Cognitive dysfunction in compulsive checkers: Further explorations

Recent evidence suggests a relationship between certain memory deficits and compulsive-checking behavior. The present study explores this relationship in the context of several additional memory capacities not yet investigated. Using the Maudsley Obsessional-Compulsive Inventory and the Everyday Checking Behavior Scale four groups of Ss were identified: (1) frequent checkers, (2) occasional checkers, (3) infrequent checkers and (4) noncheckers. Consistent with previous research, a memory-for-actions task indicated a deficit among compulsive checkers. Furthermore, checking status was found to be negatively related to memory functioning as measured by the Wechsler Memory Scale (WMS) and the Cognitive Failures Questionnaire (CFQ). This memory deficit was most pronounced on the Logical Memory subtest of the WMS. Checkers appear to have difficulty recalling details of meaningfully linked sequences, either presented in narrative form or engaged in personally. Although the reasons for these checking-related deficits are not clear, a complete understanding of checking phenomena will involve an appreciation of the role played by memory deficits.     

Memory in sub-clinical obsessive-compulsive checkers

In a series of experiments we extended the research on possible memory deficits in subclinical obsessive-compulsive Ss who reported excessive checking. Using a variety of memory tests we compared 20 subclinical checkers to 20 Ss without obsessive-compulsive symptomatology. Contrary to hypothesis, checkers remembered self-generated words better than read words just as much as did normals, but they were more likely than normals to report thinking they had studied words that, in fact, had not been on the study list. Further, they more often confused whether they read or generated the words at study. Checkers did not appear to perseverate on already-recalled words on repeated free recall tests any more than did normals. However, checkers remembered fewer actions overall and more often misremembered whether they had performed, observed, or written these actions. Such memory deficits may contribute to the development of excessive checking.     

Relationships between anger, symptoms, and cognitive factors in OCD checkers

The purpose of this study was to examine whether individuals diagnosed with obsessive-compulsive disorder (OCD) with primary checking compulsions report higher levels of trait anger and anger expression compared with a student control group, and whether trait anger and anger expression are correlated with specific beliefs and interpretations that are common among individuals who compulsively check. A group of individuals with OCD reporting significant checking compulsions (n=33) and a group of undergraduate students (n=143) completed a questionnaire package that included measures of trait anger and anger expression, as well as measures of obsessive-compulsive symptoms and beliefs. The compulsive checking group reported greater trait anger, though not greater anger expression, than the student control group. Furthermore, beliefs concerning perfectionism and intolerance of uncertainty were positively correlated with anger expression and trait anger among compulsive checkers but not among the student control group. The implications of these findings are discussed in terms of cognitive-behavioural treatments for and models of compulsive checking in OCD.     

Compulsive checking and anxiety in a nonclinical sample: Differences in cognition,behavior, personality,and affect

This study addresses the question of why some highly anxious individuals exhibit excessive levels of compulsive checking behavior while other do not. To this end, nonclinical samples of compulsive checkers (n=19), (nonchecking) anxious controls (n=16), and (nonchecking) nonanxious controls (n=12) were compared on a variety of cognitive, behavioral, personality, and affective measures hypothesized to differentiate checkers from anxious controls. Results indicated that checkers exhibited higher levels of perfectionism and worry, and demonstrated greater cognitive impairment on the Wisconsin Card Sorting Test. Furthermore, performance and subjective experiences of performance appeared to be mediated by perfectionism and worry. Findings suggest that both personality and cognitive variables are important correlates of the form of anxiety-related symptomatology.     

Prevalence of DSM-III-R disorders among nonclinical compulsive checkers and noncheckers in a college student sample.

