Cognitive deficits of executive functions and decision‐making in obsessive‐compulsive disorder

The nature of cognitive deficits in obsessive‐compulsive disorder (OCD) is characterized by contradictory findings in terms of specific neuropsychological deficits. Selective impairments have been suggested to involve visuospatial memory, set shifting, decision‐making and response inhibition. The aim of this study was to investigate cognitive deficits in decision‐making and executive functioning in OCD. It was hypothesized that the OCD patients would be less accurate in their responses compared to the healthy controls in rational decision‐making on a version of the Cambridge gambling task (CGT) and on the color‐word interference test and on a version of the Tower of Hanoi test (tower test) of executive functioning. Thirteen participants with OCD were compared to a group of healthy controls (n = 13) matched for age, gender, education and verbal IQ. Results revealed significant differences between the OCD group and the healthy control group on quality of decision‐making on the CGT and for achievement score on the tower test. On these two tasks the OCD group performed worse than the healthy control group. The symptom‐dimension analysis revealed performance differences where safety checking patients were impaired on the tower test compared to contamination patients. Results are discussed in the framework of cognition and emotion processing and findings implicate that OCD models should address, specifically, the interaction between cognition and emotion. Here the emotional disruption hypothesis is forwarded to account for the dysfunctional behaviors in OCD. Further implications regarding methodological and inhibitory factors affecting cognitive information processing are highlighted.     

Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls

Hoarding is a symptom of obsessive compulsive disorder (OCD), as well as a diagnostic criterion for obsessive compulsive personality disorder (OCPD). One recent study suggests that people who suffer from compulsive hoarding report more general psychopathology than people who do not [Frost, R.O., Krause, M.S., & Steketee, G. (1996). Hoarding and obsessive compulsive symptoms. Behavior Modification, 20, 116-132]. The present study addressed whether persons with OCD hoarding exhibit more depression, anxiety, OCD and personality disorders symptoms than community controls, OCD nonhoarders, or other anxiety disorder patients. Disability was also examined. Hoarding subjects were older than the other three groups, but age did not account for any of the differences observed among the groups. Compared to controls, OCD hoarding, nonhoarding OCD and anxiety disorder patients showed elevated YBOCS scores, as well as higher scores on depression, anxiety, family and social disability. Compared to nonhoarding OCD and anxiety disorder patients, OCD hoarding patients scored higher on anxiety, depression, family and social disability. Hoarding subjects had greater personality disorder symptoms than controls. However, OCD hoarding subjects differed from OCD nonhoarding and anxiety disorder subjects only on dependent and schizotypal personality disorder symptoms. The findings suggest that hoarding is associated with significant comorbidity and impairment compared to nonhoarding OCD and other anxiety disorders.     

Words may not be enough! No increased emotional Stroop effect in obsessive-compulsive disorder

Conflicting evidence has been obtained whether or not patients diagnosed with obsessive-compulsive disorder (OCD) share an attentional bias towards disorder-related stimuli. Some of these inconsistencies can be accounted for by suboptimal stimuli selection. In consideration of the heterogeneity of OCD, we investigated Stroop interference effects for two classes of OCD items (i.e., washing and checking) in 23 OCD patients and 23 healthy controls. In order to cover prevalent OCD concerns, item compilation was based on experts' appraisals. Patients neither displayed greater immediate as well as delayed Stroop interference nor any bias for OCD and subtype-congruent stimuli. On the contrary, for washing-related items, OCD patients, and here especially washers, displayed facilitation relative to healthy controls. Although the present study at first sight refutes the notion of an attentional bias in OCD in contrast to other anxiety disorders, several potential moderators need to be considered before this account is ultimately dismissed. In particular, an attentional bias may only be elicited using visual material that is more attention-grabbing than verbal stimuli. Finally, blockwise instead of random item administration and greater consideration of individual relevance may be crucial prerequisites for the effect to emerge.     

