The state of the art of cognitive functioning in OCD: an alternative pathway to understanding neuropsychological heterogeneity

O estado da arte do funcionamento cognitivo no TOC: um caminho alternativo para a compreensão da heterogeneidade neuropsicológica

Traditional classification systems (DSM and ICD) still represent the primary means for grouping psychiatric nosology. Nonetheless, mounting evidence suggests that these classification systems do not fully capture the natural organization of psychopathology symptoms, preventing the identification of underlying neurobiological substrates¹,². Considering that mental disorders share symptoms (e.g. affective processing, cognitive impairment, dysfunctional behaviors)³, a transdiagnostic approach appears to be more effective than the traditional classifications systems⁴. Also, a given mental disorder (e.g., depression) can show very different clinical presentations, with a huge heterogeneity regarding its psychopathology symptoms, both in nature and magnitude⁵. This heterogeneity can prevent grouping the same disorder in a homogeneous group, and therefore, restrict the ability of clinicians to stipulate treatment options, and to predict treatment outcomes and/or clinical course accurately⁶. The identification of distinct groups within the same mental disorder contributes to accuracy in clinical practice and in research. It may be particularly important in neuropsychology, where unidentified heterogeneity may leave significant sources of overlooked variance⁷.

Obsessive-compulsive disorder (OCD) is a disabling mental disorder that affects 2% to 3% of general population and show a high heterogeneity in clinical presentations⁸. Additionally, the neurobiological abnormalities present in OCD patients play a crucial role in its etiology and course⁹. Thus, neuropsychological impairment has been proposed as the intermediate phenotype between the clinical manifestation of the disorder and its neurobiological etiology¹⁰.

Cognitive deficits in OCD exhibit inconsistency in results with differential performances on identical or similar tasks, often due to methodological discrepancies¹⁰. OCD patients frequently show cognitive deficits in episodic and short term memory¹¹–¹³; executive functions¹⁴; visuoconstructive skills¹³, and processing speed¹⁵. The deficits in memorizing and recalling presented by these patients may be due to problems in executive function: the organization of information¹⁶,¹⁷. The difficulty in organizing events compromises the encoding of stimuli, resulting in a weaker memory trace. Another extensively studied executive function in patients with OCD is planning. OCD patients require more time to generate an alternative hypothesis due to a previous error or to verify if the next move is correct¹⁸. This suggests that a deficit in selective attention leads to excessive control of movement. This control arises from the fear of making mistakes or the difficulty in finding novel cognitive strategies. Additionally, deficits in planning may be due to difficulty initiating and executing moves. This deficit has been associated with psychomotor impairment¹⁹. Planning deficits differs for easier and more difficult tasks. In easier tasks, OCD patients only differ in execution time. On the other hand, in more difficult tasks, OCD patients differ in both time and accuracy²⁰.

Considering the heterogeneity in clinical presentations of OCD, there is a need of an alternative approach for studying cognitive deficits in patients suffering from this disorder. A possible solution is to group patients with similar symptom patterns and establish associated neuropsychological profiles. The understanding of the neuropsychological profiles underlying the subtypes of OCD can provide more effective and individualized treatments. A recent review²¹ identified three symptom patterns present in almost every factor analytic study, which are: “Symmetry obsessions/Ordering compulsions”; “Contamination obsessions/Cleaning compulsions” and “Checking compulsions”.

In general, the “Checking compulsions” dimension shows the lowest neuropsychological performance in all dimensions. This supports the hypothesis of potential involvement of atypical assessment of fear or attentional bias directed towards fear-based, which may impair such executive functions²². Furthermore, Cameron et al., 2020²¹, showed three cognitive clusters associated with the dimensions or subtypes of OCD, namely: 1) “executive function cluster”; 2) “episodic memory cluster”; and 3) “visualspatial skills cluster”. The Symmetry obsessions/Ordering compulsions are associated with more prominent deficits in verbal and visual episodic memory, while checking symptom patterns are linked to impairments primarily in visualspatial skills. Finally, contamination symptom patterns are associated with deficits in executive functions (core components and higher level).

In sum, current literature suggests that there is a relationship between the neuropsychological profile and the symptom pattern in OCD. Nevertheless, it is possible that the differences in observed results are partially due to methodological differences between studies, and further research linking neuropsychological profiles with symptom dimensions is necessary.

