Curr Psychiatry Rep (2016) 18:80

DOI 10.1007/s11920-016-0720-3

ANXIETY DISORDERS (A PELISSOLO, SECTION EDITOR)

Cognitive Dysfunction in Obsessive-Compulsive Disorder

Nabil Benzina 1 & Luc Mallet 1,2 & Eric Burguière 1 & Karim N’Diaye 1 & Antoine Pelissolo 2

# Springer Science+Business Media New York 2016

Abstract Obsessive-compulsive disorder (OCD) is a Keywords Attention . Obsessive-compulsive disorder .

mental disorder featuring obsessions (intrusive thoughts) Cognitive dysfunction . Memory . Neuropsychology
and compulsions (repetitive behaviors performed in the
context of rigid rituals). There is strong evidence for a
neurobiological basis of this disorder, involving limbic Introduction
cortical regions and related basal ganglion areas.
However, more research is needed to lift the veil on Obsessive-compulsive disorder (OCD) affects 2–3 % of the
the precise nature of that involvement and the way it general population and is one of the most disabling psychiatric
drives the clinical expression of OCD. Altered cognitive disorders. It is characterized by recurrent, intrusive, and un-
functions may underlie the symptoms and thus draw a wanted thoughts, impulses, and images, often associated with
link between the clinical expression of the disorder and compulsive behaviors that are repetitive, time consuming, and
its neurobiological etiology. Our extensive review dem- often ritualized. The most common obsessions involve con-
onstrates that OCD patients do present a broad range of tamination, doubting, ordering or symmetry, aggressive
neuropsychological dysfunctions across all cognitive do- thoughts, sexual imagery, and religion. Compulsions are gen-
mains (memory, attention, flexibility, inhibition, verbal erally performed in an attempt to either avoid or neutralize the
fluency, planning, decision-making), but some methodo- obsessions or more specifically, the anxiety associated with
logical issues temper this observation. Thus, future re- them. Common compulsions include washing or cleaning,
search should have a more integrative approach to cog- checking, ordering, counting, and repeating actions or words.
nitive functioning, gathering contributions of both exper- Considering the core clustering of OCD symptoms and the
imental psychology and more fundamental neurosciences. recent findings of the neuronal basis of this pathology, OCD
has newly been separated from the class of anxiety disorders
in the fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders [1].
Current approaches to obsessive-compulsive disorder sug-
This article is part of the Topical Collection on Anxiety Disorders
gest that neurobiological abnormalities play a crucial role in
the etiology and course of OCD. Both structural and function-
* Nabil Benzina
[Link]@[Link] al imaging in OCD point towards hyperactivity in limbic and
associative cortical regions (anterior cingulate cortex (ACC)
and orbitofrontal cortex (OFC)) and related basal ganglion
1
BBehaviour, Emotion, and Basal Ganglia^ Team, Inserm U1127, areas [2]. Additionally, some studies identified abnormalities
CNRS UMR 7225, Sorbonne Universités, UPMC Univ Paris 06
UMR S1127, Institut du Cerveau et de la Moelle épinière, ICM,
in cortico-basal ganglion circuits in OCD [3]. Indeed, in fMRI
75013 Paris, France and PET studies in OCD patients, abnormal hemodynamic
2
AP-HP, Service de Psychiatrie, DHU PePsy, Hôpital Henri Mondor,
responses in the OFC and ACC may decrease as patients
Université Paris-Est Créteil, INSERM U955, Fondation improve either through deep brain stimulation [4], psychother-
FondaMental, Créteil, France apy [5], or medications [6]. These data support the
80 Page 2 of 11 Curr Psychiatry Rep (2016) 18:80