Obsessive‐compulsive disorder across developmental trajectory: Cognitive processing of threat in children,adolescents and adults

Background . While the cognitive theory of obsessive‐compulsive disorder (OCD) is one of the most widely accepted accounts of the maintenance of the disorder in adults, no study to date has systematically evaluated the theory across children, adolescence and adults with OCD. Method . This paper investigated developmental differences in the cognitive processing of threat in a sample of children, adolescents and adults with OCD. Using an idiographic assessment approach, as well as self‐report questionnaires, this study evaluated cognitive appraisals of responsibility, probability, severity, thought‐action fusion (TAF), thought‐suppression, self‐doubt and cognitive control. It was hypothesised that there would be age related differences in reported responsibility for harm, probability of harm, severity of harm, thought suppression, TAF, self‐doubt and cognitive control. Results . Results of this study demonstrated that children with OCD reported experiencing fewer intrusive thoughts, which were less distressing and less uncontrollable than those experienced by adolescents and adults with OCD. Furthermore, responsibility attitudes, probability biases and thought suppression strategies were higher in adolescents and adults with OCD. Cognitive processes of TAF, perceived severity of harm, self‐doubt and cognitive control were found to be comparable across age groups. Conclusions . These results suggest that the current cognitive theory of OCD needs to address developmental differences in the cognitive processing of threat. Furthermore, for a developmentally sensitive theory of OCD, further investigation is warranted into other possible age related maintenance factors. Implications of this investigation and directions for future research are discussed.     

Potentials and Limitations of Cognitive Treatments for Obsessive‐Compulsive Disorder

Exposure and response prevention (ERP) is a well‐established treatment for obsessive‐compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure‐based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

A Brief Motivational Intervention for Treatment‐Refusing OCD Patients

Cognitive behavioral therapy involving exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive‐compulsive disorder (OCD). Despite this, ERP is not widely used by mental health practitioners, and so dissemination of ERP and other empirically supported treatment (ESTs) has become a priority. Even so, utilization of ESTs such as ERP remains below 50% even among therapists who self‐identify as having a cognitive behavioral orientation. Barriers to the acceptance of ERP include practical obstacles such as lack of training and the cost of treatment, but also patient variables such as treatment refusal. It has been estimated that approximately 25% of OCD patients refuse ERP. This paper describes a brief, 4‐session readiness intervention (RI) designed to decrease ERP refusal among patients with OCD. In this study, 12 patients with OCD who had refused ERP were randomized to RI or wait‐list (WL). 86% of participants in the RI condition and 20% of participants in WL condition agreed to begin ERP following the 4‐week period. ERP following RI, but not WL, was associated with a decrease in OCD symptoms comparable to that observed in OCD patients who did not refuse ERP. However, ERP following RI was associated with a high drop‐out rate (50%), a figure that exceeds that typically seen in OCD treatment studies. Techniques to reduce drop‐out as well as directions for future research are discussed.     

Poor cognitive flexibility,and the experience thereof,in a subclinical sample of female students with obsessive‐compulsive symptoms

Research indicates that people with obsessive‐compulsive disorder (OCD) have poor cognitive flexibility. However, studies have largely focused on actual abilities and while individuals' emotional responses may be just as important, little is known about how those with OCD experience a situation that requires cognitive flexibility. It is furthermore largely unknown whether cognitive flexibility may also be important for people with OCD symptoms, rather than only to those with full blown disorders. This study investigates the relationship between cognitive flexibility, and the experience thereof in female students with and without OCD symptoms. It was expected that poor cognitive flexibility would be positively associated to OCD symptoms, and that those with OCD symptoms would display poor cognitive flexibility, and experience situations requiring cognitive flexibility as more difficult, than those without OCD symptoms. Participants completed a measure for OCD symptoms, a neuropsychological task to measure cognitive flexibility, and a self‐report measure assessing emotional experience of situations requiring cognitive flexibility. Positive associations between OCD symptoms and both poor cognitive flexibility and negative experience of situations requiring cognitive flexibility were found. Furthermore, those with OCD symptoms performed poorer on the cognitive flexibility task than those without OCD symptoms, and reported higher scores on the cognitive inflexibility questionnaire. Results confirm a relation between OCD symptoms and poor cognitive flexibility in a subclinical sample and identify a relation between OCD symptoms and a negative experience of situations that require cognitive flexibility. Overall findings suggest that poor cognitive flexibility may be an important part of OCD symptomatology.     

