COVID-19-Specific Obsessive Compulsive Symptoms Scale (C19-OCS)

1. Abstract

The COVID-19-Specific Obsessive Compulsive Symptoms Scale (C19-OCS) is a specialized psychometric assessment instrument developed by Asiye Şengül Avşar and Volkan Avşar in 2023. It was constructed to quantify, evaluate, and monitor obsessive–compulsive (OC) symptomatology directly triggered by, or contextualized within, the coronavirus disease 2019 (COVID-19) global pandemic. While general inventories of obsessive–compulsive disorder (OCD) capture broad phenotypic manifestations across lifetime courses, they often lack the ecological sensitivity required to differentiate adaptive epidemiological vigilance from clinically elevated, dysfunctional psychopathology in the face of widespread viral threat. The C19-OCS was devised via a comprehensive operationalization process, initiating with a 49-item pool derived from extensive literature review and refined via qualitative content validation down to 17 candidate items. Administered to a primary standardization sample of adults and university students in Turkey (aged 18 to 65 years), the instrument underwent rigorous modern and classical psychometric testing.

Methodologically, the scale development incorporated Mokken Scale Analysis (MSA)—a non-parametric item response theory (IRT) model—employing the Automated Item Selection Procedure (AISP) alongside the Mokken Homogeneity Model (MHM). This identified a latent dominant trajectory while isolating an underperforming item (scalability coefficient H < 0.30), leaving a refined 16-item inventory. Subsequent exploratory factor analysis (EFA) utilizing principal axis factoring (PAF) with parallel analysis firmly established a two-factor structure accounting for 49.30% of total variance: Obsessive thoughts and Contamination fears and cleaning. Reliability assessments established excellent precision across all internal consistency indices, including Cronbach’s alpha (α = 0.82–0.92), Guttman’s lambda-2 (λ₂ = 0.82–0.92), McDonald’s omega (ω = 0.82–0.92), composite reliability (CR = 0.91–0.95), and latent class reliability coefficients (LCRC). Temporal stability over a two-week interval was confirmed via test-retest correlations ranging from r = 0.74 to 0.78 (p < 0.01). Convergent validity was evidenced by Average Variance Extracted (AVE) values of 0.53 and 0.63, while discriminant validity satisfied the Fornell–Larcker criterion with square roots of AVE (0.73 and 0.79) exceeding inter-factor correlation (0.71). The C19-OCS provides clinicians, epidemiologists, and behavioral researchers with an empirically robust tool to examine health-related obsessions and compulsions during pandemic emergencies.

2. Keywords

COVID-19, Obsessive–Compulsive Symptoms, Contamination Fears, Cleaning Compulsions, Mokken Scale Analysis, Non-parametric Item Response Theory, Psychometrics, Health Anxiety, Infectious Disease Outbreak, C19-OCS, Mental Health Assessment

3. Authors

The COVID-19-Specific Obsessive Compulsive Symptoms Scale was conceptualized, designed, and psychometrically standardized by:

• Asiye Şengül Avşar — Department of Measurement and Evaluation in Education, Faculty of Education, Recep Tayyip Erdoğan University, Rize, Turkey.
• Volkan Avşar — Department of Psychological Counselling and Guidance, Faculty of Education, Recep Tayyip Erdoğan University, Rize, Turkey. ORCID: 0000-0001-9427-9425. Corresponding author email: [email protected].

4. Purpose

The primary purpose of the COVID-19-Specific Obsessive Compulsive Symptoms Scale (C19-OCS) is to provide an empirically validated, context-sensitive psychometric metric that measures intrusive cognitive obsessions and behavioral cleaning/neutralizing compulsions specifically mobilized by the SARS-CoV-2 outbreak. Historically, large-scale epidemiological crises alter the ambient threat landscape, creating unprecedented challenges for clinical assessment. During the COVID-19 pandemic, public health authorities universally mandated protective behaviors, including frequent handwashing, sanitizing surfaces, social distancing, and respiratory masking. Under standard psychological circumstances, excessive washing and hyper-fixation on environmental pathogens serve as diagnostic hallmark criteria for obsessive–compulsive disorder under DSM-5 and ICD-11 frameworks. However, when health directives actively mandate hygiene rituals to avert severe illness or death, traditional diagnostic boundaries become blurred.

