups (Lopez et al., 2008).

Numerous studies exist in the literature exploring

the impact of clinical variables on obsessive–compul-

sive characteristics in the eating disorder population

(Altman & Shankman, 2009; Crane, Roberts, &

Treasure, 2007). This paper does not attempt a

comprehensive analysis of this topic. Rather, the aim

of this study was to determine the most appropriate

self-report measure for obsessive–compulsive traits in

the AN population by assessing their relative psycho-

metric properties, specifically discriminant validity and

internal reliability, content validity in relation to eating

disorders, and any additional aspects of the MOCI

and OCI-R which may influence their utility with

individuals with AN.

Method

Participants

Participants were 223 female volunteers between the

ages of 14 and 67. The first group were inpatients

currently in a specialist eating disorder ward for severe

AN (n¼ 30). The second group were a community

AN sample recruited from the Maudsley section of

eating disorders’ volunteer database. Volunteers that

met criteria for a lifetime diagnosis of AN based on the

Eating Disorder Diagnostic Scale (Stice, Telch, & Rizvi,

2000) were included in the study. This group was split

into those with a current BMI< 18 (AN community,

ANC; n¼ 62) and those with a current BMI� 18 (AN

community weight restored, ANC-WR; n¼ 69).

Finally, a HC general population group was collected

as a comparison (n¼ 62).

Measures

TheMaudsley Obsessive–Compulsive Inventory (MOCI)

(Hodgson & Rachman, 1977) and the Obsessive–

Compulsive Inventory-Revised (OCI-R) (Foa et al.,

2002).

Procedure

The MOCI and OCI-R were posted to all participants

on the Maudsley volunteer database (approximately

800 individuals) as part of a larger study, along with

a pre-paid return envelope. Inpatients were approached

on the ward to ask for their participation. HC were

502 Eur. Eat. Disorders Rev. 19 (2011) 501–508 � 2010 John Wiley & Sons, Ltd and Eating Disorders Association.

Measuring Self-Report Obsessionality in AN M. Roberts et al.

recruited from a volunteer research pool at the Institute

of Psychiatry (MindSearch) and through Masters level

Psychology students. HC were not included in the

study if they endorsed disordered eating or obsessive–

compulsive traits as measured by self-report on the

overview page of the SCID-I (First, Gibbon, Spitzer, &

Williams, 1997). Participation was voluntary, and no

payment was given. The study was approved by the

local ethics committee and all participants gave

informed written consent.

Statistical methods

Data was entered into SPSS 16.0 for analysis using a

significance level of 0.05. As data was normally

distributed, differences in demographic and clinical

characteristics between groups were assessed using

ANOVA (Tukey post hoc) and Cohen’s d effect size.

Effect sizes are described as negligible (<0.15), small

(0.15–0.39), moderate (0.40–0.74), large (0.75–1.14)

and very large (>1.15). Discriminant validity was also

assessed using ANOVA and Cohen’s d to compare

group means across OCI-R and MOCI full scale and

subscale scores. Cronbach’s alpha was used as the

measure of internal reliability. Participants with

missing data (OCI-R items; MOCI items; BMI) were

excluded from the dataset (n¼ 42).

Results

Clinical characteristics

Groups differed significantly by age (F(3,221)¼ 5.64,

p¼ 0.001), where the AN inpatient group (M¼ 27.33,

SD¼ 8.88) was significantly younger than both ANC

(M¼ 36.23, SD¼ 12.78; d¼ 0.76) and ANC-WR

(M¼ 37.55, SD¼ 12.85, d¼ 0.85) groups but not the

HC group (M¼ 32.06, SD¼ 13.60, d¼ 0.39). Current

BMI for the AN inpatient group ranged between 12.0

and 17.5 (M¼ 15.36, SD¼ 1.27). This was comparable

to ANC group, range 10.1–17.6 (M¼ 14.98, SD¼ 2.02;

d¼ 0.21). BMI for the ANC-WR group (M¼ 20.98,

SD¼ 2.69) was significantly lower than that of HC

(M¼ 22.82, SD¼ 3.06; d¼ 0.61). Inpatient AN, ANC

and ANC-WR groups had comparable lowest ever

BMI’s (M¼ 12.11, SD¼ 1.41; M¼ 11.97, SD¼ 2.07;