Visual Motor Behavior Rehearsal. The Basic Technique

The past decade has witnessed a significant shift toward a more cognitive emphasis in our understanding and treatment of obsessive‐compulsive disorders (OCD). This article discusses the shortcomings in more standard behavioral treatment of OCD, which despite its demonstrated efficacy, led to the recent cognitive‐behavioral approaches to the disorder. Current cognitive behavior therapy for OCD is described and a short critical review of the comparative treatment outcome literature on cognitive behavior therapy vs exposure and response prevention is provided. The article concludes that although the clinical utility of a more cognitive approach to OCD has not been consistently demonstrated, it would be premature to abandon cognitive formulations until some key research questions have been addressed.     

Relations between a ruminative thinking style and obsessive–compulsive symptoms in non-clinical samples

Abstract

There is tremendous interest in understanding the cognitive processes behind obsessive–compulsive disorder (OCD). Whereas previous research on cognitive OCD models has focused on the dysfunctional content of obsessional thinking, processes and styles of thinking have not yet been investigated. The present study investigated the relationship between a ruminative response style and obsessive–compulsive (OC) symptomatology in two non-clinical samples. In Sample 1, 261 students completed the Ruminative Response Scale, the Padua-Inventory, Revised, and the Beck Depression Inventory. Tendency to ruminate was positively correlated with the severity of OC symptoms and particularly with obsessive rumination, even after controlling for depression. Results were replicated in Sample 2 (211 students). Data indicate that a ruminative response style and obsessive rumination share common processual features. Understanding the interaction between rumination and obsessional thinking might help to further elucidate the role of cognitive vulnerability factors in OCD and to expand cognitive and metacognitive models of OCD.     

Kognitive Dissonanz nach Entscheidungen und psychische Erkrankungen

Building upon Grawe’s consistency theory the target of this study was to examine if cognitive dissonance has an influence on mental disorders. More precisely, whether post-decisional cognitive dissonance (1) is more pronounced in patients with mental disorders and (2) whether it correlates with symptom burden. Obsessive-compulsive disorder patients (OCD; n?=?15), depressive patients (n?=?20) and controls (n?=?42) completed a post-decisional cognitive dissonance scale as well as a scale assessing their respective symptom burden. Solely OCD patients showed heightened cognitive dissonance compared to controls (p?=?0.019). Among depressive patients, however, a very high correlation was found to exist between symptom burden and cognitive dissonance (r?=?0.70). Therefore, OCD seems to be related to increased cognitive dissonance which supports the assumption that cognitive dissonance plays a role in this mental disorder.     

Impaired body but not face perception in patients with obsessive–compulsive disorder

Background. Empirical evidence involving the processing of social information by patients with obsessive–compulsive disorder (OCD) has been relatively scarce. Our study investigated the perceptual abilities of patients with OCD to recognize human faces and bodies. Method. Fifty‐four drug‐free or drug‐naïve patients with OCD and 42 healthy controls performed discrimination tasks consisting of four types of stimuli: two sets of faces that were manipulated with regard to configuration and features, human bodies, and chairs. The stimuli were presented in upright and upside‐down orientations. Results. Patients with OCD were significantly less accurate in discriminating pairs of bodily postures implying actions. However, we found no significant differences between patient and control groups in the ability to recognize faces and chairs. The inversion effects for bodies and faces were also comparable between the two groups. Conclusions. The current findings suggest that patients with OCD experience difficulty in perceiving static forms of bodily postures, but are able to adequately recognize human faces. Our data indicate a selective deficit in the perception of bodily postures in those with OCD and suggest that this deficit is probably not related to the abnormal configurational processing of social objects.     

Psychostimulant-induced behavior as an animal model of obsessive-compulsive disorder: an ethological approach to the form of compulsive rituals

Rats treated chronically with the D2/D3 dopamine receptor agonist quinpirole show a pattern of behavior that meets a set of ethologically derived criteria of compulsive behavior in obsessive-compulsive disorder (OCD). Moreover, in both quinpirole-treated rats and OCD patients, the structure of compulsive rituals appear similar in being composed of relatively few motor acts that are organized in a flexible yet recurrent manner. In addition, the development of compulsive behavior in quinpirole-treated rats is attenuated by the OCD pharmacotherapeutic drug clomipramine. These similarities support the validity of quinpirole-treated rats as a psychostimulant-induced animal model of OCD. Considering that the induction of compulsive behavior in the rat model involves chronic hyperstimulation of dopamine receptors, this raises the possibility that dopaminergic mechanisms may play a role in OCD, at least in some subtypes of this disorder.     

