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Verbalizations during compulsions in obsessive-compulsive disorder
Author’s Accepted Manuscript Verbalizations during compulsions in obsessivecompulsive disorder B.A. Joanna Collaton, Christine Purdon
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To appear in: Journal of Obsessive-Compulsive and Related Disorders Received date: 25 May 2015 Revised date: 21 October 2015 Accepted date: 27 October 2015 Cite this article as: B.A. Joanna Collaton and Christine Purdon, Verbalizations during compulsions in obsessive-compulsive disorder, Journal of ObsessiveCompulsive and Related Disorders, http://dx.doi.org/10.1016/j.jocrd.2015.10.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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VERBALIZATIONS DURING COMPULSIONS Verbalizations during compulsions in obsessive-compulsive disorder Joanna Collaton, B.A. and Christine Purdon, Ph.D.1 Department of Psychology University of Waterloo
1
Corresponding author
Department of Psychology University of Waterloo Waterloo, ON N2L 3G1 Canada Ph: 519-888-4567, x33912 Fax: 519-746-8631 Email: [email protected]
Abstract Research on memory in obsessive-compulsive disorder (OCD) suggests that people with OCD lack confidence in their memory and that repetition of an action actively erodes confidence in memory for it. Meanwhile, research on general memory processes suggests that when people say aloud the material they seek to remember, just once, memory is improved (MacLeod, Gopie, Hourihan, Neary & Ozubko, 2010). It could prove useful to examine the extent to which people with OCD verbalize during their compulsions in order to better recall them later, and to examine the effectiveness of verbalizing when it is repeated. However, we do not know whether people with OCD speak aloud during compulsions. This study examined the frequency, purpose, and
2 impact of verbalization on self-reported memory accuracy and confidence in people with OCD (N = 35). Over half reported speaking aloud while engaging in their compulsions, most often to improve confidence that the action had been done properly. Tendency to verbalize was associated with better self-reported memory for the action and greater memory confidence, but not with urge to repeat the action. These data suggest that research on memory strategies may be usefully brought to bear on our understanding of the persistence of compulsions. Keywords Compulsions, memory confidence, working memory, production effect
Verbalizations during compulsions People with obsessive-compulsive disorder (OCD) engage in compulsions (washing, checking, cleaning, arranging) in order to ameliorate the distress or discomfort evoked by obsessions (American Psychiatric Association, 2013). Compulsions are often repeated multiple times within one episode. Recent research suggests that repetition results from poor confidence in memory (e.g. Radomsky, Rachman, & Hammond, 2001),combined with a high need for certainty that the compulsion has been done “properly” (e.g., Rachman, 2002). However, repetition appears to produce an ironic decline in memory confidence for an action as that action is repeated (e.g., Radomsky, Gilchrist, & Dussault, 2006; van den Hout & Kindt, 2003). In order to achieve a sense of certainty that their compulsion was done properly, people with OCD often require a vivid and detailed memory of the act, which in turn requires encoding of a wide array of internal and external details (Kuelz, Hohagen & Voderholzer, 2004; Wahl, Salkovskis & Cotter, 2008). Given the apparent role of memory confidence in the persistence of OCD, research on memory processes might be usefully brought to bear on our understanding of compulsions. Macleod et al. (2010) observed that an effective strategy for improving recall of a
3 word is to pronounce (or, produce) it aloud. They found that not only did producing a word aloud improve explicit memory for that word, but there was a direct relationship between recall and how audibly it had been produced, such that the more audible the response, the more accurately it was recalled (Forrin, MacLeod, & Ozubko, 2012). Macleod and colleagues called this the “production effect”. Saying something aloud, then, appears to be a good strategy for improving explicit recall later on, at least under normal circumstances. People with OCD, though, seek to recall a series of events in an unusually high level of detail, and those events have been repeated multiple times. This may introduce a considerable tax on working memory (WM; Harkin & Kessler, 2011). According to Baddeley (1992), WM is “the temporary storage of information in connection with the performance of other cognitive tasks” (pg. 556). The three components of WM are: a) the central executive, which controls attention; b) the visuo-spatial sketchpad which manipulates visual images; and, c) the phonological loop, which stores and rehearses speech-based information. There are individual differences in how well people are able to correctly reproduce, in order, a series of information units that have just been given. This individual difference factor is referred to as the WM span. The effects of overloading the WM vary according to whether or not one’s WM span is high or low. In people with a high WM span, information overload seems to interfere with the ability of the central executive to shift attention away from task-irrelevant back to task-relevant information. People with a low WM span perform worse on tasks in which they have to produce information, regardless of load (Rosen & Engle, 1997). If people are distracted by task-irrelevant information and are thus unable to switch attention efficiently, or they have a low WM span, memory accuracy, memory confidence, or both, might be compromised. Radomsky and Rachman (1999) found that people with OCD did not perform worse on a neuropsychological assessment of memory and that they actually had better recall of threat-
4 relevant objects than did anxious and nonanxious controls. There is now a substantive literature which suggests that people with OCD do not have memory deficits, but rather lack memory confidence (Alcolado & Radomsky, 2011; Muller & Roberts, 2005; van den Hout & Kindt, 2003) and that repeating a task reduces confidence (Radomsky et al., 2006). Jaafari et al. (2013) examined the link between WM and checking behaviours in people with OCD. Participants’ WM span was assessed, after which they completed an image comparison task in which they had to describe the differences between two images while their eye movements were tracked. Results indicated that people with OCD, as compared to healthy controls, had a low WM span, took more time comparing the drawings, and shifted their gaze between the two images more often. The researchers speculated that the WM of people with OCD may be kept permanently busy with obsessions and compulsions, which contributes to its low span. Consistent with this, Jaafari et al. (2015) found that people with schizophrenia had a low WM span and also exhibited repetitive checking, but the repetitive checking was not correlated with WM span. In a metaanalysis on the neuropsychology of OCD (Abramovitch, Abramowitz, & Mittelman, 2013), results suggested that there were small but significant differences in WM performance in a clinical sample. As one reviewer suggested, perhaps the small but robust differences are moderated by memory confidence. The findings of Jaafari et al.’s (2013) and Abramovitch et al.’s (2013) stand in contrast to numerous past findings in which observed deficits in the memory functioning of people with OCD could be attributed to depression. Indeed, Moritz et al. (2002) concluded that “nondepressed patients with OCD have no dysfunctions in concept formation and verbal (working) memory” (pg. 481). It thus remains unclear whether those with OCD have a low WM span, or, have a high WM span that is constantly overloaded, which in turn compromises ability to shift attention from task-irrelevant back to task-relevant stimuli. As Radomsky (2006)