M¼ 14.85, SD¼ 12.80; p¼ 0.13). The AN inpatient

group had a shorter duration of illness in years

(M¼ 8.20, SD¼ 5.20), compared to both ANC

(M¼ 17.03, SD¼ 7.09; d¼ 1.35) and ANC-WR

(M¼ 12.96, SD¼ 10.32; d¼ 0.53) with moderate to very

large effects. Self-report anxiety and depression as

measured by the Hospital Anxiety and Depression Scale

(Zigmond & Snaith, 1983) were both high in the inpatient

AN group (anxiety M¼ 15.5, SD¼ 3.94; depression

M¼ 13.77, SD¼ 5.99). Levels of self-report obsessive–

compulsive symptoms were high across all three clinical

groups, most notably in the inpatient AN sample and

decreasing in parallel with illness severity (see Table 1).

Discriminant validity

As seen in Table 1, both the OCI-R and MOCI total

scale scores discriminated between clinical and HC

groups, with the exception of the ANC-WR and HC

group comparison on the OCI-R (p¼ 0.06). Compar-

able effect sizes were seen across full-scale group

comparisons, decreasing in magnitude from very large

effects for AN inpatient/HC, to large for ANC/HC

comparisons, to moderate for ANC-WR/HC compari-

sons. This is likely due to the moderate correlation

between BMI and both OCI-R (r(220)¼�0.37,

p< 0.001) and MOCI (r(220)¼�0.35, p< 0.001)

scale totals. Though total and subscale scores for both

the OCI-R and MOCI trend higher in the ANC-WR

group compared to HC, both measures were poor at

discriminating significantly between these two groups.

The hoarding subscale of the OCI-R was the only

subscale across both measures to discriminate signifi-

cantly between inpatient AN and ANC groups, where

a moderate effect (d¼ 0.53) was found.

Internal reliability

Acceptable Cronbach’s alphas (a>0.7) were achieved

for the total score and all subscale scores across all

participant groups for the OCI-R. High Cronbach’s

alphas (>0.8) were observed on all but three of the 28

potential scale total and subscale scores across groups,

indicating a high level of internal reliability. For the

MOCI, such high levels of internal reliability (Cron-

bach’s alphas> 0.8) were only observed for three of four

total scores (ANC, ANC-WR and HC), and the cleaning

subscale for ANC. The majority of MOCI subscale scores

showed poor internal reliability (<0.70).

Discussion

This study aimed to evaluate the utility of the MOCI

and OCI-R within an AN population on the basis of


M. Roberts et al. Measuring Self-Report Obsessionality in AN

Table

1OCI-Ran

dMOCIscalescores,

internal

reliability

andeffect

sizes

AN

inpatient

(N¼30)

AN

community

(n¼62)

AN

community

WR(n

¼69)

Healthycontrol

(N¼62)

