Behaviour Research and Therapy 46 (2008) 1101–1104

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Behaviour Research and Therapy

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Shorter communication

Words may not be enough! No increased emotional Stroop effect in obsessive–

compulsive disorder
Steffen Moritz*, Benny-Kristin Fischer, Birgit Hottenrott, Michael Kellner, Susanne Fricke, Sarah Randjbar,
Lena Jelinek
University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistrasse 52, 20246 Hamburg, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Conflicting evidence has been obtained whether or not patients diagnosed with obsessive–compulsive
Received 6 February 2008 disorder (OCD) share an attentional bias towards disorder-related stimuli. Some of these inconsistencies
Received in revised form 27 April 2008 can be accounted for by suboptimal stimuli selection. In consideration of the heterogeneity of OCD, we
Accepted 1 May 2008
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
Keywords: based on experts’ appraisals. Patients neither displayed greater immediate as well as delayed Stroop
Obsessive–compulsive disorder
interference nor any bias for OCD and subtype-congruent stimuli. On the contrary, for washing-related
Stroop
Washer
items, OCD patients, and here especially washers, displayed facilitation relative to healthy controls. Al-
Checker though the present study at first sight refutes the notion of an attentional bias in OCD in contrast to other
Attentional bias anxiety disorders, several potential moderators need to be considered before this account is ultimately
Interference 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.
Ó 2008 Elsevier Ltd. All rights reserved.

Introduction
There is equivocal evidence whether or not patients with
obsessive–compulsive disorder (OCD) share an attentional bias for
concern-related material, a response pattern consistently reported
for patients with other anxiety disorders and depression (Mathews
& MacLeod, 2005; Williams, Meathews, & MacLeod, 1996). While
OCD is classified among the anxiety disorders, the absence of such
a bias in many studies (Kampman, Keijsers, Verbraak, Naring, &
Hoogduin, 2002; Kyrios & Iob, 1998; McNally, Riemann, Louro,
Lukach, & Kim, 1992; McNeil, Tucker, Miranda, Lewin, & Nordgren,
1999; Moritz, Jacobsen et al., 2004; Moritz & von Muhlenen, 2005;
Moritz & von Mühlenen, 2008; Unoki, Kasuga, Matsushima, & Ohta,
1999: supraliminal presentation) but not all studies (Foa, Ilai,
McCarthy, Shoyer, & Murdock, 1993; Lavy, van Oppen, & van den
Hout, 1994; Unoki et al., 1999: subliminal presentation) has been
interpreted (Summerfeldt & Endler, 1998) as a further evidence to
segregate OCD from the anxiety disorder spectrum besides differ-
ences regarding phenomenology and treatment.
Alternatively, problems to detect an attentional bias in patients
with OCD may be rooted in the idiosyncratic nature of OCD: Stimuli
* Corresponding author. Tel.: þ49 40 42803 6565; fax: þ49 40 42803 7566.
E-mail address: moritz@uke.uni-hamburg.de (S. Moritz).
eliciting concern or arousal largely differ even among patients who
share the same subtype (i.e., washing, checking, ordering, hoard-
ing). While one checker may only be concerned when leaving his
house (i.e., worry that the door has not been properly locked),
another patient may only worry while driving (i.e., fear to have hit
someone over). In contrast, in phobias, for example spider phobia,
the set of fear-eliciting stimuli is more homogeneous. Moreover,
not all prior relevant studies have looked at OCD-relevant stimuli
but some administered general anxiety, panic, or depression
stimuli (McNally et al., 1992, 1994; McNeil et al., 1999; Moritz,
Jacobsen et al., 2004). As many patients do not experience fear/
panic but disgust, tension, ‘‘not just right’’ experiences (Coles,
Heimberg, Frost, & Steketee, 2005) or an unspecified urge pre-
ceding compulsions, such material may not be best suited to cap-
ture an attentional bias.
A prominent test to elicit an attentional bias is the emotional
Stroop paradigm (MacLeod,1991). Whereas in a conventional Stroop
task (Stroop, 1935), the print-colour of an incongruently typed col-
our word has to be named resulting in strong interference (i.e.,
reading is more automatized than the target response colour nam-
ing), the emotional Stroop uses disorder-related words. As person-
ally or disorder-relevant items are attention-grabbing, the subject’s
attention is diverted from the primary task towards the distractor,
thus delaying the response. As an alternative account, rumination or
a lowered threshold for disorder-relevant material has been