The prevalence of lifetime DSM-III-R disorders was assessed in a sample of 100 college students who were classified as compulsive checkers (n = 50) or noncheckers (n = 50) on the basis of their responses to the Checking subscale of the Maudsley Obsessional-Compulsive Inventory (MOCI). DSM-III-R disorders were assessed on the basis of responses to the Diagnostic Interview Schedule, Version III Revised (DIS-III-R), administered by trained, lay interviewers, blind to Ss' checking status. Checkers, compared to noncheckers, were significantly more likely to meet lifetime diagnostic criteria for Major Depressive Episode, Drug Abuse/Dependence, and Social Phobia. Analysis of a subsample (n = 74) selected on the basis of the consistency of responses to the MOCI across two administrations replicated the above effects, with two exceptions: (1) checkers were more likely to meet criteria for Obsessive Compulsive Disorder than were noncheckers, and (2) for males, but not females, Simple Phobia was more prevalent among checkers than among noncheckers. These findings extend our previous work by demonstrating that 'nonclinical' checking behavior is associated with a broad range of psychological syndromes and may, in fact, be more strongly associated with other disorders than it is with Obsessive Compulsive Disorder in a nonclinical sample.     

How checking breeds doubt: Reduced performance in a simple workingmemory task

A paradox of memory research is that repeated checking results in a decrease in memory certainty, memory vividness and confidence [van den Hout, M. A., & Kindt, M. (2003a). Phenomenological validity of an OCD-memory model and the remember/know distinction. Behaviour Research and Therapy, 41, 369-378; van den Hout, M. A., & Kindt, M. (2003b). Repeated checking causes memory distrust. Behaviour Research and Therapy, 41, 301-316]. Although these findings have been mainly attributed to changes in episodic long-term memory, it has been suggested [Shimamura, A. P. (2000). Toward a cognitive neuroscience of metacognition. Consciousness and Cognition, 9, 313-323] that representations in working memory could already suffer from detrimental checking. In two experiments we set out to test this hypothesis by employing a delayed-match-to-sample working memory task. Letters had to be remembered in their correct locations, a task that was designed to engage the episodic short-term buffer of working memory [Baddeley, A. D. (2000). The episodic buffer: a new component in working memory? Trends in Cognitive Sciences, 4, 417-423]. Of most importance, we introduced an intermediate distractor question that was prone to induce frustrating and unnecessary checking on trials where no correct answer was possible. Reaction times and confidence ratings on the actual memory test of these trials confirmed the success of this manipulation. Most importantly, high checkers [cf. VOCI; Thordarson, D. S., Radomsky, A. S., Rachman, S., Shafran, R, Sawchuk, C. N., & Hakstian, A. R. (2004). The Vancouver obsessional compulsive inventory (VOCI). Behaviour Research and Therapy, 42(11), 1289-1314] were less accurate than low checkers when frustrating checking was induced, especially if the experimental context actually emphasized the irrelevance of the misleading question. The clinical relevance of this result was substantiated by means of an extreme groups comparison across the two studies. The findings are discussed in the context of detrimental checking and lack of distractor inhibition as a way of weakening fragile bindings within the episodic short-term buffer of Baddeley's (2000) model. Clinical implications, limitations and future research are considered.     

Memory deficits in compulsive checkers: replication and extension in a clinical sample

Thirteen checkers and twelve noncheckers, identified on the basis of their responses to the checking subscale of the Maudsley Obsessional-Compulsive Inventory (MOCI; Rachman and Hodgson, 1980), were recruited from a sample of 99 consecutive admissions to the outpatient department of a community mental health center. Consistent with our previous research with nonclinical samples of college students (Sher et al., 1983, 1984), checkers were found to show deficits in memory, especially recall for recently completed actions, compared to noncheckers. This result demonstrates the replicability of our previous findings across different types of samples and implicates deficits in memory for actions as a potentially important determinant of checking behavior. Assessment of spontaneous imagery associated with the anamnestic process suggested that checkers utilized less imagery, especially visual imagery, when recalling biographical information. Additional measures collected at the time of testing indicated that checkers were more neurotic and reported more psychological distress than noncheckers.     