involvement of limbic frontal-basal ganglion loops in OCD Revised (LM-WMS-R) [12–14]. Concerning the Rey
and suggest that their dysfunctions might result in pathologi- Auditory Verbal Learning Test (RAVLT), the results are more
cal doubt, obsessive anxiety, and compulsive behaviors. mixed with some studies finding a deficit [15–17], while
However, the nature of the deficits and their involvement in others do not [18–20]. Finally, there are some tasks where
the pathophysiology of OCD remain unclear. patients do not present any deficit like the digit span (DS)
To address these questions, there is a need to better charac- [19, 21–24], the Selective Reminding Test (SRT) [21], and
terize and assess the neuropsychological deficits that underlie the item 223 of the Luria–Nebraska neuropsychological bat-
the symptoms. Indeed, neuropsychological functioning has tery (LNNB) [25].
been proposed as an intermediate phenotype that lies some- So, how can these discrepancies among results be ex-
where between the clinical manifestation of the disorder and plained? Leaving aside the methodological factors which cer-
its neurobiological etiology. Another interest of this approach tainly play a role (small samples, heterogeneity in exclusion
is its potential impact on treatments, for example, through criteria, etc.), the explanation could arise from the tasks used
cognitive remediation. themselves. Indeed, while the CVLT, the LM-WMS-R, and
Numerous studies have investigated cognitive deficits of the RAVLT are widely validated for episodic verbal memory
patients suffering from OCD, bringing inconsistent results assessment, the others are not, in particular the DS, a task
with differential performances on identical or similar tasks, which tap on attentional abilities of the subject too. Another
often due to methodological discrepancies. Some studies have explanation could be found in the involvement of organiza-
even used self-report questionnaires to assess cognitive func- tional strategies (the strategy used to encode information). As
tioning with an obvious high risk of unreliability. The aim of many authors suggest, when an impairment is found, it is due
this review is therefore to provide a more global and compre- to failures in the deployment of such strategies required by the
hensive description of cognitive performance in OCD pa- tasks [26]. This idea is supported by Deckersbach et al. [27],
tients, supported by recent studies and focusing on the follow- who demonstrated that verbal memory impairment exhibited
ing seven main cognitive fields: memory, attention, flexibility, by OCD patients are associated with difficulties in spontane-
inhibition, verbal fluency, planning, and decision-making. ously initiating verbal organization strategies during memory
encoding. However, this ability to implement verbal organi-
zation is preserved when patients are instructed to do so.
Memory Moreover, it was demonstrated that OCD patients are slower
to analyze the semantic features of the words in comparison to
Most patients with OCD report that they are uncertain whether controls, although their accuracy in doing so was preserved.
they have carried out an action correctly as opposed to merely Thus, this slowness in feature detection could be responsible
imagining that they have done so. Apparently, as a result of for the encoding deficits too [28].
these uncertainties, they frequently engage in repetitive rituals, Concerning the nonverbal memory, the deficits reported
such as compulsive checking of their gas stove. On the basis are more consistent. The Rey-Osterrieth Complex
of these clinical observations, some studies have been carried Figure Test (RCFT) is the most frequently employed task to
out in order to examine possible memory deficits in OCD assess nonverbal memory. It allows for assessment of both
patients. immediate and delayed recall, as well as evaluation of organi-
It is important to note that memory is not a unitary phe- zational strategies employed during the encoding (copying)
nomenon but instead involves a number of somewhat inde- phase. Regarding the two recall phases, OCD patients present
pendent processes [7]. Most of the studies have focused on impaired performance compared to healthy subjects [10, 15,
episodic memory, the one that appears most relevant to OCD. 16, 18, 19, 21, 25, 29–34]. In the encoding phase, the impair-
Episodic memory refers to memory for personal events dated ment is less clear with some studies finding no impairments
in one’s past. Nonetheless, many different subtypes of episod- [10, 17, 19, 25, 30, 32–34] while others do [15, 16, 18, 21, 29,
ic memory have been described, including memory for verbal 35]. If the patients actually present an impairment in this
and nonverbal forms of information. phase, the deficit found in the recall phase could not be attrib-
Recent investigations conducted during the past decade uted to a memory impairment but rather to reduced organiza-
have produced inconsistent results on whether or not OCD tional strategies. Interestingly, almost all the studies that ad-
patients present poorer performance than controls on verbal dressed this question are in line with impaired organizational
memory tasks. Indeed, depending on the task used to explore strategies in OCD [18, 29, 30, 32, 33]. Mataix-Cols et al. [32]
verbal memory, patients perform poorer or as well as healthy and Penadés et al. [33] went further by analyzing organiza-
controls. For example, in the California Verbal Learning Test tional strategies as a confounding factor of the nonverbal
(CVLT) and its derivatives, OCD patients present a deficit memory. Their results were in line with the hypothesis that
[8–11]. The same result is found when using the subtests impaired nonverbal memory has less to do with memory per
Logical Memory I and II from the Wechsler Memory Scale– se and more to do with flawed encoding strategies.
Curr Psychiatry Rep (2016) 18:80 Page 3 of 11 80