Test

statistics

MSD

ad

MSD

ad

MSD

ad

MSD

aF

p

OCI-RTo

tala,b

31.83

19.46

0.93

1.45��

26.16

14.56

0.91

1.16��

17.48

13.46

0.92

0.51

11.26

10.86

0.92

19.54

<0.001

Hoardinga,c

5.60

4.43

0.88

0.85��

3.73

2.99

0.80

0.31

3.46

3.46

0.84

0.19

2.89

2.41

0.68

4.89

0.003

Checkinga

5.07

4.50

0.92

1.06��

3.53

3.18

0.85

0.65��

2.72

2.74

0.81

0.39

1.74

2.22

0.83

9.01

<0.001

Orderinga,b

7.60

4.14

0.95

1.52��

6.45

3.85

0.92

1.13��

4.12

3.43

0.90

0.46

2.68

2.71

0.86

19.71

<0.001

Neu

tralisinga

3.76

4.56

0.94

0.89��

2.77

3.46

0.86

0.63��

1.68

2.75

0.80

0.29

0.98

2.09

0.78

6.85

<0.001

Washinga,b

3.70

3.90

0.89

1.04��

3.42

3.65

0.88

0.86��

1.20

2.13

0.80

0.14

0.92

1.85

0.79

13.49

<0.001

Obsessingb

6.57

4.78

0.95

1.27��

6.26

3.70

0.87

1.28��

4.52

3.74

0.90

0.74��

2.05

2.81

0.87

17.20

<0.001

MOCITo

tala,b

14.70

4.38

0.66

1.58��

12.90

6.49

0.85

1.04��

9.70

5.54

0.84

0.55�

6.71

5.35

0.85

19.09

<0.001

Checkinga,b

3.70

2.12

0.59

1.18��

3.44

2.71

0.60

0.88��

2.38

1.97

0.65

0.51

1.39

1.88

0.77

11.99

<0.001

Clean

inga

4.00

2.41

0.71

0.76�

3.11

2.69

0.82

0.34

2.28

2.03

0.69

0.01

2.26

2.25

0.70

5.19

0.002

Slownessa

3.43

1.43

0.16

1.46��

2.77

1.81

0.67

0.91��

2.04

1.70

0.61

0.48�

1.26

1.51

0.65

15.01

<0.001

Doubtingb

4.70

1.60

0.54

1.66��

4.69

1.71

0.60

1.60��

3.75

2.01

0.72

0.93��

2.05

1.59

0.60

27.82

<0.001

OCI-R,Obsessive–CompulsiveInventory-Revised

;MOCI,Mau

dsley

Obsessive–CompulsiveInventory;AN,an

orexianervosa;WR,weight-restored.

a,Cronbach’s

alpha.

d,Cohen

’sdeffect

size

compared

toHC

group.

aSignificantTu

keypost

hoctest

(p<0.05)betwee

nANinpatientan

dANcommunityWRgroups.

bSignificantTu

keypost

hoctest

(p<0.05)betwee

nANcommunityan

dANcommunityWRgroups.

cSignificantTu

keypost

hoctest

(p<0.05)betwee

nAN

inpatientan

dAN

communitygroups.

� p>0.05,��p>0.01.



three main factors. These were (1) their relative

psychometric properties, specifically discriminant

validity and internal reliability, (2) their content

validity in relation to AN and (3) other features of

the instruments relevant to their routine use within an

AN population.

Psychometrics

Both the MOCI and the OCI-R total scores discrimi-

nated well (moderate to very large effect sizes) between

the clinical and HC groups, suggesting that both

measures have a high overall level of discriminant

validity. The ability of the MOCI to discriminate

reliably between AN and HC groups is contrary to

Fahy’s (1991) finding, and lends support to the MOCI’s

utility in this context.

Considering the results at a subscale level, five of the

six OCI-R subscales and three of the four MOCI

subscales discriminated between inpatient AN and

ANC-WR groups, suggesting that the measures showed

broadly comparable discriminative validity in this

respect. Similarly, three of the OCI-R and two of

the MOCI subscales discriminated between the ANC

and ANC-WR groups, again suggesting broadly

comparable ability to discriminate between these

groups. Neither measure discriminated well between

the ANC-WR group and the healthy controls, with only

the hoarding subscale of the OCI-R discriminating

between the two low-weight AN groups (discussed

below). Taken together, these results suggest that

neither measure stands out as possessing superior

discriminant validity within this population.