Standardized psychiatric instruments such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) or the Obsessive-Compulsive Inventory-Revised (OCI-R) assess symptomatology broadly across lifetime or past-week contexts without anchoring the cognitive appraisals to pandemic-specific phenomena. Consequently, individuals adhering stringently to state-sponsored hygiene advice could score artificially high on conventional contamination scales, producing false positives. Conversely, individuals suffering from genuine pandemic-triggered psychopathology—characterized by agonizing, recurring, intrusive thoughts of contamination, disproportionate functional impairment, and repetitive rituals consuming hours per day—might not have their pandemic-specific cognitive content adequately targeted by generalized inventories. The C19-OCS was developed to bridge this critical methodological gap.

In research contexts, the C19-OCS serves as an empirical instrument to quantify the behavioral and cognitive impact of viral pandemics across diverse community and clinical demographics. It permits researchers to track the longitudinal trajectory of obsessive-compulsive traits as infection waves peak and recede, correlate OC symptoms with other psychological constructs (such as cyberchondria, death anxiety, intolerance of uncertainty, and acute stress), and assess the efficacy of community-level psychological interventions. Furthermore, the scale facilitates cross-sectional epidemiological surveys seeking to establish what proportion of public health compliance transitions into disabling, perseverative clinical rituals.

In clinical practice, the C19-OCS functions as a diagnostic adjunct and screening measure. Mental health practitioners, including psychiatrists, clinical psychologists, and psychiatric nurses, can use the tool to systematically distinguish between functional health protective behavior and pathological ritualization. A critical operational objective of the C19-OCS is evaluating the subjective distress, uncontrollability, and functional interference associated with these behaviors over the preceding month. By isolating Obsessive thoughts from Contamination fears and cleaning, clinicians can develop targeted cognitive-behavioral therapy (CBT) treatment plans—specifically structuring Exposure and Response Prevention (ERP) paradigms tailored directly to viral transmission cognitive distortions rather than decontextualized dirt or general microbial contamination.

5. Psychological Construct

The C19-OCS operationalizes a multi-faceted clinical and sub-clinical psychological construct: pandemic-induced obsessive-compulsive symptomatology. Obsessive-compulsive disorder is characterized by two distinct yet deeply intertwined components: obsessions (recurrent, persistent, intrusive thoughts, urges, or mental images that provoke marked anxiety or distress) and compulsions (repetitive motor behaviors or mental acts performed to reduce distress or prevent a dreaded event according to rigid rules). In the specific context of COVID-19, this diagnostic dichotomy expresses itself through two empirically substantiated sub-dimensions: Obsessive thoughts and Contamination fears and cleaning.

Obsessive Thoughts

The first subscale captures the cognitive, internal, and intrusive manifestation of the disorder. In the context of COVID-19, cognitive intrusions revolve around hyper-salience of contagion, pervasive doubts concerning microbial contact, and catastrophic misinterpretations of normal physiological sensations or routine environmental interactions. Individuals experiencing elevated scores on this dimension report continuous, involuntary mental intrusion regarding viral presence on surfaces, in airborne particles, or on personal belongings. These thoughts possess an ego-dystonic or highly distressing quality, wherein the individual recognizes the excessive nature of the preoccupation yet finds the mental stream irresistible and uncontrollable.

Cognitive features assessed within this dimension include:

• Intrusive Viral Imagery: Persistent visualization of unseen coronavirus particles adhering to clothing, doorknobs, food packaging, or skin surfaces.
• Pathological Doubting: Relentless cognitive uncertainty regarding whether one has adequately sanitized an object, washed one’s hands, or maintained sufficient spatial distance from an asymptomatic carrier.
• Catastrophic Misinterpretation of Benign Stimuli: Interpreting a minor throat tickle, transient fatigue, or an innocuous cough as definitive proof of impending viral infection and familial transmission.
• Mental Neutralization: Engaging in exhausting covert mental processes (e.g., mentally retracing one’s steps, re-evaluating public encounters) to mentally nullify perceived contagion risks.