0005-7967/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2008.05.005
1102 S. Moritz et al. / Behaviour Research and Therapy 46 (2008) 1101–1104
postulated to explain this response pattern in mental disorders.
Response latencies in the experimental condition are compared to
a control condition (neutral stimuli, colour bars, or meaningless
strings of characters). Usually, the emotional Stroop effect is weaker
than interference effects elicited by colour words.
For the present study, we compared OCD and healthy subjects
on an emotional variant of the Stroop task involving OCD-relevant
stimuli. We looked separately at items relevant for the two most
prevalent OCD subtypes (checking and washing). This was done, as
an attentional bias may not operate for all subtypes alike and to
take into account the heterogeneous phenomenology of OCD (e.g.,
the word ‘‘dirt’’ is likely more arousing for washers than checkers).
Stimuli were chosen via expert ratings to cover the most prevalent
concerns for each subtype. Apart from subtype other prominent
moderators for group differences in OCD apart from subtypes, such
as severity of OCD as well as comorbid affective symptoms, were
carefully considered. Finally, in view of recent studies (McKenna &
Sharma, 2004; for a discussion see Phaf & Kan, 2007) that have
detected slow but not fast emotional Stroop interference, we have
looked at reaction times both for immediate (trial N) and sub-
sequent trials (N þ 1). To the best of our knowledge, it has not been
investigated whether interference effects need more time to evolve
in OCD patients.
Methods
Participants
Twenty-three patients meeting DSM-IV criteria for OCD were
recruited from the Department of Psychiatry and Psychotherapy of
the University Medical Center Hamburg/Germany (gender: 11
male, 12 female; age: M ¼ 35.57, SD ¼ 10.54; years of formal school
education: M ¼ 11.04, SD ¼ 1.69). Presence of OCD was confirmed
with the Mini International Neuropsychiatric Interview (MINI,
Sheehan et al., 1998). Any history of psychotic and manic symptoms
(grandiose or paranoid ideas, hallucinations of any modality) led to
exclusion. Most patients were medicated with psychotropic drugs
(15 patients were prescribed antidepressant drugs, six of these also
with a neuroleptic agent). Eleven patients had a depressive episode
secondary to OCD and eight patients were co-diagnosed with an-
other anxiety disorder.
Twenty-three subjects served as healthy controls who were
recruited via an established subject pool or word-of-mouth (gender:
12 male, 11 female; age: M ¼ 31.39, SD ¼ 10.66; years of formal
school education: M ¼ 11.74, SD ¼ 1.48). The MINI interview verified
absence of any axis I psychiatric disorder in controls. None of the
participants suffered from neurological disorders (e.g., stroke, epi-
lepsy) including OCD spectrum disorders (e.g., Tourette’s syndrome).
Written informed consent was obtained from all participants
prior to baseline assessment. The German version of the Yale-
Brown Obsessive–Compulsive Scale (Y-BOCS) (Goodman et al.,
1989; German translation by Hand & Büttner-Westphal, 1991)
served as an index of OCD severity (total: M ¼ 22.73; SD ¼ 6.61). For
assessing depression, the Hamilton depression rating scale (HDRS;
17 item version; Hamilton, 1960) was administered blind to neu-
rocognitive status (total score: M ¼ 12.18, SD ¼ 7.08). Subscores for
these scales were computed using algorithms derived from factor
analytic studies (Moritz et al., 2002; Moritz, Meier, Hand, Schick, &
Jahn, 2004). We administered the Hamburg Obsessional Compul-
sive Inventory (HOCI; Klepsch, Zaworka, Hand, Lünenschloss, &
Jauernig, 1991) to specify OCD subtypes. The HOCI is a self-rating
instrument that assesses core obsessions (e.g., thoughts of doing
harm to self/others) and compulsions (e.g., checking) along six