In contrast, the internal reliabilities of the MOCI and

OCI-R differed substantially. While the OCI-R showed

high Cronbach’s alphas on all but three of the 28

potential total and subscale scores, the equivalent

alphas for the MOCI were much less satisfactory with

only four of the potential 20 total or subscale scores

being above 0.8, and 12 being below 0.7, in the

unacceptable range. This suggests that the OCI-R is a

more internally reliable measure of obsessive–compul-

sive symptoms in the AN population than the MOCI.

Content validity

Two of the MOCI and OCI-R’s subscales, cleaning

(MOCI) and washing (OCI-R) are conceptually

matched. The content of the cleaning/washing subscales

is very similar, and although within the OCI-R the

factor has been labelled ‘cleaning’ rather than ‘washing’,

washing is mentioned in two of the three items within

the OCI-R subscale. Both measures have similar

properties in terms of ability to discriminate between

groups, although the MOCI did not discriminate

between ANC and the ANC-WR groups, suggesting

some benefit of using the OCI-R in this context.

The checking subscales are also similar in content,

with the exception of two questions within the MOCI

checking subscale that have a lower factor loading than

the others. With the checking subscales, the reverse

picture is seen from the washing/cleaning subscales, in

that the two measures perform similarly except that the

OCI-R does not discriminate between ANC and ANC-

WR groups, suggesting some benefit for the MOCI

within this domain.

An examination of the MOCI doubting items (e.g. ‘I

tend to get behind in my work because I repeat things

over and over again’; ‘I have a very strict conscience’)

indicates similarities between this construct and that of

clinical perfectionism, a key component in the cognitive

conceptualisation of eating disorders (Fairburn,

Cooper, & Shafran, 2003; Schmidt & Treasure, 2006).

Individuals with AN score higher than those with OCD

on the perfectionism subscale of the Obsessive Beliefs

Questionnaire (Lavender, Shubert, de Silva, & Treasure,

2006), and high perfectionism in AN is a consistent and

robust finding (Anderluh, Tchanturia, Rabe-Hesketh,

Collier, & Treasure, 2009; Bardone-Cone et al., 2007;

Goldner, Cockell, & Srikameswaren, 2002). Given

that the aim of a measure of obsessive–compulsive

complaints in this population is to identify symptoms

additional to those that are central to and to be expected

in an AN group, the inclusion of a subscale very similar

to the construct of perfectionism may be redundant.

It could also be anticipated that high scores on the

doubting subscale that reflect high levels of perfection-

ism would artificially elevate the MOCI total score for

this group.

Considering the final MOCI subscale, slowness in

individuals with OCD (e.g. ‘I am often late because

I can’t seem to get through everything on time’) may be

understood to be a result of their neutralising, which

can be extremely time consuming and may best be

conceptualised as an epiphenomenon of the disorder,

rather than a core feature. While this may be useful

to measure, two OCI-R subscales (neutralising and

ordering) provide a more direct measure of the



cognitive and behavioural underpinnings of slowness in

OCD, the specificity of which may be valuable when

assessing an eating disorder cohort.

Two items on the MOCI, ‘I find that almost every

day I am upset by unpleasant thoughts that come into

my mind against my will’ and ‘I frequently get nasty

thoughts and have difficulty in getting rid of them’,

relate to the experience of intrusive thoughts, or what

the scale authors refer to as ‘obsessional rumination’.

These items appear on both the checking and

slowness subscales, positively and negatively loaded,

respectively. The MOCI authors explain that these two

questions originally formed a fifth component, which

they ignored because it contained only two items. More

recent cognitive models of OCD (Salkovskis, 1999)

emphasise, indeed centralise, the importance of

intrusive thoughts in understanding the disorder. This

is reflected in the newer OCI-R, which contains an

obsessing subscale within which two of the three items

are nearly identical to the MOCI items above. Thus it

may make sense to include a subscale specifically

designed to measure this construct.