Obsessional-compulsive checking: Experimental replication and development

The purpose of this experiment was to resolve some inconclusive findings from an earlier study on the effects of compulsive checking rituals. Twelve obsessional-compulsive checkers carried out a provoking act followed by their compulsive checking ritual, in natural situations, under two conditions—E present and E absent. The provoking act produced subjective discomfort, tension, worry and anxiety; these feelings were reduced after completion of the checking ritual. Both the increases and post-ritual decreases in discomfort were more pronounced in the spontaneous occurrence condition (E absent). The results are consistent with the hypothesis that compulsive rituals serve to reduce discomfort.     

Believe in yourself: Manipulating beliefs about memory causes checking

One of the most common compulsions in obsessive–compulsive disorder (OCD) is repeated checking. Although individuals often report that they check to become more certain, checking has been shown to have the opposite effect – increased checking causes increased uncertainty. However, checking may also be thought of as beginning because of memory uncertainty. Beliefs about responsibility, over-estimation of threat, intolerance of uncertainty, perfectionism, and importance of and control of thoughts are already known to affect different aspects of OCD symptomatology. Beliefs about memory, however, are not currently considered to influence compulsive behaviour. In the current study, beliefs about memory were manipulated to test whether or not they affected urges to check. Ninety-one undergraduate participants received (positive or negative) false feedback about their performance on aspects of a standardized memory test, and then completed two additional memory tasks. Their urges to check following these tasks were assessed. Consistent with our hypotheses, individuals in the low memory confidence condition had greater urges to check following the memory tasks than those in the high memory confidence condition, demonstrating that manipulations of beliefs about memory can influence checking. Results and implications are discussed in terms of cognitive-behavioural models of and treatments for OCD.     

Danger Ideation Reduction Therapy for Obsessive–Compulsive Checking: Preliminary Findings

Danger Ideation Reduction Therapy (DIRT) is a cognitive treatment package developed in the mid-1990s to treat obsessive–compulsive (OC) washing. DIRT is solely directed at decreasing threat expectancies and does not involve direct or indirect exposure. The effectiveness of the DIRT package for OC washers has been examined, and to date a number of publications, including two randomised controlled trials, support its efficacy. Recently, the DIRT package was modified to treat people with the OC checking subtype. In the current study, three adult OC checkers received DIRT in 12 to 14 individual 1-hr sessions conducted by a clinical psychologist. At posttreatment, substantial and clinically significant reductions in scores on a range of standardized outcome measures of obsessive–compulsive disorder symptom severity were apparent for all three participants. Crucially, these improvements were maintained at 4-month follow-up. Although further research is clearly warranted, these preliminary findings suggest that DIRT for checkers may prove as effective as DIRT for OC washers.     

Categorization and cognitive deficits in compulsive hoarding

According to the cognitive-behavioural model of compulsive hoarding, information-processing deficits in the areas of attention, memory, decision-making, and categorization contribute to hoarding behaviour. The purpose of the current study was to examine whether individuals with compulsive hoarding exhibited impairment on executive functioning and categorization tasks. Three groups of participants were recruited (N = 60): individuals with compulsive hoarding syndrome, individuals with an Axis I mood or anxiety disorder, and non-clinical control participants. All participants completed self-report measures of cognitive difficulties, neuropsychological tests of executive functioning and decision-making, and four categorization tasks. Results suggested that hoarding participants reported more cognitive failures and more problems with attention and decision-making than non-clinical control participants. In addition, hoarding participants performed worse than both control groups on the Stockings of Cambridge (SOC), a neuropsychological test of planning ability, and were slower and more anxious during a categorization task. These findings suggest that specific deficits in executive functioning may be associated with the difficulties hoarding patients have organizing their possessions.     