Another way to explore nonverbal memory relies on the impairment [19], there is strong evidence supporting an al-
pattern recognition paradigm. Although a few studies found tered sustained attention in OCD patients with poorer perfor-
an impairment in OCD patients using this paradigm [36, 37], a mance on the Continuous Performance Test [44, 45, 46••] and
majority does not [28, 38–41]. This could be explained by the analogous tasks [16, 23, 42].
use of verbal mediation strategies which could mask a possi- There has been little research on selective attention, leading
ble impairment as Olley et al. suggested [28]. to mixed results. Indeed, two studies, one using the d2 test
Another component of nonverbal memory is spatial mem- [54] and the other the ACS [53], found an impairment, while
ory. Most of the studies assessing it found an impairment in another study using a different paradigm, a modified Choice
OCD patients [18, 21, 23, 36, 38–44]. As Chamberlain et al. Reaction Time task, did not [55]. Concerning the divided at-
[26] suggest it, the commonly used tasks to explore this type tention, although a very few studies addressed the question,
of memory (the spatial working memory task and the spatial the trend is towards an altered divided attention in OCD pa-
recognition task inter alia) are strategy dependent. Thus, the tients [16, 52•, 53].
impairment could be explained by strategy failures, as for the In conclusion and considering the two meta-analyses per-
RCFT. This hypothesis is supported by the fact that in tasks formed by Shin et al. [46••] and Abramovitch et al. [47••],
requiring no encoding strategy like the Penn Facial Memory there is supporting evidence for altered attentional processes
Test and comparable tasks, no deficit is found [33, 45]. in patients suffering from OCD, regardless the type of atten-
In conclusion, whether for verbal or nonverbal episodic tion. Even though more research is needed concerning the
memory, OCD patients do present an impairment. This im- selective and divided attention to confirm the impairment,
pairment is confirmed by the three meta-analyses performed some authors suggested with good reasons that these impair-
by Shin et al. [46••], Abramovitch et al. [47••], and Snyder ments could be explained by prescribed psychotropic drugs
et al. [48••]. But, there are strong arguments that tend to con- and/or psychiatric comorbidities. This hypothesis is weakened
sider that this impairment is not due to a primary memory by the study of Rajender et al. [16], which included only drug-
defect but rather to an alteration in encoding underpinned by naïve patients without any psychiatric comorbidity and did
a failure in organizational strategies. find an impairment of attentional performances.

Attention
Flexibility
Attention can be divided in the following four components:
focused attention, the ability to concentrate on one sensory As already mentioned, OCD is characterized by repetitive
stimulus to the exclusion of all others; sustained attention, behavior, performed through rigid rituals. This phenomeno-
the ability to maintain a consistent behavioral response during logical observation has led to explore the idea that OCD pa-
continuous and repetitive activity; selective attention, the abil- tients have a diminished behavioral flexibility, which is the
ity to maintain a behavioral or cognitive set in the face of ability to change one’s behavior according to contextual cues.
distracting stimuli; and divided attention, the ability to re- Different tasks were designed to assess this cognitive di-
spond simultaneously to multiple tasks or multiple-task mension. The most classical are the Trail Making Task Part B
demands. (TMT-B), where the subject has to connect letters and num-
Focused attention was the most studied across the litera- bers sequentially, alternating between them, and the
ture. The Trail Making Task Part A (TMT-A), where the sub- Wisconsin Card Sorting Test (WCST), where the subject has
ject has to connect numbers sequentially, and its derivatives to classify cards according to an implicit and changing rule.
are frequently used by the studies exploring this type of atten- On the TMT-B, the results seem to be inconsistent with some
tion in OCD patients. Although some studies did not find any studies finding equal performances between OCD patients
defect [8, 13, 17, 19, 25, 49–51], the trend is towards a focused and healthy controls [13, 19, 20, 25, 34, 35, 51], while others
attention impairment in OCD patients [11, 14–16, 18, 20, 24, do not [11, 17, 30, 33]. With the WCST, there is far less
30, 33, 34, 52•]. The meta-analyses performed by Shin et al. inconsistencies, especially with regard to perseverative errors,
[46••] and Snyder et al. [48••], which had included 23 studies with a pronounced trend towards poorer performance exhibit-
and 32 studies, respectively, evaluating this cognitive ability, ed by OCD patients [8, 11, 14–16, 19, 22, 34–36, 40, 44, 45,
confirmed this observation. We can also mention the study by 51, 56–58, 59•, 60, 61], even though some studies failed to
Armstrong et al. [53], which, even though they used the report this difference [13, 21, 24, 25, 31, 49, 62, 63]. The three
Attentional Control Scale (ACS), a 20-item self-report ques- meta-analyses performed by Shin et al. [46••], Abramovitch
tionnaire, led to the same conclusion. et al. [47••], and Snyder et al. [48••] confirm this trend for
Sustained attention is the second most studied type of at- WCST but also for the TMT-B despite the apparent
tention. Although one of the reviewed studies did not find any inconsistency.
80 Page 4 of 11 Curr Psychiatry Rep (2016) 18:80