Contamination Fears and Cleaning

The second subscale represents the overt behavioral and motoric rituals executed in direct response to the distressing cognitive obsessions. Within classic psychopathology, cleaning compulsions are secondary behavioral adaptations designed to temporarily down-regulate the acute autonomic arousal elicited by contamination obsessions. In the COVID-19 paradigm, these behaviors mimic, but vastly exceed, standard public health disinfection recommendations in frequency, duration, intensity, and ritualistic rigidity.

Behavioral manifestations evaluated within this dimension include:

• Repetitive and Prolonged Hand Hygiene: Handwashing routines that extend far beyond the 20-second guidance, often involving scalding water, industrial solvents, or washing sequences repeated a predetermined number of times until an internal feeling of “purity” or safety is reached.
• Compulsive Disinfection of Inanimate Objects: Sterilizing groceries, mail, delivered packages, keys, footwear, and outer garments using bleach or caustic sanitizing chemicals, frequently resulting in physical destruction of personal property or chemical exposure.
• Rigid Decontamination Protocols: Establishing elaborate “quarantine airlocks” within domestic spaces, requiring complex sequential shedding of clothing, multiple consecutive showers, and prohibiting family members from touching shared surfaces before strict chemical cleansing.
• Avoidance and Paralyzing Inhibition: Extreme avoidance behaviors that transcend rational mitigation, including total refusal to open windows, touch essential mail, or interact with essential healthcare providers out of an intense fear of biological contamination.

Together, these dimensions construct a bidirectional feedback loop: viral contamination fears trigger intrusive obsessive thoughts, which elevate subjective anxiety, compelling the execution of cleaning rituals. The transient relief provided by these compulsive acts negatively reinforces the belief that the ritual was necessary to avert death or severe illness, cementing the chronic obsessive-compulsive cycle.

6. Theoretical Framework

The architecture of the C19-OCS is rooted in foundational cognitive-behavioral theories of psychopathology, integrated with modern evolutionary perspectives on the behavioral immune system and contemporary neurobiological models of anxiety.

The Cognitive Model of OCD (Rachman & Salkovskis)

The theoretical bedrock of the scale rests upon Salkovskis’s (1985) cognitive theory of OCD and Rachman’s (1997, 2004) conceptualization of contamination obsessions. According to Salkovskis, intrusive thoughts are ubiquitous; virtually all human beings experience fleeting, irrational, or bizarre intrusions. The critical transition from a normal intrusive thought to a clinical obsession occurs when the individual appraises the intrusion as indicating that they are personally responsible for preventing catastrophic harm to themselves or others (inflated responsibility). In the COVID-19 landscape, this theoretical mechanism became amplified. The public was constantly informed that personal non-compliance could lead directly to the death of vulnerable family members or neighbors. This message resonated directly with individuals predisposed to inflated responsibility and overestimation of threat. The C19-OCS explicitly measures the consequences of these cognitive distortions, where failing to execute a cleansing routine is cognitively equated with moral culpability for lethal transmission.

The Behavioral Immune System (BIS)

From an evolutionary psychology perspective, the scale aligns with Schaller and Park’s (2007) behavioral immune system model. The BIS evolved as a proactive suite of psychological mechanisms designed to detect visual and olfactory cues of infectious pathogens in the immediate environment and trigger immediate avoidance behaviors (e.g., disgust, withdrawal). Unlike the physiological immune system, which neutralizes pathogens post-infection at high energetic and metabolic costs, the BIS acts preemptively. However, during an airborne viral pandemic where pathogens are microscopic and asymptomatic transmission is rampant, the BIS becomes chronically hyperactivated. Lacking tangible sensory cues to signal safety, the human mind relies on heuristic threat appraisal. In vulnerable individuals, this hyperactive pathogen-avoidance program escalates into severe contamination OCD, manifesting as the repetitive behavioral cleaning patterns operationalized in the C19-OCS.

