Blackwell Publishing AsiaMelbourne, AustraliaPCNPsychiatry and Clinical Neurosciences1323-13162007 Folia Publishing SocietyFebruary 20076114553Regular Articles ttention and

cognition in OCDF. de Geus et al. A

Psychiatry and Clinical Neurosciences (2007), 61, 45–53

doi:10.1111/j.1440-1819.2007.01609.x

Regular Article

Attention and cognition in patients with obsessive–compulsive disorder
FEMKE DE GEUS, msc, DAMIAAN A. J. P. DENYS, md, phd, MARGRIET M. SITSKOORN, phd AND HERMAN G. M. WESTENBERG, phd
Rudolf Magnus Institute of Neuroscience, Department of Psychiatry, University Medical Center Utrecht, Utrecht, the Netherlands

Abstract

Although a dysfunctional prefrontal-striatal system is presupposed in obsessive–compulsive disorder (OCD), this is not sustained by neuropsychological studies. The aim of this study was twofold: (i) to investigate the cognitive deficits in patients with OCD compared to matched healthy controls; and (ii) to relate cognitive performance to clinical characteristics in patients with OCD. In this study, 39 patients with primary OCD according to Diagnostic and Statistical Manual, fourth edition criteria were compared to 26 healthy control subjects on a battery measuring verbal memory and executive functioning. Patients with OCD showed slowed learning on the verbal memory task and made more errors on the Wisconsin Card Sorting Test. Errors were failures to maintain set, which were related to severity of OCD symptomatology. The results show that patients with OCD have cognitive deficits. The authors hypothesize that these deficits may be interpreted by attentional deficits caused by a dysfunctional anterior cingulate cortex. anterior cingulate cortex, attention, executive functioning, neuropsychology, obsessive– compulsive disorder, Wisconsin Card Sorting Test.

Key words

INTRODUCTION
Patients with obsessive–compulsive disorder (OCD) suffer from recurrent anxiety-provoking thoughts (obsessions), and ritualized behaviors directed at reducing this anxiety (compulsions). Most neurobiological studies in OCD point toward an underlying dysfunctional prefrontal-striatal system. For instance, several structural neuroimaging studies showed reduced orbitofrontal cortex and basal ganglia volumes.1–3 In addition, functional neuroimaging studies showed hyperactivity in these same regions during rest-state, symptom provocation, and cognitive activity.4–7 This hyperactivity normalizes after successful treatment with serotonin reuptake inhibitors (SRI) or behavioral therapy.8–10 Moreover, OCD symptoms might decrease following neurosurgical disruption of prefrontal-striatal circuits.11
Correspondence address: Femke de Geus, MSc, UMC Utrecht, B.01.206, PO Box 85500, 3508 GA Utrecht, the Netherlands. Email: f.degeus@umcutrecht.nl Received 17 February 2006; revised 24 July 2006; accepted 6 August 2006.

If the neurobiological underpinning of OCD is the prefrontal-striatal system, one would expect deficits in domains such as set shifting, spatial working memory, focused attention and verbal fluency.12–14 However, neuropsychological findings are inconsistent, with some studies finding these deficits,15–17 some studies finding no deficits,18–20 and other studies finding no deficits other than slowed performance.21–23 These conflicting findings can be explained in part by methodological factors such as inadequate matching of patients to controls or lack of control for medication status and the presence of comorbid disorders. The aim of this study was twofold: (i) to investigate the cognitive deficits in patients with OCD compared to matched healthy controls; and (ii) to examine the relationship between clinical characteristics and cognitive performance in patients with OCD. In this study, patients and controls were carefully matched for age, gender and IQ. All patients with OCD were on stable antidepressant medication and free of major comorbid disorders. The authors hypothesized that patients with OCD would perform worse than healthy controls on the cognitive tests used and the authors expected
© 2007 The Authors Journal compilation © 2007 Folia Publishing Society