More recently, computerized tasks were developed to as- only in an OCD-specific context, but not in a neutral one. This
sess behavioral flexibility with more specificity and in a more result suggests that activated disorder-specific fears may im-
controlled fashion. Indeed, even though they were designed to pair the flexible adoption of efficient behaviors.
assess flexibility, the TMT-B and WCST are not specific to
this cognitive dimension; other processes are involved such as
attention, speed processing, motor speed, or working memory.
Moreover, the test-taking conditions (presence of an assessor Inhibition
for example) may affect the results and impact the reliability
of these tasks. That is how the following three paradigms have Due to the inability to suppress repetitive and unpleasant
recently come into use: the reversal learning (RL), the intra/ thoughts and actions, inhibitory control dysfunction has long
extradimensional set shifting (ID/ED), and the task switching been theorized to be a central feature of OCD [26]. Inhibitory
(TS). However, the studies using these paradigms in the con- control is not a unitary function and consists of motor (or
text of OCD are still limited and leading to inconsistent find- behavioral) response inhibition and interference control (or
ings. For example, with the RL paradigm, two studies did find cognitive inhibition) [75]. Behavioral inhibition involves the
poorer performance in OCD patients [64, 65] but six did not inhibition of pre-potent and automatic motor responses.
[38, 59•, 66–69]. This inconsistency in RL paradigm is ex- Cognitive inhibition, on the other hand, refers to the cognitive
plained by the lack of homogeneity between studies control needed to prevent interference due to competition by
concerning the measure of interest (some focusing on the irrelevant stimuli or irrelevant stimulus characteristics.
number of trials to reach reversal criterion for example, while Cognitive inhibition is mainly assessed by the Stroop task.
others taking in account the total number of errors before Across the literature, while a few studies failed to report a
reversal occurs or the number of perseverative errors just after difference using this task [13, 20, 24, 39, 50, 76, 77], the vast
a reversal) or even the task design itself (some studies have a majority of studies did [11, 15, 16, 19, 22, 33, 51, 56, 78–81].
reversal occurring after a fixed number of trials, while others More important, the meta-analysis performed by Shin et al.
have a reversal criterion which ensures that the subject made [46••], which included 12 studies for this task, confirms the
an association before to reverse the contingencies). impairment of OCD patients. However, a few studies used
Concerning the ID/ED paradigm, the findings are more con- different paradigms to assess cognitive inhibition, yielding
sistent with seven studies demonstrating a difference [37, 42, mixed results. For example, Bohne et al. [82] tested the sub-
62, 69–70], while only one do not [41]. Shin et al. [46••], jects with a directed forgetting task and found a defect in OCD
Abramovitch et al. [47••], and Snyder et al. [48••] confirmed patients compared to healthy subjects only with negative va-
this observation with their respective meta-analyses. Finally, lence words, echoing the observation made by Zetsche et al.
with the TS paradigm, the results are more mixed, with Gu [74•] for the behavioral flexibility. By contrast, seven studies
et al. [71] finding an impairment in OCD patients while used the Flanker task and failed to find an impairment, when
Moritz et al. [72] and Remijnse et al. [73] not. they did not find better performance in OCD patients [83–89].
Thus, despite the apparent discrepancy depending on the Morein-Zamir et al. [90], using the thought stop-signal task,
paradigm used, for the most part, the evidence supports the found an intact unintentional thought suppression in OCD
hypothesis of an impaired behavioral flexibility in OCD. patients. Similarly, Moritz et al. [81] used a negative priming
Concerning the paradigms with mixed results, namely, the paradigm to assess cognitive inhibition and failed to show a
RL and the TS, it is important to note that the studies finding difference between OCD and healthy groups. Nevertheless,
no difference in terms of number of errors did find a difference while interesting, these studies are not sufficient to counter-
in terms of reaction time. Indeed, OCD patients present a balance the trend towards an impaired cognitive inhibition in
longer reaction time in these tasks but in a very specific con- OCD.
text, just before changing their response strategy after a Concerning the motor response inhibition, this ability can
reversal/task switch [66–68, 72, 73]. Interestingly, Valerius be differentiated into action restraint and action cancelation.
et al. [68] found that this prolonged reaction time positively The go/no go task (G/NG), where the subject has to inhibit his
correlates with the severity of compulsions, demonstrating response when a Bno go^ cue appears, is considered to probe
stronger reluctance to change the response strategy with in- action restraint, whereas the stop-signal task (SST), where the
creasing compulsion severity in OCD and thus a less flexible subject has to inhibit an already initiated response when a
behavior than healthy controls. Finally, an interesting study Bstop^ cue appears, measures action cancelation [75]. The
conducted by Zetsche et al. [74•] revealed that the emotional results with G/NG are mixed with some studies showing al-
context is an important factor to take into account for future tered performances in OCD patients [37, 56, 78, 80, 91•],
research. They have indeed demonstrated, using a probabilis- while others do not [92–99]. By contrast, there is no ambiguity
tic classification learning paradigm, that OCD patients have an with SST as all the reviewed studies demonstrate an altered
impaired behavioral flexibility compared to healthy controls performance in OCD patients [42, 69, 80, 90, 100–104].
Curr Psychiatry Rep (2016) 18:80 Page 5 of 11 80