Information Processing and Threat Hyper-vigilance

The operational framework of the scale also incorporates Beck and Clark’s (1997) cognitive processing model of anxiety disorders. Under continuous exposure to alarming pandemic media reporting, individuals develop hypersensitive cognitive schemas centered on biological vulnerability. These schemas bias attentional resources toward threat-related cues (e.g., someone clearing their throat across a room, a fingerprint on a polished surface). This attentional bias reinforces cognitive intrusions (captured by the Obsessive thoughts subscale) and disrupts reality testing, perpetuating compulsions (captured by the Contamination fears and cleaning subscale). By mapping directly onto these dual cognitive-behavioral axes, the C19-OCS captures the structural and functional core of the clinical phenomenology.

7. Validity

The psychometric validation of the C19-OCS was conducted using rigorous modern and classical validation protocols in accordance with the standards outlined by the American Educational Research Association (AERA), APA, and NCME (2014). The initial 49-item pool was scrutinized by panels of psychological and measurement experts to establish content validity, leading to the retention of 17 psychometrically sound items targeting the intended theoretical construct.

Construct and Structural Validity

Construct validity was established via a sequential combination of non-parametric Item Response Theory (Mokken Scale Analysis) and parametric Exploratory Factor Analysis. The Mokken Homogeneity Model demonstrated that the scale items conform to a cumulative, unidimensional latent continuum at the macro level, while factor analytic procedures established an optimal two-factor empirical structure explaining 49.30% of the common variance across the operationalized symptoms.

Convergent Validity

Convergent validity was evaluated by assessing factor loadings and calculating the Average Variance Extracted (AVE) from the measurement model. In structural equation modeling and factor analysis, AVE represents the grand mean value of the squared loadings of the indicators associated with a construct, indicating the percentage of variance captured by the construct relative to measurement error. According to established psychometric criteria (Hair et al., 2019), an AVE of 0.50 or higher demonstrates robust convergent validity, confirming that the latent variable accounts for more than half of the variance of its observed indicators:

• Factor 1 (Obsessive thoughts): AVE = 0.53
• Factor 2 (Contamination fears and cleaning): AVE = 0.63

Because both subscales yielded AVE coefficients substantially exceeding the 0.50 threshold, empirical support for convergent validity is robust.

Discriminant Validity

Discriminant validity assesses whether the operationalized subscales are genuinely distinct theoretical dimensions rather than redundant measurements of the same underlying variable. The developers evaluated discriminant validity utilizing the stringent Fornell–Larcker (1981) criterion. According to this rule, discriminant validity is established if the square root of the AVE for each latent factor is higher than the correlation between that factor and any other factor in the structural model.

• Inter-factor correlation between Factor 1 and Factor 2: r = 0.71
• Square root of AVE for Factor 1: 0.73 (√0.53)
• Square root of AVE for Factor 2: 0.79 (√0.63)

Because both √AVE values (0.73 and 0.79) are demonstrably greater than the inter-factor correlation coefficient of 0.71, the Fornell–Larcker criterion is fully met. This confirms that while Obsessive thoughts and Contamination fears and cleaning are functionally related components of COVID-19 psychopathology, they represent empirically distinct psychological constructs.

8. Reliability

The C19-OCS was subjected to an unusually extensive battery of reliability analyses, moving far beyond standard single-metric reporting to encompass classical test theory, latent class modeling, and temporal stability assessments. Across all evaluations, the scale exhibited high measurement precision and minimal error variance.