Utrecht. stroke within the last year.9 2. HAM-A.20 0.5 106. Y-BOCS. the controls were recruited by newspaper advertisements.55 P 0. Patients with OCD were divided into subtypes based on the Y-BOCS checklist.4 27.24 Inclusion criteria for patients were: aged between 18 and 65 years.0 1.0 13.0 n=7 n=6 n=5 n = 10 n = 11 Controls Mean ± SD 10:16 34. This study is part of a larger study. Cognitive Behavioral Therapy. A full description of inclusion and exclusion criteria can be found in the article by Denys et al.0 ± 11.0 ± 6.3 ± 5. Serotonin Reuptake Inhibitor. primary OCD according to Diagnostic and Statistical Manual.6 ± 10.0 13. and minimal Yale–Brown Obsessive–Compulsive Scale (Y-BOCS25. METHODS Subjects The study population consisted of 39 severely ill.N.2 102. negative correlations between performance and OCD severity.4 12. All patients showed significant symptoms. despite previous and current treatments. obsessive–compulsive disorder.3 94–118 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA F χ2 = 1. Hamilton Depression rating scale. Table 1. the Netherlands.26) score of 18 or 12 if only obsessions or compulsions were present. as described by Denys et al. SRI. Hamilton Anxiety rating scale. National Adult Reading Test Intelligence Quotient. Yale–Brown Obsessive–Compulsive Scale.1 ± 1. current psychotherapeutic treatment. NA.29 Clinical characteristics of the OCD subjects are shown in Table 1. anxiety disorder. All patients and controls gave written informed consent. de Geus et al. sexual and religious obsessions Somatic obsessions and checking Symmetry and counting/arranging High risk-assessment and checking 10:29 36.)28 was given to assess DMS-IV disorders. OCD. © 2007 The Authors Journal compilation © 2007 Folia Publishing Society . primary personality disorder. Clinical characteristics of patients with obsessive–compulsive disorder (n = 39) and controls (n = 26) OCD Mean ± SD Gender distribution (male : female) Age NART IQ Range Medication at time of testing Paroxetine n = 14 dose Citalopram n = 11 dose Venlafaxine n = 5 dose Fluoxetine n = 4 dose Fluvoxamine n = 3 dose Imipramine n = 1 dose Clomipramine n = 1 dose Duration of illness (years) Y-BOCS Obsessions Compulsions Total HAM-D HAM-A Number of previous SRI treatments Number of previous CBT treatments OCD subtype Contamination and cleaning Aggressive.2 81–118 47 ± 15 52 ± 13 300 ± 0 35 ± 19 150 ± 86 150 75 21. therapy resistant patients with OCD and 26 healthy controls. SD.I.8 ± 1.064 CBT. The patients with OCD were recruited at the department of psychiatry of the University Medical Center Utrecht.9 ± 3. not applicable. The Mini-International Neuropsychiatric Interview (M.46 F.1 ± 12.289 0.2 ± 6. in which the effect of quetiapine addition was investigated.0 ± 10. organic mental disorders. epilepsy or other central nervous system disorders.9 13.477 0. fourth edition (DSM-IV) criteria. bipolar disorder. standard deviation.4 ± 4. HAM-D. substance abuse within the past 6 months.7 ± 5.I. Exclusion criteria were: significant depressive symptoms (defined as a score of 15 or more on the Hamilton Depression rating scale [HAM-D]27). NART IQ.51 3. schizophrenia or any other psychotic condition.