In conclusion, there is supporting evidence towards an al- did find one in terms of planning, performance, and move-
tered inhibitory control in OCD. This observation is con- ment time which are increased [13, 16, 40, 41, 70]. Thus, it
firmed by the meta-analyses realized by Shin et al. [46••], indicates an abnormal slowing, reflecting planning difficul-
Abramovitch et al. [47••], and Snyder et al. [48••]. This alter- ties, but they may not be sufficient to impact the overall per-
ation is expressed both in the cognitive and behavioral com- formance. Some could suggest that this slowing may be ex-
ponents of inhibition. Concerning the behavioral component, plained by the general slowdown showed by these patients.
the impairment is unambiguous for action cancelation, while The meta-analysis by Snyder et al. [48••] addressed this issue
we cannot conclude for action restraint. Interestingly, three and does not support this hypothesis.
studies showed that the emotional context affects the inhibi-
tory control with threat [105], punishment [91•], or simply
words with negative valence [82] worsening/revealing the im- Decision-Making
pairment, as observed for flexibility [74•].
Decision-making is a cognitive process resulting in a course of
action among several alternative possibilities. OCD is charac-
Verbal fluency terized by chronic doubting and an apparent inability to make
decisions. According to this observation, it has been suggested
Verbal fluency is an indicator of both verbal ability (more that compulsive behaviors in OCD may be conceptualized as
specifically lexical access ability) and executive control failures in decision-making [26]. However, a few studies ad-
[106]. Its assessment relies on the Controlled Oral Word dressed this question with most of them using gambling par-
Association Test (COWA) and its derivatives, a simple task adigms to evaluate decision-making skills.
where the subject have to say as many words as possible from Among the reviewed literature, three studies found altered
a category in a given time (usually 60 s). This category can be decision-making with the Iowa Gambling Task (IGT) [15, 58,
semantic, such as animals, or phonemic, such as words that 59•], while only one did not [108]. With the Cambridge
begin with letter P. Gambling Task (CGT), there is an opposite trend with only
The literature is inconsistent concerning this dimension, one study finding an alteration of decision-making [76], while
with some studies showing an impairment [11, 17, 20, 24, three studies do not [37, 69, 71]. The discrepancy between
25, 31, 34, 35, 52•], while others do not [8, 13, 15, 18, 19, these two results could be explained by the different nature
21, 30, 37, 50, 56, 62, 63]. However, Shin et al. [46••] have of these tasks. Indeed, according to a behavioral economics
incorporated in their meta-analysis 37 studies probing verbal dichotomy, the IGT probes decision-making under ambiguity
fluency and have shown that OCD patients do have an im- (the state of the world, i.e., the reward probability is unknown
paired verbal fluency. The meta-analysis by Snyder et al. to the subject), while the CGT probes decision-making under
[48••] included 40 studies and reports the same result but, risk (the reward probabilities are known to the subject).
more importantly, also shows that the slowdown characteriz- Therefore, OCD patients seem to have an impaired decision-
ing OCD patients does not explain this impairment. making only under ambiguity, while they performed well un-
der risk. This observation was confirmed by Kim et al. [59•],
which compared OCD patients to healthy volunteers in IGT
Planning and the Game of Dice Task (GDT) for the risk context.
Another aspect of decision-making relies on information
Planning is the process of thinking about and organizing the sampling, i.e., the ability to gather a sufficient amount of in-
activities required to achieve a desired goal. This cognitive formation to take a valid decision. The Information Sampling
ability is probed by problem-solving tasks like the Tower of Task (IST) gives a convenient way to probe this ability. Only
Hanoi (ToH) and its derivatives. two studies were found to address the question of altered in-
According to the literature, there is a trend towards im- formation sampling in OCD using this task. The one by
paired planning ability in OCD patients [11, 15, 18, 30, 36, Bersani et al. [42] did report an impairment but only in fixed
38, 39, 42, 51, 52•, 58, 69, 76, 107], although some studies do win condition (i.e., the gain stays the same regardless the
not support this result [13, 16, 19, 20, 37, 40, 41, 56, 70]. This amount of information retrieved), the impairment
observation is reflected in the three meta-analyses by Shin disappearing in decreasing win condition (i.e., the more the
et al. [46••], Abramovitch et al. [47••], and Snyder et al. subject picks up information, the less he wins). The other by
[48••], which did find a planning impairment in OCD, thereby Chamberlain et al. [38] found that OCD patients did not adapt
establishing a link with memory impairment which relies on a their information sampling behavior in accordance with the
failure in organizational strategies as we have seen above. change in reinforcement contingencies (i.e., switch between
Interestingly, the studies which do not find a difference in fixed and decreasing win). An interesting study by Banca et al.
performance (number of moves needed to achieve the task) [109•] went further in the information sampling probing.
80 Page 6 of 11 Curr Psychiatry Rep (2016) 18:80