Finally, the OCI-R includes a hoarding subscale not

seen in the MOCI. High levels of hoarding have been

reported in the AN literature, with no difference in the

frequency of hoarding obsessions found between eating

disorder and OCD samples as measured by the clinical

rated Yale–Brown Obsessive–Compulsive Scale (Halmi

et al., 2003). Hoarding has also been found to be

elevated in a sub-clinical eating disorder population

(Roberts, 2006). It therefore seems appropriate for a

measure of OCD used in the eating disorder population

to include a hoarding component or subscale. As noted

above, the hoarding subscale of the OCI-R was the only

one across both measures to discriminate between the

inpatient AN and low weight ANC sample. It might be

that hoarding is a particular difficulty for severely ill

inpatient groups, a proposition that could usefully be

explored further. Hoarding is currently being intensively

studied and debated in the OCD literature with respect

to potential classification of ‘hoarding disorder’ as a

stand-alone diagnosis to OCD (Mataix-Cols et al., 2010).

It is, therefore, pertinent to increase our understanding of

this domain within the eating disorder population.

Other features

As noted in the introduction, the MOCI and OCI-R

differ in terms of their response formats (categorical vs.

5-point Likert scale, respectively). An advantage of the

latter in clinical practice is that it allows for gradations

of response, enabling the assessor a clearer picture of

the relevance of individual items or domains than a

dichotomous format permits. Another advantage of the

OCI-R over the MOCI for both clinical and research

purposes is that it is a shorter instrument, with 18

compared to 30 items, making its administration

quicker, easier and less demanding for the participant.

Additionally, the information gathered is richer given

that the OCI-R measures six rather than four subscales.

Limitations

The current study had a number of limitations. The first

of these was the heterogeneity of our community AN

sample, who were at various stages within their eating

disorder including some who at the time of the study

did not meet diagnostic criteria for AN. We addressed

this difficulty by dividing the community group into

those with a currently low weight, and those whose

weight had been restored. However, in the absence of

clinical diagnoses for these individuals, this remains a

limitation. Another limitation was the relatively smaller

sample of inpatient participants compared with the

community AN and HC groups. This limitation was a

consequence of the clinical reality that there are many

fewer inpatients than outpatients within our service. A

third limitation was the absence of a formal OCD

diagnostic assessment within the samples. This may

have masked scores elevated due to comorbidity with

Axis I OCD, across the groups.

Conclusion

This study aimed to evaluate the utility of the MOCI

and OCI-R within four female samples: inpatients with

current AN, community participants with lifetime

AN and a current low BMI (<18), community

participants with lifetime AN and a current healthy

weight and a healthy control group. While discriminant

validity was broadly similar between the measures,

when taking into account the findings for internal

reliability, content validity and other factors relevant

to assessing OCD in the AN population, the OCI-R

emerged as the superior measure.

The MOCI and the OCI-R are both valuable

instruments and each has its merits in the assessment

of obsessive–compulsive symptoms. TheMOCI is time-

tested and, being the more widely employed measure,



its use particularly for research purposes enables cross

comparison of data more easily than the newer OCI-R.

However, for the assessment of obsessive–compulsive

symptoms in individuals with AN, the OCI-R offers a

number of advantages. Higher internal reliability within

the AN population in addition to the length and format

of the OCI-R offer clear benefits over the MOCI.

Additionally, an analysis of both measures’ scale/

subscale content suggests that the OCI-R offers a more

useful approach for the assessment of a broader range of

obsessive–compulsive symptoms in the AN population.

We, therefore, suggest that the OCI-R be used in place

of the MOCI when a short, reliable self-report measure

of OCD is required in the AN population.

Acknowledgements

M. Roberts was funded by a Nina Jackson Fellowship

(RIED) with the Psychiatry Research Trust. Data were

part of the BIAL funded project awarded to K. Tchan-

turia (grant numbers 88/02, 61/04). The authors wish to

acknowledge students Mandy Dimmer, Thomas Liao

and Laura Prytherch for assistance with data collection.

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Measuring self-report obsessionality in anorexia nervosa: Maudsley obsessive–compulsive inventory...

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