Deficits in set-shifting ability in nonclinical compulsive checkers

Recent studies suggest deficits in set-shifting ability in patients with obsessive-compulsive disorder (OCD) as measured by tasks such as the Wisconsin Card Sorting Test (WCST; Berg, 1948). The present study examined the extent to which these deficits were demonstrated by nonclinical subjects selected on the basis of their checking scores on the Maudsley Obsessional-Compulsive Inventory. A multivariate analysis revealed that frequent checkers performed significantly worse on the WCST than noncheckers, making more total errors and more perseverative errors and requiring more time to complete the test. A follow-up analysis on a subset of the original sample found similar performance deficits in checkers. While the poorer performance of checkers could be statistically accounted for by anxiety during the first administration of the WCST, anxiety could not explain the relationship between checking status and WCST performance at follow-up. Therefore, there does appear to be some relationship between checking status and WCST performance beyond what can be explained by affective variables.     

Phenomenological validity of an OCD-memory model and the remember/know distinction

In earlier experiments using interactive computer animation with healthy subjects, it was found that displaying compulsive-like repeated checking behavior affects memory. That is, checking does not alter actual memory accuracy, but it does affect 'meta-memory': as checking continues, recollections are experienced as less vivid and less detailed while confidence in memory is undermined. This procedure provides a model of OCD checking and suggests that checking is a counterproductive strategy to reduce memory distrust. The present experiment was carried out to specify the phenomenological quality of memory distrust after checking and to see if repeated checking produces a shift in the memory source that is used to decide about the outcome of checking: from 'remembering' to 'knowing' (Tulving, 1985). Using the same interactive computer-animation, the earlier findings on vividness, detail and confidence were replicated. In addition, it was found that checking made participants endorse quotations from OCD patients (Reed, 1985) expressing a specific ambivalence about memory: 'It is as though the memory is there, but is isn't definite enough', 'I remember doing it in a way, but it's all fuzzy....' And 'I can remember that I've done it. But the memory isn't clear somehow'. This finding adds to the validity of the experimental model. Furthermore, after checking subjects' beliefs about the outcome of checking became based on (general) knowing instead of (specific) remembering. It is suggested that OCD checkers feel a general and relatively strong need to be certain about the veracity of recollections and that they have high standards for memory performance. This may explain earlier findings that OCD checkers have a general tendency to distrust their episodic memory. A need for certainty and a critical attitude towards memory performance may not be problematic or abnormal. It is suggested that clinical problems arise when the patient tries to fight memory distrust by repeated checking. The latter does not reduce distrust but rather increases distrust and the patient may get trapped in a spiral of mutually reinforcing checking behavior and memory distrust.     

Exploring the boundaries of memory distrust from repeated checking: increasing external validity and examining thresholds

Checking behavior is among the most common forms of compulsions in OCD. Recent research suggests that repeated checking decreases memory confidence, and supports theoretical models of how repeated checking is maintained. The current paper presents findings from two studies exploring the boundaries of memory distrust from repeated checking. Results of study 1 show that repeated checking of a real stove decreases memory confidence, vividness, and detail (i.e., metamemory), and leads to a greater reliance on knowing as a source of memory, without meaningfully altering memory accuracy. Results of study 2 suggest that these changes in metamemory are observed after performing a relatively low number of checks on one occasion. The findings are considered within the context of theoretical models of checking and future directions are delineated.     

A mood-as-input account of perseverative checking: the relationship between stop rules, mood and confidence in having checked successfully

The present paper reports the results of two experiments designed to test predictions from the mood-as-input account of perseverative checking. Using an analogue checking task, both experiments showed that perseveration, as indicted by a range of measures relevant to compulsive checking, was affected by the configuration of the stop rule for the task and mood at the outset of checking. Perseveration was most significant in the condition that most closely resembled the characteristics of obsessive-compulsive checkers (negative mood combined with a stop rule that specifies that the task should be done as thoroughly as possible--namely, an 'as many as can' stop rule). The studies also indicated that confidence at having completed the checking task successfully was (1) significantly related to the use of 'as many as can' stop rules at the outset of checking, (2) mood ratings at the end of checking, and (3) checking perseveration generally. These findings provide support for a mood-as-input explanation of perseverative psychopathologies such as compulsive checking, and begin to cast some light on how anxiety-reduction and 'confidence' models of compulsive checking, might be explained within broader mechanisms of perseveration.     