subjects are asked to read aloud a list of phonetically irregular words. By repeating the same list five times. OCD severity measured by the Y-BOCS (obsessions and compulsions subscales. the authors calculated the number of categories completed (10 consecutive correct sorts). known to be a good indication for verbal IQ. an outcome measure for set shifting measured by the TMT is time B divided by time A. After 10 consecutive sorts. retrieval after short delay. such as set-shifting.32 Healthy controls and patients with OCD were matched groupwise for age. encoding strategy. the amount of words remembered for each presentation).37 Clinical characteristics The clinical characteristics included in the analyses were: age.44 depressive symptoms measured by the HAM-D.e. it measures so called ‘frontal’ functions. percentage of errors made. the examiner can study the learning curve (i. where part B focuses more on alternated attention.Attention and cognition in OCD 47 Exclusion criteria for the healthy control group were: neurological illness or other disorders of the central nervous system and substance abuse within the past 6 months.39 In the WCST. ‘A’) and semantic (‘animals’.34 In this test. The scores for the two phonemic trials are added and so are the scores for the two semantic trials. percentage of perseverative errors and failure to maintain set (five to nine consecutive correct sorts followed by an error) as described in the manual.41 Cognitive measures National Adult Reading Test 33. patients with OCD and controls did not differ with respect to demographic and clinical characteristics. or number). The authors used the version as described by Milner43 in which two packs of 64 cards are used and the test is discontinued when the subject reaches six categories.. Further exclusion criteria were history of psychiatric disease (assessed by Comprehensive Assessment of Symptoms and History [CASH)30).35 Trail Making Test 36 In this task the time required to track a number sequence (Trail Making Test [TMT] A) and a sequence of alternating numbers and letters (TMT B) is measured. © 2007 The Authors Journal compilation © 2007 Folia Publishing Society .5 (SPSS Inc. the subject has to discover criteria by which to sort cards (according to three ‘sets’: color. For each subject. total). The first presentation of the list is generally regarded as a test of immediate word span.40 A Dutch version of the CVLT was used. shape. duration of illness. Since performances in both parts exhibit a close linear relationship. Verbal fluency The authors measured verbal fluency with a word-generation tasks in which subjects are given 1 min to retrieve as many words as possible in response to letter (‘N’. To prevent practice effects due to the two administrations.34). number of words learned over five trials (trial 5 minus trial 1). semantic clustering index. an identical list of words. category formation and set maintenance. The authors transformed the raw scores into IQ scores. which were then used to match the two groups. history of personality disorder (assessed by Structured Interview for DSM-IV Personality Disorders [SIDPIV])31 and psychiatric disease in first or second degree relatives (assessed by Family Interview for Genetic Study [FigS]). the examiner changes the set unbeknown to the subject (this is only indicated by feedback from the examiner). the authors used the parallel version of this test in a counterbalanced design. Verbal fluency is considered to be a measure of executive function. recall after a long and short delay and recognition. OCD symptom subtype. These four trials result in four scores: number of unique words. number of previous treatments. anxiety symptoms measured by the Hamilton Anxiety Rating Scale (HAM-A). more closely related to attention than to memory per se. retrieval after long delay. California Verbal Learning Test 38 The California Verbal Learning Test (CVLT) is a verbal memory task that consists of five presentations of Statistical analyses Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 11. ‘professions’) cues. number of hits on recognition trial. Wisconsin Card Sorting Test 42 The Wisconsin Card Sorting Test (WCST) is one of the most widely used tasks in the assessment of neurocognitive function.39 The measures used in analysis were: total recall in five trials. The test also yields information on the subject’s memory capacity. Time needed for part A and part B can both be considered a measure of visual scanning and mental speed. handedness and IQ (measured by the Dutch version of the National Adult Reading Test33. gender. As can be seen in Table 1. Subjects are asked to reproduce as many words as they can.