Combining Pharmacotherapy with Cognitive‐Behavioral Interventions for Obsessive‐Compulsive Disorder

This paper reviews the evidence‐based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive‐compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin re‐uptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision‐making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.     

Sleep disturbances in treatment‐seeking OCD‐patients: Changes after concentrated exposure treatment

Research indicates that patients with Obsessive Compulsive Disorder (OCD) frequently suffer from comorbid sleep difficulties, and that these difficulties often are not clinically recognized and diagnosed. There has been limited research investigating if comorbid sleep difficulties impair treatment outcome for OCD and if the sleep difficulties change following OCD‐treatment. Thirty‐six patients with obsessive compulsive disorder underwent concentrated exposure treatment delivered in a group over four consecutive days and were assessed with measures of OCD, depressive symptoms and sleep disturbance at three different time points (pre, post and 6 months follow‐up). The sample was characterized by a high degree of comorbidity with other psychiatric disorders. At pre‐treatment nearly 70% of the patients reported sleep difficulties indicative of primary insomnia. The results showed that patients had large reductions of OCD‐symptoms as well as significant improvements in sleep disturbance assessed after treatment, and that these improvements were maintained at follow‐up. Sleep disturbance did not impair treatment outcome, on the contrary patients with higher degree of sleep disturbance at pre‐treatment had better outcome on OCD‐symptoms after treatment. The results indicated that the majority of the OCD sample suffered from sleep disturbances and that these sleep disturbances were significantly reduced following adequate treatment of OCD without specific sleep interventions. However, a proportion of the patients suffered from residual symptoms of insomnia after treatment.     

Rearing practices and impulsivity/hyperactivity symptoms in relation to inflated responsibility and obsessive‐compulsive symptoms

Smári, J., Rúrik Martinsson, D., & Einarsson, H. (2010). Rearing practices and impulsivity/hyperactivity symptoms in relation to inflated responsibility and obsessive‐compulsive symptoms. Scandinavian Journal of Psychology, 51, 392–397. The aim of the study was to investigate potential precursors of inflated responsibility (responsibility attitudes) and obsessive‐compulsive (OCD) symptoms. It was argued that both parental overprotection and impulsivity, separately and in interaction with each other, contribute to inflated responsibility and OCD symptoms. In a large sample of young adults (N = 570), self‐report measures of OCD symptoms (OCI‐R), responsibility attitudes (RAS), anxiety/depression (HADS), rearing practices (EMBU), present and past impulsivity/hyperactivity symptoms (IMP/HY) were administered. Overprotection as well as IMP/HY were found to predict OCD symptoms as well as inflated responsibility. Finally, a significant interaction was found between IMP/HY and overprotection with regard to both OCD symptoms and inflated responsibility. This effect reflected that IMP/HY was more strongly related to OCD symptoms and responsibility in people who had not been overprotected than in people who had been. Conversely overprotection was related to OCD symptoms and responsibility in people low but not in people high in IMP/HY. The results seem to indicate that the inadequacy between offer and need for parental control may play a role in the development of OCD symptoms.     

Do patients with OCD and pathological gambling have similar dysfunctional cognitions?

The obsessive-compulsive spectrum disorder (OCSD) theory postulates that a wide range of disorders is closely related to OCD. Current cognitive models ascertain that certain beliefs leading to misinterpretation of the significance of intrusions are important in the etiology and maintenance of OCD. This study examined whether pathological gambling, a disorder belonging to the OC spectrum, is characterized by similar dysfunctional cognitions as OCD. Dysfunctional beliefs of OCD patients were compared to those of patients with pathological gambling, panic disorder and normal controls. These beliefs were measured by the Obsessive-compulsive Beliefs Questionnaire-87 (OBQ-87), which was developed by a group of leading OCD researchers [Behav. Res. Ther. 35 (1997) 667]. It was hypothesized that according to the OCSD theory, pathological gamblers would exhibit similar cognitions to OCD patients, as well as increased levels of OCD symptoms. Analysis showed that OCD patients exhibited higher OBQ-87 scores than both panic patients and normal controls, but equal to pathological gambling patients. Pathological gamblers exhibited, however, no increase in OCD symptoms. These mixed results do not seem to support the OC spectrum theory for pathological gambling, moreover being contradictory to contemporary cognitive OCD models.     