Indeed, they applied a drift diffusion model to a Random-Dot reported by some of the studies are related to a lack of statis-
Motion Task and found that, compared to healthy subjects, tical power (type II error).
OCD patients have higher decision thresholds but only under Another concern that came to light while reviewing the
high uncertainty. Moreover, they present a slower evidence literature was the major tendency to study OCD as a homoge-
accumulation regardless the uncertainty level. Their last ob- neous condition, including only global measures of symptom
servation was that by emphasizing speed (i.e., the slower is the severity (e.g., the Yale–Brown Obsessive-Compulsive Scale).
subject, the greater is the loss), OCD subjects normalized their That is, whereas the thematic heterogeneity and dimensional
behavior. structure of OCD is well established [110], the vast majority of
In conclusion, OCD patients do have impaired decision- studies have made no attempts to examine possible associa-
making. This impairment is limited to ambiguous/uncertain tions between cognitive performances and OCD subtypes nor
contexts and is reversible, the OCD patients being able to assess the types of obsessions and compulsions present in their
normalize their behavior when the situation expressly requires samples. In consequence, the risk is important to falsely con-
it (inadequate behavior leading to negative outcomes). clude to an absence of impairment. Indeed, the rare studies
taking this clinical factor into account pointed out that the
cognitive functions are likely to be differently affected across
OCD subtypes [29, 36, 61, 76, 111–113].
Discussion and Conclusion There is another factor which could hamper the reliable
identification of cognitive impairments in OCD, the presence
Despite some inconsistencies across the literature, OCD pa- of confounding moderators, more precisely, the presence of
tients do present impairments across the seven studied cogni- psychiatric comorbidities and the use of psychotropic drugs.
tive domains, i.e., memory, attention, flexibility, inhibition, Indeed, it is obvious that OCD is not the only condition af-
verbal fluency, planning, and decision-making. fecting cognitive functioning, and the presence of a psychiat-
The inconsistencies described may be explained by the ric comorbidity, the main one being mood disorders, can lead
extensive use of traditional tests. Designed originally to ascer- to misleading conclusions. A similar statement could apply to
tain the presence or absence of brain dysfunction, or overall psychotropic drugs which may affect cognitive functioning.
skill level, they may not be sensitive to the subtle impairments The three meta-analyses by Shin et al. [46••], Abramovitch
that characterize OCD. However, more obvious explanations et al. [47••], and Snyder et al. [48••] addressed this issue and
could be found, the first being methodological issues. Among found that neither psychiatric comorbidities nor psychotropic
them, small sample size is the more evident. Indeed, almost all drug use influence the cognitive performances.
the reviewed studies included on average 20 subjects per We want to know not only whether an impairment exists
group. This means that small to moderate impairments would but also how important it is. According to the meta-analyses
be difficult to detect, and it is possible that the null results by Shin et al. [46••], Abramovitch et al. [47••], and Snyder