scales. Seven of the patients displayed both checking and washing
symptoms, while each three patients only showed checking or
washing symptoms.
Experimental task
The emotional Stroop task was constructed using SuperLabÒ
software and was individually presented via a Macintosh computer.
Following a short practice task with six items to familiarize subjects
with the task requirements, 15 stimuli from each of the nine dif-
ferent conditions were presented in random order.
Words for the non-OCD conditions were similar to stimuli used
in a prior experiment (Moritz, Jacobsen et al., 2004) and compiled
following consensus ratings by experienced clinicians. The OCD
items were newly collected after an iterative reduction process
guided by ratings from six clinical psychologists or psychiatrists
with extensive experience with OCD patients. The final set of words
was rated OCD-relevant by the majority of assessors. The conditions
were similar according to word length, initial letters (plosive vs.
non-plosive) and word frequency (all contrasts p > 0.1). The emo-
tional word conditions were as follows: OCD-checking relevant
(e.g., lock, accident), OCD-washing relevant (e.g., blood, dirt), anxiety
(e.g., anxiety, panic), depression (e.g., weakness, loneliness), positive
(e.g., beauty, success), and paranoia-relevant (e.g., spy, surveillance).
There were two non-affective control conditions: neutral (e.g.,
bag, table) and Stroop interference (e.g., incongruently written
colour words). Naming of horizontal colour bars served as baseline
condition. As noted, the non-OCD conditions were similar to
a previous experiment with one exception: in the neutral condi-
tion, two formerly presented items that could be considered OCD-
relevant (soap, sink) were substituted for the present experiment.
Colors were evenly distributed across all conditions: red (Ger-
man: rot), green (grün), yellow (gelb), and blue (blau). Words were
presented in German language; all participants were German na-
tive speakers.
Each trial consisted of the following sequence: a small fixation
point (300 ms) was first followed by a 200 ms blank trial. Sub-
sequently, the target stimulus (font 30, type Geneva) was shown
until the individual triggered the voice-key via microphone. Par-
ticipants were instructed to respond as fast as possible and to avoid
making mistakes. Following each response, the experimenter
pressed a button to denote correct (i.e., ‘‘C’’) and incorrect re-
sponses (i.e., ‘‘X’’) which initiated the next trial.
Strategy of data analysis
Reaction time latencies were recorded for correct trials only.
Reaction times faster than 300 ms and slower than 4000 ms were
excluded from analyses. As dependent variables, we computed
reaction times from the median response latencies for target words
(N) as well as subsequent words (trial N þ 1), as we were interested
if an attentional bias persists over time and/or manifests after
a delay due to, for example, rumination. A 2  9 mixed analysis of
variance (ANOVA) was conducted with the experimental condi-
tions as within-subject and Group (healthy, OCD) OCD as between-
subject factor. Since our hypothesis was undirected, for exploratory
purposes we also computed single comparisons.
Results
Sociodemographic background variables and immediate
interference
Samples did not differ with respect to sociodemographic back-
ground variables (age, gender, school education; all p > .1).
In the mixed ANOVA neither the effect of Group, F(1,44) ¼ 0.84,
p > .3, h2partial ¼ .02, nor the interaction of Group  Condition,
F(8,352) ¼ 0.78, p > .3, h2partial ¼ .02, surpassed the level of signifi-
cance. As can be seen in Fig. 1, the significant effect of Condition is
mainly owing to discrepant reaction times in the control condition
 S. Moritz et al. / Behaviour Research and Therapy 46 (2008) 1101–1104 1103