5 theorized, perhaps people with OCD hold their attention on the specific actions they are completing and are unable to shift their attention to cues that they have completed the action. Theoretically, this would result in high memory accuracy but low memory confidence. Given that people with OCD may either have a low WM span, and thus are less able to produce recalled information, or have a high WM span that is overtaxed by rumination and compulsions, it is quite possible that they use compensatory strategies to facilitate recall, such as verbalizing the information they want to remember. Clinical anecdotal evidence suggests that people with OCD do indeed speak aloud while completing their compulsions. Laboratory studies of the production effect have found that just one repetition facilitates recall of straightforward information. If people with OCD are repeating an action, and verbalizing each time, might the production effect diminish? Bucarelli and Purdon (in press) found that people with OCD repeated their compulsions an average of 5 times within each compulsive episode and that greater repetition was associated with the need to encode evermore detail of the action for recall later. In order to better understand the persistence of compulsions it may be worthwhile to better understand the use of compensatory memory strategies and their effectiveness under circumstances of greater repetition and increasing tax on working memory. However, to our knowledge there is no phenomenological data on the extent to which people with OCD actually do verbalize the information they hope to recall later while completing their compulsions, nor its success in achieving its goal. The purposes of the current study were to: a) determine how much, on average, people with clinical and subclinical symptoms of OCD who repeat actions verbalize while completing those actions; b) the content of their verbalizations; c) what verbalizing is intended to accomplish and how successful it is; and, d) the extent to which verbalizing during compulsions is associated
6 with memory confidence and perceived accuracy. Participants who had received a diagnosis of OCD within the past 4 years completed a measure of OCD symptom severity and were then administered an online questionnaire developed for the current study to address each of the queries above. The essential purpose of this study was to obtain phenomenological data on the use of verbalization during compulsions on which to base further queries about the role of overt verbalization in memory confidence and accuracy and its relationship to the persistence of compulsions. Methods Participants Participants were recruited from the Anxiety Studies Division (ASD) of the University of Waterloo Centre for Mental Health Research participant pool. This pool comprises adults from the community who have undergone the MINI International Neuropsychiatric Interview, Version 6.0.0, Sheehan et al., 1998, provided demographic information, have completed a battery of selfreport measures, and have agreed to be contacted for research studies. The ASD research pool included 136 participants who had received a clinical or subclinical diagnosis of OCD over the 4 years since the pool was started. All 136 were contacted by email and invited to participate in an online study for a chance at winning 1 of 2 $25.00 gift certificates. Participants were given an information letter describing the study and provided their consent to participate. Ten participants could not be contacted at the time of the study and of the remaining 126 a total of 42 (33%) agreed to participate. Of these, three were excluded because they did not report a repetitive action in the last week and four more had incomplete data, leaving a final total of 35 participants. The sample consisted of 71.4% (N = 25) females and 28.6% males (N = 10) with the majority of participants identifying as White/Caucasian (N = 27, 77.1%). The rest of the sample
7 identified as: Asian (n = 3, 8.5%), South Asian (n = 2, 5.7%), West Indian (n = 1, 2.9%), or did not report ethnicity (n = 2, 5.7%). Participants’ ages ranged from 18 to 69 with an average of 34 years of age (SD = 13.5). They had an average of 15.2 years of education (SD = 2.08). All participants (n = 35) had either a clinical (Clinician’s Severity Rating (CSR) ≥ 4) or subclinical (CSR ≤ 3) diagnosis of OCD. Of those, n = 22 (62.5%) had a principal or co-principal diagnosis of OCD, n = 10 (28.5%) had a secondary diagnosis of OCD (that is, had two diagnoses of which the OCD was the less severe), and n = 3 had a subclinical diagnosis. The majority (n = 4) of those with a co-principal diagnosis of OCD were also diagnosed with an equally significant anxiety-related disorder; the rest of the sample (n = 2) were diagnosed with an equally significant mood disorder. The CSR’s ranged from 2 to 7 on a 1 to 8 scale with a score 4 or above being clinically significant (n = 31 with CSR ≥ 4). Participants with a principal diagnosis of OCD had an average CSR of 5.35 (SD = 0.93). Similarly, participants with a co-principal diagnosis of OCD had an average CSR of 5.33 (SD = 0.52). Participants whose OCD was secondary to another disorder had an average CSR of 4.63 (SD = 0.58) and participants with subclinical OCD had an average CSR of 2.5 (SD = 0.58). The length of time between initial diagnoses and study participation ranged from 12-48 months, with 9 participants being diagnosed in the past year. After data collection was complete, we sampled a subset of those with diagnoses more than 1 year old and all remained clinically symptomatic. Measures Vancouver Obsessional Compulsive Inventory (VOCI)
8 The VOCI is a 55-item self-report measure created to “provide assessment of a [wide] range of obsessions, compulsions, avoidance behaviour, and personality characteristics of known or theoretical importance in OCD” (Thordarson, Radomsky, Rachman, Shafran, Sawchuk, & Hakstian, 2004, p. 1290). Responses are scored on 5-point scale (0 = not at all, 4 = very much). There are six subscales: contamination, checking, obsessions, hoarding, just right, and indecisiveness and each item is summed for a total score. The scale has demonstrated good internal consistency for both the subscales and the total score; α = 0.94 with an OCD sample and α = 0.92 in this sample. Verbalization during Repetitive Actions Questionnaire This questionnaire was developed by the authors to determine the extent to which participants verbalized during repetitive actions such as checking, washing, and arranging. Participants who reported that they had completed a repetitive action (defined as "behaviours or acts that you feel driven to perform although you may recognize them as senseless or excessive") were asked to identify the action that they completed the most in the past week. They were then asked to report, verbatim, on the fear or preoccupation associated with that particular action, how distressing the fear or preoccupation was (0-100 Likert scale), how many times they repeated the action, on average, within their compulsive episodes in the past week, and how much time the episodes took, on average. Next, they were asked whether or not they ever mouthed, whispered, or spoke aloud during the action they described earlier. Those who endorsed doing so were asked to report on the percentage of time they verbalized and how loudly they did so, using the response options of mouthing, whispering too quietly for anyone else to hear, whispering loudly enough that someone else could hear, low speaking voice, normal speaking voice and loud speaking voice.