Table 1 Summary of cognitive

impairments in OCD according to Trend Effect size
three meta-analyses
Shin et al. [46••] Abramovitch et al. [47••] Snyder et al. [48••]

Verbal memory ↘ −0.441 −0.332 −0.31

Nonverbal memory ↘ −0.624 −0.761 −0.47
Focused attention ↘ −0.444 NA −0.57
Sustained attention ↘ −0.452 −0.499 NA
Selective attention ↘ NA NA NA
Divided attention ↘ NA NA NA
Flexibility ↘ −0.373 to −0.511 −0.517 −0.5
Cognitive inhibition ↘ −0.547 −0.54 −0.37
Behavioral inhibition ↘ NA −0.33
Verbal fluency ↘ −0.385 to −0.415 NA −0.36
Planning ↘ −0.732 −0.44 −0.44
Decision-making ↘ NA NA NA

A negative effect size reflects an impairment. Interpretation: <0.2 = unsignificant, 0.2–0.5 = small, 0.5–0.8 =
moderate, and >0.8 = large
NA not assessed
Curr Psychiatry Rep (2016) 18:80 Page 7 of 11 80

et al. [48••], OCD patients appear to have broad, albeit not example, Palminteri et al. [117], combining a computational
severe, cognitive dysfunction (average mean effect size rang- approach with neurotransmitter modulation, demonstrated
ing from −0.478 [46••] to −0.499 [47••]; see Table 1). When that the serotoninergic system is involved in the procedural
considering the effect size for each cognitive domain, it ap- learning deficit in OCD. We can also mention Chamberlain
pears that nearly all of them are mildly impaired with effect et al. [118], who, combining fMRI with cognitive assessment,
sizes ranging from approximately −0.3 to −0.5, except for found that OCD is associated with a reduced activation of
planning and for nonverbal memory, which present a large orbitofrontal cortex in a reversal learning paradigm. Very in-
effect size (−0.8 approximately) but with a discrepancy be- teresting too is the study by Da Rocha et al. [119], which,
tween the three meta-analyses. Indeed, Shin et al. [46••] did combining genetics with cognitive assessment, found that
find a large effect size (−0.732), while Abramovitch et al. the BDNF Val66Met polymorphism is associated with im-
[47••] and Snyder et al. [48••] found a medium effect size paired decision-making under uncertainty in OCD. These ex-
(−0.44). Concerning the nature of the large effect size found amples demonstrate how this integrative approach is a major
for nonverbal memory, as discussed, it may be related to an way to bring new insights on cognitive functioning in OCD
alteration in encoding underpinned by a failure in organiza- and thus to unveil the neurobiological basis of this disorder
tional strategies and less with memory impairments per se. [120], potentially leading to the development of more efficient
One important criticism that can be made about the neuro- treatments.
psychological tasks used to probe cognitive dysfunctions in
OCD is that they lack ecological validity, impairing generali- Acknowledgments A special thank you to Dr. Robert Friedel for taking
the time to review this manuscript.
zation of the findings. Indeed, for almost all the studies
reviewed, subjects perform tasks in a standardized, neutral Compliance with Ethical Standards
context. But considering the clinical expression of OCD, it
is likely that the cognitive impairments may be most signifi- Conflict of Interest The authors declare that they have no conflict of
cant in an OCD-related context. A few studies addressed this interest.
issue and effectively found that OCD patients, while present- Human and Animal Rights and Informed Consent This article does
ing no or mild cognitive defects in neutral condition, are sig- not contain any studies with human or animal subjects performed by any
nificantly impaired in emotional, OCD-related context [74•, of the authors.
79, 82, 91•, 105]. Thus, a way to improve the ecological va-
lidity of neuropsychological assessment of OCD patients may
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