REFERENCES

• ¹
  Tiego J, Oostermeijer S, Prochazkova L, Parkes L, Dawson A, Youssef G, et al. Overlapping dimensional phenotypes of impulsivity and compulsivity explain co-occurrence of addictive and related behaviors. CNS Spectr. 2019 Aug;24(4):426-40. doi: 10.1017/S1092852918001244.
  » https://doi.org/10.1017/S1092852918001244
• ²
  Parkes L, Tiego J, Aquino K, Braganza L, Chamberlain SR, Fontenelle LF, et al. Transdiagnostic variations in impulsivity and compulsivity in obsessive-compulsive disorder and gambling disorder correlate with effective connectivity in cortical-striatal-thalamic-cortical circuits. Neuroimage. 2019 Nov 15;202:116070. doi: 10.1016/j.neuroimage.2019.116070.
  » https://doi.org/10.1016/j.neuroimage.2019.116070
• ³
  Nolen-Hoeksema S, Watkins ER. A heuristic for developing transdiagnostic models of psychopathology: explaining multifinality and divergent trajectories. Perspect Psychol Sci. 2011 Nov;6(6):589-609. doi: 10.1177/1745691611419672.
  » https://doi.org/10.1177/1745691611419672
• ⁴
  McGorry PD, Hartmann JA, Spooner R, Nelson B. Beyond the “at risk mental state” concept: transitioning to transdiagnostic psychiatry. World Psychiatry. 2018 Jun;17(2):133-42. doi: 10.1002/wps.20514.
  » https://doi.org/10.1002/wps.20514
• ⁵
  Regier DA, Narrow WE, Kuhl EA, Kupfer DJ. The conceptual development of DSM-V. Am J Psychiatry. 2009 Jun;166(6):645-50. doi: 10.1176/appi.ajp.2009.09020279.
  » https://doi.org/10.1176/appi.ajp.2009.09020279
• ⁶
  Mataix-Cols D, Rosario-Campos MC, Leckman JF. A multidimensional model of obsessive-compulsive disorder. Am J Psychiatry. 2005 Feb;162(2):228-38. doi: 10.1176/appi.ajp.162.2.228.
  » https://doi.org/10.1176/appi.ajp.162.2.228
• ⁷
  Abramovitch A, Abramowitz JS, Mittelman A. The neuropsychology of adult obsessive-compulsive disorder: A meta-analysis. Clin Psychol Rev. 2013 Dec;33(8):1163-71. doi: 10.1016/j.cpr.2013.09.004.
  » https://doi.org/10.1016/j.cpr.2013.09.004
• ⁸
  McKay D, Abramowitz JS, Calamari JE, Kyrios M, Radomsky A, Sookman D, et al. A critical evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms. Clin Psychol Rev. 2004 Jul;24(3):283-313. doi: 10.1016/j.cpr.2004.04.003.
  » https://doi.org/10.1016/j.cpr.2004.04.003
• ⁹
  Menzies L, Chamberlain SR, Laird AR, Thelen SM, Sahakian BJ, Bullmore ET. Integrating evidence from neuroimaging and neuropsychological studies of obsessive-compulsive disorder: the orbitofronto-striatal model revisited. Neurosci Biobehav Rev. 2008;32(3):525-49. doi: 10.1016/j.neubiorev.2007.09.005.
  » https://doi.org/10.1016/j.neubiorev.2007.09.005
• ¹⁰
  Benzina N, Mallet L, Burguière E, N'Diaye K, Pelissolo A. Cognitive Dysfunction in Obsessive-Compulsive Disorder. Curr Psychiatry Rep. 2016 Sep;18(9):80. doi: 10.1007/s11920-016-0720-3.
  » https://doi.org/10.1007/s11920-016-0720-3
• ¹¹
  Sahu A, Das B, Gupta P. Visuospatial memory in patients with obsessive-compulsive disorder. J Mental Health Hum Behav. 2017;22(1):55-60. doi: 10.4103/jmhhb.jmhhb_37_16
  » https://doi.org/10.4103/jmhhb.jmhhb_37_16
• ¹²