07 0.26 12.51 56. which is a measure of set shifting. IL.38 ± 1.56 6. verbal fluency and TMT.46 ± 1.39 ± 9.649 0.62 ± 1.376. P = 0.629 0.77 ± 1. Duration of illness was related to age (r = 0. The authors used multivariate anova (factor is Group with two levels: OCD and healthy controls) to compare patients with OCD and healthy controls.70 7.49 ± 21.45 ± 23. standard deviation. Patients with OCD showed greater learning on the CVLT (measured by the ‘number of words learned Table 2.04 ± 8.406 0.15 ± 1.70 0.38 ± 9.025 CVLT.72 63.29 1.92 ± 9.90 ± 2.15 ± 2.13 0.28 ± 1.27 22. Number of previous SRI and CBT treat- OCD (n = 39) Mean ± SD Verbal fluency Phonemic Semantic TMT Time A Time B Time B/time A CVLT Total recall 5 trials Recall 1st trial Recall 2nd trial Recall 3rd trial Recall 4th trial Recall 5th trial Number of words learned over 5 trials Semantic clustering index Retrieval after short delay Retrieval after long delay Number of hits on recognition trial WCST Number of categories completed % errors % perseverative errors Failure to maintain set 24.152 0.811 0. SD.48 F. Trail Making Test.33 0.69 11.24 44.819.82 12.87 11.34 1.21 4.228 0.95 ± 7. HAM-D was also related to age (r = 0.85 ± 2.59 4.037 0.68 ± 8. P = 0.916 0.87 31.000) and HAM-A score (r = 0.54 ± 1.86 0. OCD.013 0. obsessive–compulsive disorder.87 1.018).04 0.56 ± 2.13 2.42 2.42 ± 0. P = 0. Clinical characteristics and neuropsychological performance The authors performed exploratory correlational analyses to examine the relationships between the clinical measures.05 were considered significant.007 0.69 ± 2.64 ± 1.30 0.31 ± 0.08 6. and used Pearson’s coefficients to calculate correlations between clinical characteristics and neuropsychological performance.01 0.40 0.000).48 0.49 0.04 ± 2.784.77 0. USA).88 6. These analyses showed that HAM-A and HAM-D scores correlated significantly (r = 0. TMT.74 ± 2. P = 0.57 0. showed no abnormalities either.792 0.93 42.54 15.32 12. © 2007 The Authors Journal compilation © 2007 Folia Publishing Society .00 ± 1.24 0. The patients with OCD and healthy controls did not differ in the two timed tasks. California Verbal Learning Test.720 0.98 11.33 4. de Geus et al.46 ± 7.08 12.32 ± 14.51 ± 3.81 ± 1.37 8.07 10.532 0. The patients with OCD performed worse on the WCST compared to the controls: they completed significantly fewer categories.28 ± 0.18 15. Chicago.57 2. Performance on neuropsychological measures over five trials’ variable).24 ± 0.007 0.074 0. this was caused by a significantly lower performance on the first trial (see Table 2: recall 1st trial).96 ± 1. the percentage of errors was higher as was the number of failures to maintain set.313 0.92 12. WCST.16 Controls (n = 26) Mean ± SD 24.59 2.01 7.01 3.399.38 ± 2.15 ± 2.54 30. The percentage of perseverative errors was not elevated in the OCD group. RESULTS Patients with obsessive–compulsive disorder versus healthy controls Table 2 summarizes the group mean performance and statistical comparisons for each task.81 F P 0.05 65.357 0.64 ± 14.00 2.03 ± 1.02 28. The ratio between part A and part B of the TMT.88 ± 9.17 14.72 ± 10.940 0.013).00 0. P-values under 0.924 0.77 5. The performance on the other four trials did not differ.79 1. Wisconsin Card Sorting Test.90 ± 13.77 53.10 5.