Internal Consistency

To avoid the known mathematical limitations and restrictive assumptions of tau-equivalence associated with standalone Cronbach’s alpha, multiple internal consistency coefficients were computed:

• Cronbach’s Alpha (α): Coefficients for the total 16-item scale and its constituent subscales ranged between 0.82 and 0.92, demonstrating excellent internal homogeneity well above the customary 0.70 benchmark for research tools and the 0.80 benchmark for clinical screening.
• Guttman’s Lambda-2 (λ₂): Values ranged from 0.82 to 0.92. Guttman’s λ₂ serves as a robust alternative that relaxes the equal error variance assumptions of alpha, providing lower-bound reliability estimates that closely mirrored the alpha parameters.
• McDonald’s Omega (ω): Omega coefficients ranged between 0.82 and 0.92. McDonald’s omega does not assume essential tau-equivalence and provides a more realistic assessment of reliability in congeneric measurement models where factor loadings vary across items.
• Composite Reliability (CR): Derived from structural modeling parameters, CR values ranged from 0.91 to 0.95, surpassing the standard 0.70 cutoff and confirming high construct reliability.
• Latent Class Reliability Coefficient (LCRC): Computed within the non-parametric item response framework, LCRC confirmed robust person-score reliability across latent proficiency strata.

Test-Retest Reliability (Temporal Stability)

The temporal stability of the C19-OCS was evaluated by re-administering the instrument to a sub-sample of participants after a two-week interval. Pearson product-moment correlation coefficients between Time 1 and Time 2 scores ranged from r = 0.74 to 0.78 (p < 0.01) across the subscales and total score. These figures demonstrate that while the scale remains sensitive to evolving contextual circumstances over the course of a pandemic, its measurement properties exhibit solid test-retest reliability across short-to-medium diagnostic intervals.

9. Factor Analysis

The internal dimensionality and structural integrity of the C19-OCS were evaluated through a multi-stage analytic pipeline combining non-parametric Item Response Theory (IRT) with exploratory and confirmatory factor analyses.

Mokken Scale Analysis (MSA)

Before conducting linear factor analyses, the authors applied Mokken Scale Analysis—specifically testing the Mokken Homogeneity Model (MHM). MSA evaluates whether items fall along a cumulative, hierarchical Guttman-like continuum without imposing strict parametric distributional requirements. In MSA, the primary scalability metric is Loevinger’s scalability coefficient (H), calculated for individual items (Hᵢ) and the overall scale (H). An item is considered psychometrically scalable within an MHM framework if its Hᵢ coefficient exceeds 0.30.

During the Automated Item Selection Procedure (AISP), 16 of the 17 candidate items demonstrated strong scalability. However, Item 3 (“I am tired of watching the news about COVID-19”) yielded an Hᵢ scalability coefficient below the 0.30 threshold. This indicated that feeling fatigued by media coverage did not scale hierarchically with the clinical continuum of pandemic-specific obsessive-compulsive symptomatology. Item 3 was consequently eliminated from the scale. Re-analysis of the remaining 16 items confirmed that all item scalability coefficients exceeded 0.30, demonstrating a cohesive, monotonically increasing non-parametric scale.

Exploratory Factor Analysis (EFA)

Following item reduction, Exploratory Factor Analysis was executed on the 16 retained items using the Principal Axis Factoring (PAF) extraction method. To objectively determine the number of factors to retain and avoid subjective over-extraction (such as relying solely on Kaiser’s eigenvalue > 1 rule), Parallel Analysis (PA) was conducted. The empirical eigenvalues from the sample data were compared against the 95th percentile eigenvalues generated from 1,000 synthetic random datasets of identical dimensions.

Parallel analysis unambiguously justified the retention of two dominant factors. The two-factor solution accounted for 49.30% of the total cumulative variance:

• Factor 1: Obsessive thoughts — Grouped items characterizing cognitive intrusions, repetitive mental loops, unshakeable doubts regarding infection, and distressing mental imagery related to SARS-CoV-2.
• Factor 2: Contamination fears and cleaning — Grouped items measuring behavioral decontamination routines, excessive surface sanitizing, ritualized hand hygiene, and avoidance of physical contact with public objects.

Confirmatory Factor Analysis (CFA)

Confirmatory factor analysis was subsequently utilized to confirm the indicator-factor correspondence and generate parameter estimates for structural validity verification. Factor loadings across both latent dimensions were statistically significant (p < 0.001) and substantial in magnitude, enabling the direct calculation of the Average Variance Extracted (AVE = 0.53 and 0.63) and Composite Reliability (CR = 0.91 and 0.95). Rather than relying solely on global fit indices (e.g., RMSEA, CFI), the authors leveraged CFA to confirm measurement model adequacy and substantiate the convergence and distinctiveness of the subscales.