850 group differences were rather small and for the washing-related
healthy words even a counter-intuitive facilitation occurred: here, espe-
reaction times in ms

800
OCD cially washers, displayed less interference!
750 While it is thus tempting to infer that OCD is not associated with
an attentional bias, particularly in view of many studies unable to
700 detect such a cognitive preference in OCD (see introduction) and in
line with claims made by Summerfeldt and Endler (1998), we
650
should not jump to conclusions. First, although we gathered stimuli
600 that deal with the prominent concerns of OCD washers and
checkers, we cannot rule out that for a subgroup of patients sharing
550
idiosyncratic and very isolated worries these items were not at-
g

ng

id

ve

ty

op
ra

tention-grabbing enough thus attenuating group differences. The

in

io

m r
no

na colo
ti
hi

ut

ro
g
ck

ss

xi
si

in
as

ra
ne

St
an
po
e

e counter-intuitive facilitation for washing-related material could be

pa
ch

pr
w

de

owed to greater familiarity in patients with such stimuli acting

Fig. 1. The two-way ANOVA did not yield any group differences regarding condition.
However, post hoc analyses revealed a slight speeding of OCD patients for washing-
relevant words in the colour bar naming condition but not in the neutral condition
relative to controls.
colour naming versus the conventional Stroop interference condi-
tion, F(8,352) ¼ 28.50, p < .001, h2partial ¼ 0.39. When we subtracted
reaction times in the two OCD and the Stroop interference condi-
tion from the neutral word and non-word control condition (colour
naming), no evidence for greater interference emerged for OCD
patients even before Bonferroni-correction for multiple compari-
sons. On the contrary, for washing-relevant material, the difference
achieved significance (washing vs. colour bars, p ¼ .03) or trend
level (washing vs. neutral word, p ¼ .09) indicating facilitation in
patients. For checking-relevant items (p > .3) and conventional
Stroop interference (p > .1) no such effects emerged.
Delayed interference
For trials following the critical trials (N þ 1) groups displayed
a similar response pattern: the main effect of Group and the in-
teraction did not produce significant effects (both p > 0.3, both
h2partial < 0.028). Moreover, none of the post hoc comparisons (e.g.,
washing condition – neutral) yielded significance (p > 0.3).
Subgroup analysis
According to HOCI scores, the OCD sample was split into
washers and checkers. None of the ANOVA results yielded signifi-
cance except for the washing condition with colour naming as
baseline, F(2,41) ¼ 3.34, p < .05. Post hoc comparisons showed that
washers (M ¼ 48 ms) showed significantly less interference than
healthy participants (M ¼ 124 ms). OCD-non-washers performed
intermediate (M ¼ 92 ms). Finally, we investigated whether a sub-
group of patients would display strong interference. To our sur-
prise, for washing-relevant material six healthy subjects were
among the 10 participants with the highest interference latencies,
whereas for checking-relevant items both five healthy and OCD
patients displayed highest interference.
Discussion
The present study revealed no evidence for greater interference
on any of the experimental conditions of an emotional Stroop task
in OCD. Specifically, no retardation was detected for OCD-relevant
material – irrespective of subtype. The OCD stimuli were collected
after a thorough iterative reduction process involving experts’
opinion to assure that central OCD concerns were covered. More-
over, special care was devoted to equate conditions for several
important moderators such as words length and language fre-
quency. Our findings unlikely reflect a lack of statistical power, as
against a pop-out effect of the distractor, which may only be found
for the most fear-evoking stimuli. We would like to point out that
Kyrios and Iob (1998) also found facilitation for OCD and other
anxiety words in both OCD and healthy subjects. Interestingly, Lavy
et al. (1994) reported greater interference for negatively valenced
OCD words while for positively valenced OCD words the response
pattern reversed in OCD patients. Nonetheless, future studies may
benefit from greater consideration of individual concerns and may
also employ paradigms that may tease apart the relative contri-
bution of vigilance and disengagement problems in the emergence
of Stroop interference (Amir, Elias, Klumpp, & Przeworski, 2003).
If the attentional bias in OCD is existent, it is apparently more
subtle than in PTSD patients or patients with simple phobias.
Therefore, a verbal paradigm may not be sufficiently sensitive to
elicit a heightened attentional bias, especially when involving ran-
dom item administration precluding prolonged confrontation with
disorder-related items. The worries of OCD patients are mostly
triggered by visual cues or images (e.g., dirt on the table, key lock)
and a visual paradigm may thus be fairer to put this hypothesis to
test. Indeed, a recent study using neutral, anxiety and OCD pictures
in the context of a modified inhibition of return (IOR) paradigm was
able to show greater distractibility of OCD patients for OCD-relevant
but not neutral and anxiety material relative to controls (Moritz
et al., submitted for publication). Therefore, while we are safe to
assume that any attentional bias in OCD is less pronounced than in
other anxiety disorders, especially PTSD, researchers should con-
tinue to pursue this account with other paradigms before ultimately
dismissing it. Moreover, subjective appraisal ratings may help to
determine whether stimuli sufficiently cover patients’ concerns. In
line with this, we found that washers but not checkers were slowed
on a primed Stroop task for OCD-relevant targets when the sample
was split in subjects endorsing more than one-third of the items as
personally relevant versus those that did not meet this criterion
(Fischer, 2007). So far, stimuli of past research were either rated by
other subjects for relevance (Foa et al., 1993; Lavy et al., 1994; Unoki
et al., 1999), experts (Moritz, Jacobsen et al., 2004, and present
study) or not at all. None of these studies performed a subanalysis of
items with special personal relevance. Finally, the blockwise ad-
ministration of conditions may be more powerful to elicit effects
(e.g., Lavy et al., 1994) if an attentional bias in OCD needs time to
evolve and/or needs multiple triggers and prolonged exhibition (see
Phaf & Kan, 2007), although the present analysis of delayed effects in
trial N þ 1 did not provide evidence for this assumption.
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