097.10 −0.18 0. In particular.10 Retrieval after long delay 0. When HAM-D scores were corrected for age.17 0.443.20 0.16 0.167. because verbal memory is known to be related to age.03 −0.27 0.33* −0. number of hits on recognition: r = −0. retrieval after a long delay and number of hits on recognition.13 −0. semantic clustering index. retrieval after long delay: r = −0. When corrected for age (which correlates with both failure to maintain set and HAM-D).11 −0.277. P = 0. The authors inter- preted these results as an artifact.02 −0.09 0.39* 0.26 −0. these effects could be explained by duration of illness and age. as can also be seen in Table 3. measured with HAM-D was also related to failure to maintain set.133. retrieval after long delay: r = 0. correlated significantly with several CVLT measures: total recall.09 0. SRI.07 0. CBT.03 0.Attention and cognition in OCD 49 ments correlated significantly (r = 0.327.08 0.31 0. Y-BOCS.38* −0.27 −0. Trail Making Test.03 0.093.28 Number of hits on recognition trial −0. After correction for age (since duration of illness is closely linked to age). the significant results disappeared (total recall: r = −0. P = 0.14 −0. OCD severity did not have any effect on cognitive measures other than the WCST. P = 0.006).44** WCST Number of categories completed % errors % perseverative errors Failure to maintain set −0. Duration of illness correlated significantly with several CVLT measures: total recall. Serotonin Reuptake Inhibitor.07 0.34* 0.00 0. No other effects achieved significance. © 2007 The Authors Journal compilation © 2007 Folia Publishing Society .130.20 −0.01 −0.53** 0. P = 0.14 −0.41* 0.045). P = 0.15 0.11 0.43** −0.433. Again.17 0.277. P = 0.00 Semantic clustering index −0.30 0.00055 level (Bonferonni corrected α).54** Number of words learned over 5 trials 0.28 −0.29 Retrieval after short delay 0.19 0.05 −0. There were no differences Table 3.04 0.270. semantic clustering index: r = −0.01 0. semantic clustering index and long-term retrieval. Correlations between clinical and neuropsychological variables are shown in Table 3.06 −0.13 −0. but the relationship with CVLT total recall disappeared (r = −0.15 −0.521). P = 0. P = 0.28 CVLT Total recall 5 trials −0. Hamilton Anxiety rating scale. Yale–Brown Obsessive–Compulsive Scale.13 0.35* −0. Hamilton Depression rating scale.38* * Correlation is significant at the 0. Depressive symptomatology.21 0.10 −0.21 0. Severity of OCD symptomatology.09 −0.57** −0.07 −0.03 −0. WCST.14 0.11 0.08 −0.21 0. P = 0.01 −0.25 −0. previous SRI CBT treatments treatments −0.20 0. measured by the Y-BOCS.24 0.32* −0.01 0.04 0.12 0. this effect disappeared (r = 0. WCST number of categories completed was negatively related to number of previous SRI treatments.101).32 0. measured by HAMA. California Verbal Learning Test.111. These relationships were taken into account in further analyses.044). previous No.05 level (two-tailed). P = 0.12 0. CVLT. the authors corrected for factors by means of partial correlations.29 −0.329.15 0. TMT.09 0. After correction for duration of illness. semantic clustering index: r = 0.28 0.099. correlated significantly with failure to maintain set on the WCST.31 0. semantic verbal fluency showed a significant relationship with depressive symptoms (r = −0. ** Correlation is significant at the 0. Wisconsin Card Sorting Test.23 −0.10 −0.328. HAM-A. all significant results disappeared (total recall: r = −0.38* 0. the authors interpreted the results as an artifact. Depressive symptomatology and anxiety symptoms did not relate to any of the cognitive measures.05 −0.316).33* −0. Because of the direct relationship between duration of illness and age.09 Age Verbal fluency Phonemic Semantic TMT Time B/time A Duration of illness Y-BOCS HAM-A HAM-D −0.39 Severity of anxiety symptoms.04 −0. P = 0.01 −0. Pearson correlation coefficients between clinical and neuropsychological variables in the obsessive–compulsive disorder group (n = 39) No.22 0.30 −0. Cognitive Behavioral Therapy.271.09 0. HAMD.