  Nakamae T, Narumoto J, Sakai Y, Nishida S, Yamada K, Fukui K. The neural basis of dysfunctional beliefs in non-medicated patients with obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2012 Apr 27;37(1):22-5. doi: 10.1016/j.pnpbp.2011.11.017.
  » https://doi.org/10.1016/j.pnpbp.2011.11.017
• ¹³
  Shin N, Lee TY, Kim E, Kwon JS. Cognitive functioning in obsessive-compulsive disorder: a meta-analysis. Psychol Med. 2014 Apr;44(6):1121-30. doi: 10.1017/S0033291713001803.
  » https://doi.org/10.1017/S0033291713001803
• ¹⁴
  Tükel R, Gürvit H, Ertekin BA, Oflaz S, Ertekin E, Baran B, et al. Neuropsychological function in obsessive-compulsive disorder. Compr Psychiatry. 2012 Feb;53(2):167-75. doi: 10.1016/j.comppsych.2011.03.007.
  » https://doi.org/10.1016/j.comppsych.2011.03.007
• ¹⁵
  Abramovitch A, Cooperman A. The cognitive neuropsychology of obsessive-compulsive disorder: A critical review. J Obsessive Compuls Relat Disord. 2015;5:24-36. doi: https://doi.org/10.1016/j.jocrd.2015.01.002
  » https://doi.org/10.1016/j.jocrd.2015.01.002
• ¹⁶
  Segalàs C, Alonso P, Real E, Garcia A, Miñambres A, Labad J, et al. Memory and strategic processing in first-degree relatives of obsessive-compulsive patients. Psychol Med. 2010 Dec;40(12):2001-11. doi: 10.1017/S0033291710000310.
  » https://doi.org/10.1017/S0033291710000310
• ¹⁷
  Harkin B, Kessler K. The role of working memory in compulsive checking and OCD: a systematic classification of 58 experimental findings. Clin Psychol Rev. 2011 Aug;31(6):1004-21. doi: 10.1016/j.cpr.2011.06.004.
  » https://doi.org/10.1016/j.cpr.2011.06.004
• ¹⁸
  Veale DM, Sahakian BJ, Owen AM, Marks IM. Specific cognitive deficits in tests sensitive to frontal lobe dysfunction in obsessive-compulsive disorder. Psychol Med. 1996 Nov;26(6):1261-9. doi: 10.1017/s0033291700035984.
  » https://doi.org/10.1017/s0033291700035984
• ¹⁹
  Rajender G, Bhatia MS, Kanwal K, Malhotra S, Singh TB, Chaudhary D. Study of neurocognitive endophenotypes in drug-naïve obsessive-compulsive disorder patients, their first-degree relatives and healthy controls. Acta Psychiatr Scand. 2011 Aug;124(2):152-61. doi: 10.1111/j.1600-0447.2011.01733.x.
  » https://doi.org/10.1111/j.1600-0447.2011.01733.x
• ²⁰
  Martoni RM, Risso G, Giuliani M, de Filippis R, Cammino S, Cavallini C, et al. Evaluating Proactive Strategy in Patients with OCD During Stop Signal Task. J Int Neuropsychol Soc. 2018 Aug;24(7):703-14. doi: 10.1017/S1355617718000267.
  » https://doi.org/10.1017/S1355617718000267
• ²¹
  Cameron DH, Rowa K, McKinnon MC, Rector NA, McCabe RE. Neuropsychological performance across symptom dimensions of obsessive-compulsive disorder: a comment on the state and critical review of the literature. Expert Rev Neurother. 2020 May;20(5):425-38. doi: 10.1080/14737175.2020.1746644.
  » https://doi.org/10.1080/14737175.2020.1746644
• ²²
  Da Victoria MS, Nascimento AL, Fontenelle LF. Symptom-specific attentional bias to threatening stimuli in obsessive-compulsive disorder. 2012 Aug;53(6):783-8. doi: 10.1016/j.comppsych.2011.12.005.
  » https://doi.org/10.1016/j.comppsych.2011.12.005

Publication Dates

• Publication in this collection
  17 Nov 2023
• Date of issue
  2023

History

• Received
  10 Oct 2023
• Accepted
  16 Oct 2023