9 They then reported, verbatim on what they said and its intended purpose. Finally, using 5-point Likert scales ranging from “not at all” to “a lot” they rated the extent to which verbalizing: decreased the time it took to complete the action, decreased the number of times they had to repeat it, improved their memory for the action, improved their confidence in the memory for the action, improved the vividness and detail of the memory, helped them to get the “right” feeling or sense of completion, and achieved the intended purpose. Results Prior to conducting analyses, data were checked for outliers (that is, cases more than three standard deviations above the mean and discontinuous from the distribution). There were two outliers on the number of times the action was repeated and the amount of time the episode lasted. These were adjusted by assigning them a value one unit above the second highest value. Types of Repetitive Actions and their Triggers Data on the types of repetitive actions and the fear, preoccupation or concern that evoked the action are presented in Tables 1 and 2 respectively. The obsessions and compulsions reported by participants were classified by the authors post hoc and were representative of OCD symptoms clusters identified in large scale studies (Eǧrilmez, A., Gülseren, L., Gülseren, Ş., & Kültür, S., 1997; Shavitt et al., 2014). d there were no observed differences between the obsessions and compulsions reported by those with a clinical vs subclinical diagnosis of OCDs. Prevalence and Frequency of Verbalization The means, medians, and standard deviations of the prevalence and frequency of verbalization during repetitive acts are presented in Appendix A. Fifty-four percent (n = 19) of participants indicated they mouthed, whispered, or spoke aloud during their repetitive action. On
10 average, they reported speaking aloud 40% of the time (M = 40.79) but there was wide variability in the data (SD = 35.24; range = 1-100%). About half of the participants (n = 10) reported that they verbalized in a low speaking voice. Only one reported verbalizing in a normal speaking voice and the remaining eight either mouthed the words (n = 2), spoke in an inaudible whisper (n = 4) or an audible whisper (n = 1). Of those who did not report verbalizing 50% (n = 8) reported that they verbalized covertly (i.e., in their head) while they repeated. Note that only participants who reported overt verbalization provided responses for questions about the impact of verbalizing on their repetitive action. The most commonly endorsed reason for verbalizing was to reassure self that harm had been avoided and/or that the action had been done properly (n = 11). Others reported that it distracted them from the obsessional concern or other upsetting thoughts (n = 3) whereas the others (n = 5) were unsure why they did it. The content of the reported verbalizations is presented in Table 3. The content of covert verbalization was similar to that of the overt verbalization. Memory Accuracy and Confidence Means and standard deviations of self-reported impact of overt verbalization on memory accuracy and confidence are presented in Appendix A. Overall, participants reported that verbalizing improved their confidence in their memory “somewhat” (M = 2.67, SD = 1.33), and that it “somewhat” improved their memory for the last repetition of the action (M = 2.39, SD = 1.04). They also reported that speaking increased their confidence “somewhat” that harm had been avoided (M = 2.89, SD = 1.18). In fact, verbalizing tended to help “somewhat” on most indices.
11 Relationship between extent of Verbalization and Memory Accuracy, Confidence and Symptom Severity Zero-order correlations between percentage time verbalizing and reports of memory accuracy and confidence and symptom severity are presented in Table 4. Consistent with the production effect, there was a large correlation between percent of time speaking aloud and selfreport of how detailed the memory was of the final repeat of the action (r = .589, p = .01, 35% shared variance) such that the more often participants verbalized, the more they perceived their memory of the final repeat to be detailed. Similar results were found for the correlation between percentage time speaking aloud and ratings of vividness (r = .511, p = .03, 26% shared variance) and improvement in memory (r = .519, p = .03, 26% shared variance). Tendency to verbalize also had a moderate (although nonsignificant) correlation with achieving the purpose of the repetitive act (r = .440, ns, 19% shared variance) and with confidence that harm had been avoided (r = .410, ns, 17% shared variance). Percent of time speaking aloud and improved confidence had smaller correlations with decrease in the need to repeat the compulsion, increased confidence in memory and achievement of the “right” feeling. Discussion The central purpose of this study was to determine the extent to which people with a clinical or subclinical diagnosis of OCD verbalize while repeating actions, and the influence of overt verbalization on aspects of memory for the action and memory confidence. More than half of the participants reported that they verbalized, on average, 40% of the time, most commonly in a low speaking voice. The most commonly reported purpose of the verbalizations was to provide reassurance and this was reflected in their content. Use of verbalization was rated as being “somewhat” effective in improving aspects of memory and memory confidence, getting the
12 “right” feeling, and in increasing confidence that danger had passed. This subjective report was consistent with the observed pattern of correlations between the percentage time verbalization was used and memory vividness, accuracy, and confidence; the more people verbalized the more people felt it improved memory and confidence. Interestingly, verbalization had a notably weaker relationship with confidence that the action had been done properly, achieving the “right” feeling, and the amount of time spending doing the action. These findings suggest that participants may have an implicit awareness of the production effect and be using verbalization as a strategy to improve memory for the action. Participants most often verbalized in a low speaking voice, often because other people were around. Past research (MacLeod et al., 2010) suggests that speaking aloud leads to better recall. In future research it might be interesting to compare compulsive episodes in which verbalization was soft vs. loud to determine if the latter confers any benefits with respect to the number of repetitions required. Tendency to verbalize had a weaker association with confidence that the action had been done properly and amount of time taken to complete. This could suggest that memory for completing the action alone may not be the key to the decision to terminate the compulsion. It may be the case that although people are motivated to get a clear memory for the action and, facilitated by verbalization, are able to recall it quite well, they may go on to doubt that the action taken was actually adequate to avert harm. On the other hand, it is possible that the vividness and detail of the memory deteriorates quite rapidly. Research on the production effect to date has focused on recall of phonological information. It is possible that the production effect for visual and or tactile information is more transient, particularly under conditions of memory load.
13 The sample size in this study was small and the repetitive behaviours were overrepresented by checking compulsions. It has been argued that memory and memory confidence are much more important in the persistence of checking compulsions than other types of compulsions (Muller et al., 2005) although some have found an ironic effect of repetition of washing on memory (Radomsky & Rachman, 1999). The sample also comprised people whose diagnosis was established between 1-4 years previously. However, only people who reported engaging in repetitive actions in the previous week were included in the study. The average number of repetitions was 10 and the average amount of time conducting the compulsive episode was 17 minutes, which suggests that the compulsive acts were clinically significant. Only 33% of those invited to participate in the study did, but there is no reason to expect that people who declined participation differed in terms of their use of verbalization than those who participated. Finally, the study relied on retrospective self-report which can be influenced by numerous factors. Data on the number and length of repetitions is based on participants’ estimates and is thus subject to considerable error. In the current study, the average number of repetitions reported was 10, yet in other phenomenological studies (e.g., Bucarelli & Purdon, in press) the average number was five. The subjective self-report of the general use, content, purpose and outcome of verbalizing is perhaps more reliable. Despite these limitations this study does suggest that there may be merit in studying the use of verbalization during compulsions and its impact on the persistence of compulsions more systematically. Future research might examine differences across compulsive episodes in which verbalization is used versus those in which it is not used. As noted above it might be interesting to compare the outcome of episodes in which verbalization is soft vs. loud. It could prove worthwhile to determine whether the production effect has a threshold after which it degrades,
14 rather than facilitates, recall. An experiment in which repetition and verbalizing are manipulated would best address this question. Acknowledgements This study was supported by a Social Sciences and Humanities Research Council of Canada Insight Grant awarded to the second author.