Cognitive processing and motor execution in the lexical decision task: a developmental study

We investigated lexical decision making in children and adults by analyzing spatiotemporal characteristics of responses involving a hand movement. Children’s and adults’ movement trajectories were assessed in three tasks: a lexical decision task (LDT), a pointing task that involved minimal cognitive processing, and a symbol task requiring a simple binary decision. Cognitive interference on motor performance was quantified by analyzing movement characteristics in the LDT and symbol task relative to the pointing task. Across age groups, movements in the LDT were less smooth, slower, and more strongly curved to the opposite response option, and these interference effects decreased steadily with age. Older children showed stronger interference effects than did adults, even though their reaction times were similar to adults’ performance. No comparable effects were found in the symbol task, indicating that task characteristics such as response mapping and decision selection alone are not able to explain the developmental differences observed in the LDT. Our results indicate substantial overlap between cognitive processing and motor execution in the LDT in children that is not captured by computational models of visual word recognition and cognitive development.     

Effects of September 11 on patients with obsessive compulsive disorder

Effects of the September 11, 2001 terrorist attacks in the USA were investigated in 25 patients with obsessive compulsive disorder and 27 normal controls 4–6 months after the attacks. Participants completed a 15‐item questionnaire to retrospectively assess changes in mood, cognition, behavior and somatic complaints since September 11, 2001. Overall, both patients with obsessive compulsive disorder and normal controls reported minor changes in mood, behavior and somatic complaints. However, normal controls reported severe to extreme initial impact, slightly more cognitive symptoms (uncertainty about the future, intrusive recollections and greater desire to be with loved ones) and a slightly greater degree of overall impact on emotion and behavior at 1, 2 and 3 months after September 11 than did patients with obsessive compulsive disorder. Results support previous research that has found a relatively minor lasting impact of September 11 on both clinical and normal populations. Differences in cognition and coping mechanisms between normal controls and patients with obsessive compulsive disorder are proposed.     

Cognitive Mediation of Symptom Change in Exposure and Response Prevention for Obsessive-Compulsive Disorder

This study examined cognitive mediators of symptom change during exposure and response prevention (EX/RP) for obsessive–compulsive disorder (OCD). Based on cognitive models of OCD, obsessive beliefs were hypothesized as a mediator of symptom change. Participants were 70 patients with primary OCD receiving EX/RP either as part of a randomized controlled trial (n = 38) or in open treatment following nonresponse to risperidone or placebo in the same trial (n = 32). Blinded evaluations of OCD severity and self-report assessments of three domains of obsessive beliefs (i.e., responsibility/threat of harm, importance/control of thoughts, and perfectionism/intolerance of uncertainty) were administered during acute (Weeks 0, 4 and 8) and maintenance treatment (Weeks 12 and 24). Study hypotheses were examined using cross-lagged multilevel modeling. Contrary to predictions, the obsessive beliefs domains investigated did not mediate subsequent OCD symptom reduction. In addition, OCD symptoms did not significantly mediate subsequent change in obsessive beliefs. The present study did not find evidence of cognitive mediation during EX/RP for OCD, highlighting the need to investigate other plausible mediators of symptom improvement.     

Examination of emotional Stroop interference in obsessive-compulsive disorder

Previous research has produced conflicting findings on whether or not patients with subclinical or manifest obsessive-compulsive disorder (OCD) share an attentional bias for anxiety-related material. In the present study, 35 OCD patients were compared with 20 healthy controls on their performance in an emotional Stroop paradigm. Nine different stimulus conditions were compiled, including sets for depression-related and anxiety-related words as well as stimuli from two constructs with a potential relevance for the pathogenesis and maintenance of OCD symptomatology: responsibility and conscientiousness. Patients did not show enhanced interference for any of the conditions. Syndrome subtype and severity, avoidance and speed of information processing did not moderate results. The present study concurs with most prior research that OCD patients display no interference effect for general threat words. It deserves further consideration, that emotional interference effects in OCD as seen in other anxiety disorders occur when using idiosyncratic word material with a direct relation to the individual's primary concerns.