10. Instrument / Measurement Tool

The operational and structural characteristics of the COVID-19-Specific Obsessive Compulsive Symptoms Scale are organized as follows:

• Test Name: COVID-19-Specific Obsessive Compulsive Symptoms Scale
• Acronym: C19-OCS
• Authors: Asiye Şengül Avşar & Volkan Avşar (2023)
• Instrument Type: Self-report rating inventory / Psychological assessment tool
• Number of Items: 16 items
• Factor Structure: Two distinct subscales:
  • Factor 1: Obsessive thoughts
  • Factor 2: Contamination fears and cleaning
• Response Format: 5-point Likert rating scale:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Neither Agree nor Disagree (Neutral)
  • 4 = Agree
  • 5 = Strongly Agree
• Administration Instruction: Participants are instructed to rate their agreement with each item based on their experiences over the past month. A 5-point Likert scale is used for responses, ranging from 1 = strongly disagree to 5 = strongly agree. The administration method is electronic.
• Administration Mode: Self-administered via computerized, mobile, or web-based survey software (electronic administration); paper-and-pencil adaptation is feasible under standard testing conditions.
• Target Population: General and clinical adult populations (aged 18 to 65 years), spanning young adulthood, middle age, and older adults.
• Estimated Completion Time: Approximately 3 to 6 minutes.
• Scoring Procedure: Items are scored from 1 to 5. Subscale scores are derived by summing the items corresponding to each respective factor. A total scale score is obtained by summing all 16 items (ranging from 16 to 80), with higher composite scores reflecting greater severity of pandemic-specific obsessive-compulsive symptomatology.

11. Permissions & Fee and Test Year

• Test Year: 2023
• Publication Medium: Published in the International Journal of Cognitive Therapy (Springer Nature).
• Fee: Free of charge for academic, non-commercial research, and educational applications.
• Permissions & Licensing: Researchers and clinicians wishing to use the C19-OCS in formal empirical investigations, clinical trials, or commercial applications should contact the corresponding author, Volkan Avşar, via email at [email protected]. Standard copyright protections apply under Springer Nature licensing.

12. References

American Educational Research Association, American Psychological Association, & National Council on Measurement in Education. (2014). Standards for educational and psychological testing. American Educational Research Association.

Beck, A. T., & Clark, D. A. (1997). An information processing model of anxiety: Automatic and strategic processes. Behaviour Research and Therapy, 35(1), 49–58. https://doi.org/10.1016/S0005-7967(96)00069-1

Fornell, C., & Larcker, D. F. (1981). Evaluating structural equation models with unobservable variables and measurement error. Journal of Marketing Research, 18(1), 39–50. https://doi.org/10.1177/002224378101800104

Hair, J. F., Black, W. C., Babin, B. J., & Anderson, R. E. (2019). Multivariate data analysis (8th ed.). Cengage Learning.

Mokken, R. J. (1971). A theory and procedure of scale analysis: With applications in political research. De Gruyter Mouton. https://doi.org/10.1515/9783110813203

Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35(9), 793–802. https://doi.org/10.1016/S0005-7967(97)00040-5

Rachman, S. (2004). Fear of contamination. Behaviour Research and Therapy, 42(11), 1227–1255. https://doi.org/10.1016/j.brat.2003.10.009

Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23(5), 571–583. https://doi.org/10.1016/0005-7967(85)90105-6

Schaller, M., & Park, J. H. (2007). The behavioral immune system (and why it matters). Current Directions in Psychological Science, 16(2), 67–71. https://doi.org/10.1111/j.1467-8721.2007.00478.x

Şengül Avşar, A., & Avşar, V. (2023). Development of the COVID-19-specific obsessive compulsive symptoms scale with various validity and reliability proofs. International Journal of Cognitive Therapy, 16(1), 58–80. https://doi.org/10.1007/s41811-022-00155-9

13. Items of the Scale