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16 References Abramovitch, A., Abramowitz, J.S., & Mittelman, A. (2013). The neuropsychology of adult obsessive-compulsive disorder: A meta-analysis. Clinical Psychology Review 33, 11631171. doi:10.1016/j.cpr.2013.09.004 Alcolado, G.M. & Radomsky A.S. (2011). Believe in yourself: Manipulating beliefs about memory causes checking. Behaviour Research and Therapy 49(1), 42-49. doi:10.1016/j.brat.2010.10.001 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Baddeley, A. (1992). Working memory. Science, 255(5044), 556-559. doi:10.2307/2876819 Eǧrilmez, A., Gülseren, L., Gülseren, Ş., & Kültür, S. (1997). Phenomenology of obsessions in a Turkish series of OCD patients. Psychopathology, 30 (2), 106-110. Retrieved from www.scopus.com. Forrin, N.D., MacLeod, C.M., & Ozubko, J.D. (2012). Widening the boundaries of the production effect. Memory Cognition, 40, 1046-1055. doi:10.3758/s13421-012-0210-8 Harkin, B. & Kessler, K. (2011). The role of working memory in compulsive checking and OCD: A systematic classification of 58 experimental findings. Clinical Psychology Review, 31(6), 1004-1021. doi:10.1016/j.cpr.2011.06.004 Jaafari, N., Frasca, M., Rigalleau, F., Rachid, F., Gil, R., Olié, J.-P., … & Vibert, N. (2013). Forgetting what you have checked: a link between working memory impairment and checking behaviors in obsessive-compulsive disorder. European Psychiatry, 28, 87-93. doi:10.1016/j.eurpsy.2011.07.001
17 Jaafari, N., Chopin, N., Levy, C., Rotgé, J-Y., Lafay, N., Hammi, W.,… & Vibert, N. (2015). Excessive checking behavior during an image comparison task in schizophrenia. European Psychiatry 30(2), 233-241. doi:10.1016/j.eurpsy.2014.11.012 Kuelz, A.K., Hohagen, F., & Voderholzer, U. (2004). Neuropsychological performance in obsessive-compulsive disorder: A critical review. Biological Psychology, 65, 185-236. doi:10.1016/j.biopsycho.2003.07.007 MacLeod, C.M., Gopie, N., Hourihan, K.L., Neary, K.N., & Ozubko, J.D. (2010). The production effect: delineation of a phenomenon. Journal of Experimental Psychology: Learning, Memory, and Cognition, 36(3), 671-685. Retrieved from www.scopus.com. Moritz, S., Birkner, C., Kloss, M., Jahn, H., Hand, I., Haasen, C., & Krausz, M. (2002). Executive functioning in obsessive-compulsive disorder, unipolar depression, and schizophrenia. Archives of Clinical Neuropsychology, 17, 477-483. Retrieved from www.psycnet.apa.org. Muller, J., & Roberts, J.E. (2005). Memory and attention in obsessive-compulsive disorder: a review Journal of Anxiety Disorders 19, 1-28. doi:10.1016/j.janxdis.2003.12.001 Rachman, S. (2002). A cognitive theory of compulsive checking. Behavior Research and Therapy, 40, 625–639 Radomsky, A.S., & Rachman, S. (1999). Memory bias in obsessive-compulsive disorder (OCD). Behaviour Research and Therapy, 37, 605-618. Retrieved from www.scopus.com. Radomsky, A.S., Rachman, S., & Hammond, D. (2001). Memory bias, confidence and responsibility in compulsive checking. Behaviour Research and Therapy, 39(7), 813–822. Retrieved from www.scopus.com.
18 Radomsky, A.S., Gilchrist, Philippe T., & Dussault, D. (2006). Repeated checking really does cause memory distrust. Behaviour Research and Therapy, 44, 305-316. doi:10.1016/j.brat.2005.02.005 Rosen, V.M., & Engle, R.W. (1997). The role of working memory capacity in retrieval. Journal of Experimental Psychology: General, 126(3), 211-217. doi:10.1037/0096-3445.126.3.211 Shavitt, R. G., de Mathis, M. A., Oki, F., Ferrao, Y. A., Fontenelle, L. F., Torres, A. R., . . . Simpson, H. B. (2014). Phenomenology of OCD: Lessons from a large multicenter study and implications for ICD-11. Journal of Psychiatric Research, 57(Complete), 141-148. doi:10.1016/j.jpsychires.2014.06.010 Sheehan, D. V., Lecrubier, Y., Harnett, K., Amorim, P., Janavs, J., Weiller, E., … Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22–33 Wahl, K., Salkovskis, P.M., & Cotter, I. (2008). “I wash until it feels right”: The phenomenology of stopping criteria in obsessive-compulsive washing. Journal of Anxiety Disorders 22(2), 143-161. doi:10.1016/j.janxdis.2007.02.009 Thordarson, D.S., Radomsky, A.S., Rachman, S., Shafran, R., Sawchuk, C.N., & Hakstian, A.R. (2004). The Vancouver Obsessional Compulsive Inventory (VOCI). Behaviour Research and Therapy, 42, 1289-1314. doi:10.1016/j.brat.2003.08.007 van den Hout, M., & Kindt, M. (2003). Repeated checking causes memory distrust. Behaviour Research and Therapy, 41, 301-316. doi:10.1016/S0005-7967(02)00012-8
Appendix A Descriptive Statistics for All Variables
19 M
SD
n
How distressing? (%)
50.94
25.685
35
How often did you repeat?
10.84
16.27
35
How many minutes per episode?