What Drives OCD Symptom Change During CBT Treatment? Temporal Relationships Among Obsessions and Compulsions

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment.     

Memory and metamemory for semantic information in obsessive-compulsive disorder

Several studies have been conducted on OCD patients' memory and metamemory performance in episodic tasks. However, there is a clear lack of research addressing these issues for semantic memory (i.e., retrieval of information from long-term memory). Although findings regarding a memory deficit is somewhat equivocal, the empirical evidence clearly demonstrates that OCD patients with primarily checking compulsions show reduced confidence in their memory performance. The purpose of the present study was to investigate memory and metamemory performance of checkers in semantic memory domain. We compared checker OCD patients, non-checker OCD patients and normal controls on their ability to retrieve answers to general knowledge questions with a recall as well as a recognition test. We also investigated prospective (feeling-of-knowing (FOK)) and retrospective (confidence) metamemory judgments. Checker OCs were not poorer in retrieving semantic information from long-term memory. Neither were they less confident about their ability to remember currently unrecallable information in the future (FOK judgments) or about the accuracy of retrieved information (confidence judgments). Moreover, accuracy of metamemory judgments were comparable across groups. Overall, our results revealed that checker OCs do not show a memory or metamemory deficit when semantic memory was concerned, suggesting that any memory and metamemory deficit may be special to recently experienced materials.     

Obsessive compulsive disorder,checking, and non-verbal memory: a neuropsychological investigation

There is considerable evidence in the literature for the presence of non-verbal and praxic memory deficits in OCD. Such deficits may represent the cognitive substrate of doubt-related phenomenon such as checking. Neuropsychological tests of non-verbal memory functioning and memory for actions were administered to patients with OCD (whose predominant symptom was checking) and a group of matched healthy controls. Significant differences were found between the experimental and control groups, suggesting some memory impairment in the OCD group; however, no significant relationship was found linking neuropsychological test indices with checking. Significant relationships were found linking recognition memory problems and immediate memory for actions with general symptom severity.     

Reading skills in hyperlexia: a developmental perspective.

Hyperlexia is characterized by advanced word-recognition skills in individuals who otherwise have pronounced cognitive, social, and linguistic handicaps. Language, word recognition, and reading-comprehension skills are reviewed to clarify the nature and core deficits associated with the disorder. It is concluded that hyperlexia should be viewed as part of the normal variation in reading skills, which are themselves associated with individual differences in phonological, orthographic, and semantic processing, short-term memory, and print exposure. A compulsive preoccupation with reading may also be crucial to the development of a hyperlexic reading profile. A theoretical framework, based on recent connectionist models of reading development, is described. This perspective provides a satisfactory account for how individual differences in a number of different skills can lead to a variety of manifestations of reading behavior, including hyperlexia.     

Event‐based prospective memory and obsessive–compulsive disorder intrusive obsessional thoughts

Recent studies have found poorer prospective remembering among students selected for elevated obsessive–compulsive disorder (OCD) checking and washing. However, as prospective memory performance also requires retrospective remembering, it is not clear from earlier work whether deficits in prospective memory in samples with OCD symptomatology are due to problems with prospective remembering, or to retrospective memory failures that result in poorer performance on prospective memory tasks. The present study examines performance on matched prospective and retrospective memory tasks among students selected for high (n = 48) and low (n = 44) scores on the Obsessive–Compulsive Inventory‐Revised Obsession subscale. Significant differences between the groups were found in prospective memory (regardless of whether the word was neutral or harm/danger‐related), but not retrospective memory. The findings are consistent with the prediction that obsessional thoughts that occupy working memory capacity would have a deleterious effect on a resource‐demanding prospective memory task. An additional finding was that there were no group differences in self‐reported complaints of problems with prospective memory.