suggest- .6. In 2001. Almost all studies investigating verbal memory tasks (like the CVLT) show normal performance in patients with OCD. the latter being related to severity of OCD symptoms. Monchi et al. The current sample consisted of depression-free patients with OCD. namely.47–49 confirming that there is no mnemonic deficit. This is another argument for the hypothesis that the deficits in WCST performance in the current sample might be due to ACC abnormalities. The patients in the current sample showed a lower performance on the first trial.17. the lower performance on the first presentation of the CVLT can also be explained in terms of an attention deficit. First of all. Failure to maintain set occurs when the subject makes an error after five or more consecutive correct responses (the subject ‘loses’ the set) and is often explained as reflecting difficulty in sustaining attention and remaining ‘on task’. When the material is non-verbal (e. where they performed at the same level as controls.50–55 In patients with OCD. The slower performance of patients in other studies might be explained by depressive comorbidity.16.g. with a mean Hamilton–Depression score of 12. one would expect to find a profile of deficits associated with prefrontal-striatal dysfunction. a disorder renowned for its slowness of thought and movement. event-related potential studies demonstrated an increased error-related negativity (a negative waveform time-locked to incorrect responses) in patients with OCD.72 showed that receiving negative feedback during the WCST leads to activity in the dorsal part of the ACC of healthy subjects.39 They made up for this in later trials.69–71 This error-related negativity is attributed to the action-monitoring function of the ACC.46 Schmidtke et al. therefore. the authors did not find deficits in tasks such as verbal fluency and TMT (set shifting. the authors conclude that these patients do not suffer from a verbal memory deficit. failure to maintain set correlated significantly with the Y-BOCS.7.16 showed that abnormalities in executive function were related to comorbid depressive severity and argued that conflicting findings in past studies regarding executive functioning are due to comorbid depression. found deficits in patients with OCD on timed tests. approximately 50% to 80% of patients with OCD suffer from comorbid depression. the authors did not find any deficits in verbal memory. but this is most often explained in terms of a failure to use organizational strategies. which in its turn leads to the doubt and checking behavior characteristic for OCD. probably reflecting a lack of attention. The deficit found on the WCST is a failure to maintain set. several authors argue that the TMT should be seen as a measure of cognitive flexibility. de Geus et al. a task sometimes considered to be a measure of attention.. the structures that are most consistently shown to be involved in OCD are the orbitofrontal cortex and basal ganglia structures (especially caudate nucleus). Rey complex figure test). Studies in OCD patients consistently showed hypermetabolism of the ACC during symptom provocation. most studies do find differences in recall scores between patients with OCD and healthy controls. attention). a structure involved in attention functions and conflict monitoring in information processing (for an overview see References59. verbal fluency). Eight of the 29 patients (28%) had a lifetime diagnosis of major depressive disorder. However.67 and white matter abnormalities. it is plausible to assume that the CVLT and WCST data indicate a deficit in the attention system of the subjects with OCD.17 for instance. In contrast to many studies.60). In summary. DISCUSSION The main finding in the present study is that patients with OCD showed slowed learning on the CVLT and deficits in set maintenance as measured by the WCST.12–14 The most prominent feature of executive/frontal dysfunction is © 2007 The Authors Journal compilation © 2007 Folia Publishing Society perseverative behavior. focused attention and verbal fluency. This attention deficit could be due to abnormal functioning of the anterior cingulate cortex (ACC).1–11 To be more precise. the authors did find a deficit in WCST performance (set shifting).50 F. might include executive deficits leading to.62 and during the execution of neuropsychological tasks.61 at rest.58 Therefore. This could explain their normal performance on timed tests.39 The authors did not find deficits on the TMT. Furthermore. other than a slightly slower learning curve. the cognitive deficits found in patients with OCD do not fit the profile of deficits associated with prefrontal-striatal dysfunction. Regarding the CVLT. The deficits found in the current patient sample did not fit this profile.56. Basso et al. but failed to find the expected elevated level of perseverative errors. An alternative line of explanation is that the current results on the CVLT and the WCST can be explained by a deficit in the attention system.45 the present study failed to find slower performance on timed tests (TMT. which is indicative of mild depressive symptoms.8.63–65 Structural studies found abnormalities in the ACC as well: more total gray matter66. A cognitive profile matching dysfunction in these structures. Many authors argue that an overactive actionmonitoring system leads to constant feelings of erroneous performance.57 As mentioned earlier. visual scanning and simple motor skills. errors in set shifting. Furthermore.4.17.68 In line with this. between the five symptom subtypes for any of the cognitive measures.

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