17.09
32.14
35
What percentage of time did you mouth, whisper or speak aloud? (%)
40.79
35.235
19
How loudly? (1-7)
4.21
1.182
19
Decrease the amount of time you have to spend doing the action? (1-5)
1.83
1.150
18
Decrease the number of times you have to repeat the action? (1-5)
2.06
1.162
18
Improve your memory that it was done properly? (1-5)
2.39
1.037
18
Improve your confidence that it was done properly? (1-5)
2.67
1.328
18
Improve how vivid your memory is of the final repeat of the action? (1-5)
2.50
1.098
18
Improve how detailed your memory is of the 2.39 final repeat of the action? (1-5)
1.195
18
Help you get the "right" feeling, a sense of "completion" and/or a sense of certainty that 2.83 it is okay to stop? (1-5)
1.098
18
Increase your confidence that harm has been 2.89 avoided? (1-5)
1.183
18
Achieve the purpose you reported in the question above? (1-5)
2.95
1.268
19
OCD_CSR (1-8)
4.8571
1.167
35
VOCI_Total
81.00
31.282
33
Table 1 Types of Compulsionsa
20 Action Checking
n 12
% 34.3
Hand-washing/cleaning
7
20.0
Rearranging
5
14.3
Magical/ nonsensical
4
11.4
Body-related
4
11.4
Other
3
8.6
a
N = 35
Table 2 Thought, Image, Fear, Concern, or Preoccupation that Sparked Compulsiona Thought, image, fear, concern, or preoccupation Contamination
n
%
7
20.0
To get the right feeling
7
20.0
Losing items
5
14.3
Protect others
4
11.4
Miscellaneous
3
8.6
Personal appearance
3
8.6
Cause a fire
2
5.7
Prevent someone from
2
5.7
Being late
1
2.9
Unknown
1
2.9
breaking in
a
N = 35
Table 3 Content of Words Said Aloud during Repetitive Actiona
21 Content Reassurance
n 11
% 57.9
Prayers
2
10.5
Specific to the action (reading
2
10.5
Dangers of not doing the action
1
5.2
Questions about the
1
5.2
Concern / worry
1
5.2
Unknown
1
5.2
the time, reading words on the page)
completeness of the action
a
N = 19
Table 4 Correlations between results of verbalizing with percent of time speaking aloud Variable Improve how detailed your memory is of the final repeat of the action?
Percent of Time .589*
Improve your memory that it was done properly?
.519*
Improve how vivid your memory is of the final repeat of the action?
.511*
How distressing?
.346
Achieve the purpose you had reported in the question above?
.441
Increase your confidence that harm has been avoided?
.405
Decrease the number of times you have to repeat the action?
.354
Improve your confidence that it was done properly?
.349
22 Help you get the “right” feeling, a sense of “completion” and/or a sense of certainty that it is okay to stop? Decrease the amount of time you have to spend doing the action? VOCI_Total OCD_CSR
*
.349
.243 -.196 -.376
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
**
Highlights
Verbalizing during compulsions was common
Verbalizing most often took the form of reassurance
Verbalizing was associated with greater memory confidence
Verbalizing was associated with better memory
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S2211-3649(15)30021-X http://dx.doi.org/10.1016/j.jocrd.2015.10.004 JOCRD229
To appear in: Journal of Obsessive-Compulsive and Related Disorders Received date: 25 May 2015 Revised date: 21 October 2015 Accepted date: 27 October 2015 Cite this article as: B.A. Joanna Collaton and Christine Purdon, Verbalizations during compulsions in obsessive-compulsive disorder, Journal of ObsessiveCompulsive and Related Disorders, http://dx.doi.org/10.1016/j.jocrd.2015.10.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
VERBALIZATIONS DURING COMPULSIONS Verbalizations during compulsions in obsessive-compulsive disorder Joanna Collaton, B.A. and Christine Purdon, Ph.D.1 Department of Psychology University of Waterloo
1
Corresponding author
Department of Psychology University of Waterloo Waterloo, ON N2L 3G1 Canada Ph: 519-888-4567, x33912 Fax: 519-746-8631 Email: [email protected]
Abstract Research on memory in obsessive-compulsive disorder (OCD) suggests that people with OCD lack confidence in their memory and that repetition of an action actively erodes confidence in memory for it. Meanwhile, research on general memory processes suggests that when people say aloud the material they seek to remember, just once, memory is improved (MacLeod, Gopie, Hourihan, Neary & Ozubko, 2010). It could prove useful to examine the extent to which people with OCD verbalize during their compulsions in order to better recall them later, and to examine the effectiveness of verbalizing when it is repeated. However, we do not know whether people with OCD speak aloud during compulsions. This study examined the frequency, purpose, and
2 impact of verbalization on self-reported memory accuracy and confidence in people with OCD (N = 35). Over half reported speaking aloud while engaging in their compulsions, most often to improve confidence that the action had been done properly. Tendency to verbalize was associated with better self-reported memory for the action and greater memory confidence, but not with urge to repeat the action. These data suggest that research on memory strategies may be usefully brought to bear on our understanding of the persistence of compulsions. Keywords Compulsions, memory confidence, working memory, production effect
Verbalizations during compulsions People with obsessive-compulsive disorder (OCD) engage in compulsions (washing, checking, cleaning, arranging) in order to ameliorate the distress or discomfort evoked by obsessions (American Psychiatric Association, 2013). Compulsions are often repeated multiple times within one episode. Recent research suggests that repetition results from poor confidence in memory (e.g. Radomsky, Rachman, & Hammond, 2001),combined with a high need for certainty that the compulsion has been done “properly” (e.g., Rachman, 2002). However, repetition appears to produce an ironic decline in memory confidence for an action as that action is repeated (e.g., Radomsky, Gilchrist, & Dussault, 2006; van den Hout & Kindt, 2003). In order to achieve a sense of certainty that their compulsion was done properly, people with OCD often require a vivid and detailed memory of the act, which in turn requires encoding of a wide array of internal and external details (Kuelz, Hohagen & Voderholzer, 2004; Wahl, Salkovskis & Cotter, 2008). Given the apparent role of memory confidence in the persistence of OCD, research on memory processes might be usefully brought to bear on our understanding of compulsions. Macleod et al. (2010) observed that an effective strategy for improving recall of a
3 word is to pronounce (or, produce) it aloud. They found that not only did producing a word aloud improve explicit memory for that word, but there was a direct relationship between recall and how audibly it had been produced, such that the more audible the response, the more accurately it was recalled (Forrin, MacLeod, & Ozubko, 2012). Macleod and colleagues called this the “production effect”. Saying something aloud, then, appears to be a good strategy for improving explicit recall later on, at least under normal circumstances. People with OCD, though, seek to recall a series of events in an unusually high level of detail, and those events have been repeated multiple times. This may introduce a considerable tax on working memory (WM; Harkin & Kessler, 2011). According to Baddeley (1992), WM is “the temporary storage of information in connection with the performance of other cognitive tasks” (pg. 556). The three components of WM are: a) the central executive, which controls attention; b) the visuo-spatial sketchpad which manipulates visual images; and, c) the phonological loop, which stores and rehearses speech-based information. There are individual differences in how well people are able to correctly reproduce, in order, a series of information units that have just been given. This individual difference factor is referred to as the WM span. The effects of overloading the WM vary according to whether or not one’s WM span is high or low. In people with a high WM span, information overload seems to interfere with the ability of the central executive to shift attention away from task-irrelevant back to task-relevant information. People with a low WM span perform worse on tasks in which they have to produce information, regardless of load (Rosen & Engle, 1997). If people are distracted by task-irrelevant information and are thus unable to switch attention efficiently, or they have a low WM span, memory accuracy, memory confidence, or both, might be compromised. Radomsky and Rachman (1999) found that people with OCD did not perform worse on a neuropsychological assessment of memory and that they actually had better recall of threat-
4 relevant objects than did anxious and nonanxious controls. There is now a substantive literature which suggests that people with OCD do not have memory deficits, but rather lack memory confidence (Alcolado & Radomsky, 2011; Muller & Roberts, 2005; van den Hout & Kindt, 2003) and that repeating a task reduces confidence (Radomsky et al., 2006). Jaafari et al. (2013) examined the link between WM and checking behaviours in people with OCD. Participants’ WM span was assessed, after which they completed an image comparison task in which they had to describe the differences between two images while their eye movements were tracked. Results indicated that people with OCD, as compared to healthy controls, had a low WM span, took more time comparing the drawings, and shifted their gaze between the two images more often. The researchers speculated that the WM of people with OCD may be kept permanently busy with obsessions and compulsions, which contributes to its low span. Consistent with this, Jaafari et al. (2015) found that people with schizophrenia had a low WM span and also exhibited repetitive checking, but the repetitive checking was not correlated with WM span. In a metaanalysis on the neuropsychology of OCD (Abramovitch, Abramowitz, & Mittelman, 2013), results suggested that there were small but significant differences in WM performance in a clinical sample. As one reviewer suggested, perhaps the small but robust differences are moderated by memory confidence. The findings of Jaafari et al.’s (2013) and Abramovitch et al.’s (2013) stand in contrast to numerous past findings in which observed deficits in the memory functioning of people with OCD could be attributed to depression. Indeed, Moritz et al. (2002) concluded that “nondepressed patients with OCD have no dysfunctions in concept formation and verbal (working) memory” (pg. 481). It thus remains unclear whether those with OCD have a low WM span, or, have a high WM span that is constantly overloaded, which in turn compromises ability to shift attention from task-irrelevant back to task-relevant stimuli. As Radomsky (2006)
5 theorized, perhaps people with OCD hold their attention on the specific actions they are completing and are unable to shift their attention to cues that they have completed the action. Theoretically, this would result in high memory accuracy but low memory confidence. Given that people with OCD may either have a low WM span, and thus are less able to produce recalled information, or have a high WM span that is overtaxed by rumination and compulsions, it is quite possible that they use compensatory strategies to facilitate recall, such as verbalizing the information they want to remember. Clinical anecdotal evidence suggests that people with OCD do indeed speak aloud while completing their compulsions. Laboratory studies of the production effect have found that just one repetition facilitates recall of straightforward information. If people with OCD are repeating an action, and verbalizing each time, might the production effect diminish? Bucarelli and Purdon (in press) found that people with OCD repeated their compulsions an average of 5 times within each compulsive episode and that greater repetition was associated with the need to encode evermore detail of the action for recall later. In order to better understand the persistence of compulsions it may be worthwhile to better understand the use of compensatory memory strategies and their effectiveness under circumstances of greater repetition and increasing tax on working memory. However, to our knowledge there is no phenomenological data on the extent to which people with OCD actually do verbalize the information they hope to recall later while completing their compulsions, nor its success in achieving its goal. The purposes of the current study were to: a) determine how much, on average, people with clinical and subclinical symptoms of OCD who repeat actions verbalize while completing those actions; b) the content of their verbalizations; c) what verbalizing is intended to accomplish and how successful it is; and, d) the extent to which verbalizing during compulsions is associated
6 with memory confidence and perceived accuracy. Participants who had received a diagnosis of OCD within the past 4 years completed a measure of OCD symptom severity and were then administered an online questionnaire developed for the current study to address each of the queries above. The essential purpose of this study was to obtain phenomenological data on the use of verbalization during compulsions on which to base further queries about the role of overt verbalization in memory confidence and accuracy and its relationship to the persistence of compulsions. Methods Participants Participants were recruited from the Anxiety Studies Division (ASD) of the University of Waterloo Centre for Mental Health Research participant pool. This pool comprises adults from the community who have undergone the MINI International Neuropsychiatric Interview, Version 6.0.0, Sheehan et al., 1998, provided demographic information, have completed a battery of selfreport measures, and have agreed to be contacted for research studies. The ASD research pool included 136 participants who had received a clinical or subclinical diagnosis of OCD over the 4 years since the pool was started. All 136 were contacted by email and invited to participate in an online study for a chance at winning 1 of 2 $25.00 gift certificates. Participants were given an information letter describing the study and provided their consent to participate. Ten participants could not be contacted at the time of the study and of the remaining 126 a total of 42 (33%) agreed to participate. Of these, three were excluded because they did not report a repetitive action in the last week and four more had incomplete data, leaving a final total of 35 participants. The sample consisted of 71.4% (N = 25) females and 28.6% males (N = 10) with the majority of participants identifying as White/Caucasian (N = 27, 77.1%). The rest of the sample
7 identified as: Asian (n = 3, 8.5%), South Asian (n = 2, 5.7%), West Indian (n = 1, 2.9%), or did not report ethnicity (n = 2, 5.7%). Participants’ ages ranged from 18 to 69 with an average of 34 years of age (SD = 13.5). They had an average of 15.2 years of education (SD = 2.08). All participants (n = 35) had either a clinical (Clinician’s Severity Rating (CSR) ≥ 4) or subclinical (CSR ≤ 3) diagnosis of OCD. Of those, n = 22 (62.5%) had a principal or co-principal diagnosis of OCD, n = 10 (28.5%) had a secondary diagnosis of OCD (that is, had two diagnoses of which the OCD was the less severe), and n = 3 had a subclinical diagnosis. The majority (n = 4) of those with a co-principal diagnosis of OCD were also diagnosed with an equally significant anxiety-related disorder; the rest of the sample (n = 2) were diagnosed with an equally significant mood disorder. The CSR’s ranged from 2 to 7 on a 1 to 8 scale with a score 4 or above being clinically significant (n = 31 with CSR ≥ 4). Participants with a principal diagnosis of OCD had an average CSR of 5.35 (SD = 0.93). Similarly, participants with a co-principal diagnosis of OCD had an average CSR of 5.33 (SD = 0.52). Participants whose OCD was secondary to another disorder had an average CSR of 4.63 (SD = 0.58) and participants with subclinical OCD had an average CSR of 2.5 (SD = 0.58). The length of time between initial diagnoses and study participation ranged from 12-48 months, with 9 participants being diagnosed in the past year. After data collection was complete, we sampled a subset of those with diagnoses more than 1 year old and all remained clinically symptomatic. Measures Vancouver Obsessional Compulsive Inventory (VOCI)
8 The VOCI is a 55-item self-report measure created to “provide assessment of a [wide] range of obsessions, compulsions, avoidance behaviour, and personality characteristics of known or theoretical importance in OCD” (Thordarson, Radomsky, Rachman, Shafran, Sawchuk, & Hakstian, 2004, p. 1290). Responses are scored on 5-point scale (0 = not at all, 4 = very much). There are six subscales: contamination, checking, obsessions, hoarding, just right, and indecisiveness and each item is summed for a total score. The scale has demonstrated good internal consistency for both the subscales and the total score; α = 0.94 with an OCD sample and α = 0.92 in this sample. Verbalization during Repetitive Actions Questionnaire This questionnaire was developed by the authors to determine the extent to which participants verbalized during repetitive actions such as checking, washing, and arranging. Participants who reported that they had completed a repetitive action (defined as "behaviours or acts that you feel driven to perform although you may recognize them as senseless or excessive") were asked to identify the action that they completed the most in the past week. They were then asked to report, verbatim, on the fear or preoccupation associated with that particular action, how distressing the fear or preoccupation was (0-100 Likert scale), how many times they repeated the action, on average, within their compulsive episodes in the past week, and how much time the episodes took, on average. Next, they were asked whether or not they ever mouthed, whispered, or spoke aloud during the action they described earlier. Those who endorsed doing so were asked to report on the percentage of time they verbalized and how loudly they did so, using the response options of mouthing, whispering too quietly for anyone else to hear, whispering loudly enough that someone else could hear, low speaking voice, normal speaking voice and loud speaking voice.
9 They then reported, verbatim on what they said and its intended purpose. Finally, using 5-point Likert scales ranging from “not at all” to “a lot” they rated the extent to which verbalizing: decreased the time it took to complete the action, decreased the number of times they had to repeat it, improved their memory for the action, improved their confidence in the memory for the action, improved the vividness and detail of the memory, helped them to get the “right” feeling or sense of completion, and achieved the intended purpose. Results Prior to conducting analyses, data were checked for outliers (that is, cases more than three standard deviations above the mean and discontinuous from the distribution). There were two outliers on the number of times the action was repeated and the amount of time the episode lasted. These were adjusted by assigning them a value one unit above the second highest value. Types of Repetitive Actions and their Triggers Data on the types of repetitive actions and the fear, preoccupation or concern that evoked the action are presented in Tables 1 and 2 respectively. The obsessions and compulsions reported by participants were classified by the authors post hoc and were representative of OCD symptoms clusters identified in large scale studies (Eǧrilmez, A., Gülseren, L., Gülseren, Ş., & Kültür, S., 1997; Shavitt et al., 2014). d there were no observed differences between the obsessions and compulsions reported by those with a clinical vs subclinical diagnosis of OCDs. Prevalence and Frequency of Verbalization The means, medians, and standard deviations of the prevalence and frequency of verbalization during repetitive acts are presented in Appendix A. Fifty-four percent (n = 19) of participants indicated they mouthed, whispered, or spoke aloud during their repetitive action. On
10 average, they reported speaking aloud 40% of the time (M = 40.79) but there was wide variability in the data (SD = 35.24; range = 1-100%). About half of the participants (n = 10) reported that they verbalized in a low speaking voice. Only one reported verbalizing in a normal speaking voice and the remaining eight either mouthed the words (n = 2), spoke in an inaudible whisper (n = 4) or an audible whisper (n = 1). Of those who did not report verbalizing 50% (n = 8) reported that they verbalized covertly (i.e., in their head) while they repeated. Note that only participants who reported overt verbalization provided responses for questions about the impact of verbalizing on their repetitive action. The most commonly endorsed reason for verbalizing was to reassure self that harm had been avoided and/or that the action had been done properly (n = 11). Others reported that it distracted them from the obsessional concern or other upsetting thoughts (n = 3) whereas the others (n = 5) were unsure why they did it. The content of the reported verbalizations is presented in Table 3. The content of covert verbalization was similar to that of the overt verbalization. Memory Accuracy and Confidence Means and standard deviations of self-reported impact of overt verbalization on memory accuracy and confidence are presented in Appendix A. Overall, participants reported that verbalizing improved their confidence in their memory “somewhat” (M = 2.67, SD = 1.33), and that it “somewhat” improved their memory for the last repetition of the action (M = 2.39, SD = 1.04). They also reported that speaking increased their confidence “somewhat” that harm had been avoided (M = 2.89, SD = 1.18). In fact, verbalizing tended to help “somewhat” on most indices.
11 Relationship between extent of Verbalization and Memory Accuracy, Confidence and Symptom Severity Zero-order correlations between percentage time verbalizing and reports of memory accuracy and confidence and symptom severity are presented in Table 4. Consistent with the production effect, there was a large correlation between percent of time speaking aloud and selfreport of how detailed the memory was of the final repeat of the action (r = .589, p = .01, 35% shared variance) such that the more often participants verbalized, the more they perceived their memory of the final repeat to be detailed. Similar results were found for the correlation between percentage time speaking aloud and ratings of vividness (r = .511, p = .03, 26% shared variance) and improvement in memory (r = .519, p = .03, 26% shared variance). Tendency to verbalize also had a moderate (although nonsignificant) correlation with achieving the purpose of the repetitive act (r = .440, ns, 19% shared variance) and with confidence that harm had been avoided (r = .410, ns, 17% shared variance). Percent of time speaking aloud and improved confidence had smaller correlations with decrease in the need to repeat the compulsion, increased confidence in memory and achievement of the “right” feeling. Discussion The central purpose of this study was to determine the extent to which people with a clinical or subclinical diagnosis of OCD verbalize while repeating actions, and the influence of overt verbalization on aspects of memory for the action and memory confidence. More than half of the participants reported that they verbalized, on average, 40% of the time, most commonly in a low speaking voice. The most commonly reported purpose of the verbalizations was to provide reassurance and this was reflected in their content. Use of verbalization was rated as being “somewhat” effective in improving aspects of memory and memory confidence, getting the
12 “right” feeling, and in increasing confidence that danger had passed. This subjective report was consistent with the observed pattern of correlations between the percentage time verbalization was used and memory vividness, accuracy, and confidence; the more people verbalized the more people felt it improved memory and confidence. Interestingly, verbalization had a notably weaker relationship with confidence that the action had been done properly, achieving the “right” feeling, and the amount of time spending doing the action. These findings suggest that participants may have an implicit awareness of the production effect and be using verbalization as a strategy to improve memory for the action. Participants most often verbalized in a low speaking voice, often because other people were around. Past research (MacLeod et al., 2010) suggests that speaking aloud leads to better recall. In future research it might be interesting to compare compulsive episodes in which verbalization was soft vs. loud to determine if the latter confers any benefits with respect to the number of repetitions required. Tendency to verbalize had a weaker association with confidence that the action had been done properly and amount of time taken to complete. This could suggest that memory for completing the action alone may not be the key to the decision to terminate the compulsion. It may be the case that although people are motivated to get a clear memory for the action and, facilitated by verbalization, are able to recall it quite well, they may go on to doubt that the action taken was actually adequate to avert harm. On the other hand, it is possible that the vividness and detail of the memory deteriorates quite rapidly. Research on the production effect to date has focused on recall of phonological information. It is possible that the production effect for visual and or tactile information is more transient, particularly under conditions of memory load.
13 The sample size in this study was small and the repetitive behaviours were overrepresented by checking compulsions. It has been argued that memory and memory confidence are much more important in the persistence of checking compulsions than other types of compulsions (Muller et al., 2005) although some have found an ironic effect of repetition of washing on memory (Radomsky & Rachman, 1999). The sample also comprised people whose diagnosis was established between 1-4 years previously. However, only people who reported engaging in repetitive actions in the previous week were included in the study. The average number of repetitions was 10 and the average amount of time conducting the compulsive episode was 17 minutes, which suggests that the compulsive acts were clinically significant. Only 33% of those invited to participate in the study did, but there is no reason to expect that people who declined participation differed in terms of their use of verbalization than those who participated. Finally, the study relied on retrospective self-report which can be influenced by numerous factors. Data on the number and length of repetitions is based on participants’ estimates and is thus subject to considerable error. In the current study, the average number of repetitions reported was 10, yet in other phenomenological studies (e.g., Bucarelli & Purdon, in press) the average number was five. The subjective self-report of the general use, content, purpose and outcome of verbalizing is perhaps more reliable. Despite these limitations this study does suggest that there may be merit in studying the use of verbalization during compulsions and its impact on the persistence of compulsions more systematically. Future research might examine differences across compulsive episodes in which verbalization is used versus those in which it is not used. As noted above it might be interesting to compare the outcome of episodes in which verbalization is soft vs. loud. It could prove worthwhile to determine whether the production effect has a threshold after which it degrades,
14 rather than facilitates, recall. An experiment in which repetition and verbalizing are manipulated would best address this question. Acknowledgements This study was supported by a Social Sciences and Humanities Research Council of Canada Insight Grant awarded to the second author.
15
16 References Abramovitch, A., Abramowitz, J.S., & Mittelman, A. (2013). The neuropsychology of adult obsessive-compulsive disorder: A meta-analysis. Clinical Psychology Review 33, 11631171. doi:10.1016/j.cpr.2013.09.004 Alcolado, G.M. & Radomsky A.S. (2011). Believe in yourself: Manipulating beliefs about memory causes checking. Behaviour Research and Therapy 49(1), 42-49. doi:10.1016/j.brat.2010.10.001 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Baddeley, A. (1992). Working memory. Science, 255(5044), 556-559. doi:10.2307/2876819 Eǧrilmez, A., Gülseren, L., Gülseren, Ş., & Kültür, S. (1997). Phenomenology of obsessions in a Turkish series of OCD patients. Psychopathology, 30 (2), 106-110. Retrieved from www.scopus.com. Forrin, N.D., MacLeod, C.M., & Ozubko, J.D. (2012). Widening the boundaries of the production effect. Memory Cognition, 40, 1046-1055. doi:10.3758/s13421-012-0210-8 Harkin, B. & Kessler, K. (2011). The role of working memory in compulsive checking and OCD: A systematic classification of 58 experimental findings. Clinical Psychology Review, 31(6), 1004-1021. doi:10.1016/j.cpr.2011.06.004 Jaafari, N., Frasca, M., Rigalleau, F., Rachid, F., Gil, R., Olié, J.-P., … & Vibert, N. (2013). Forgetting what you have checked: a link between working memory impairment and checking behaviors in obsessive-compulsive disorder. European Psychiatry, 28, 87-93. doi:10.1016/j.eurpsy.2011.07.001
17 Jaafari, N., Chopin, N., Levy, C., Rotgé, J-Y., Lafay, N., Hammi, W.,… & Vibert, N. (2015). Excessive checking behavior during an image comparison task in schizophrenia. European Psychiatry 30(2), 233-241. doi:10.1016/j.eurpsy.2014.11.012 Kuelz, A.K., Hohagen, F., & Voderholzer, U. (2004). Neuropsychological performance in obsessive-compulsive disorder: A critical review. Biological Psychology, 65, 185-236. doi:10.1016/j.biopsycho.2003.07.007 MacLeod, C.M., Gopie, N., Hourihan, K.L., Neary, K.N., & Ozubko, J.D. (2010). The production effect: delineation of a phenomenon. Journal of Experimental Psychology: Learning, Memory, and Cognition, 36(3), 671-685. Retrieved from www.scopus.com. Moritz, S., Birkner, C., Kloss, M., Jahn, H., Hand, I., Haasen, C., & Krausz, M. (2002). Executive functioning in obsessive-compulsive disorder, unipolar depression, and schizophrenia. Archives of Clinical Neuropsychology, 17, 477-483. Retrieved from www.psycnet.apa.org. Muller, J., & Roberts, J.E. (2005). Memory and attention in obsessive-compulsive disorder: a review Journal of Anxiety Disorders 19, 1-28. doi:10.1016/j.janxdis.2003.12.001 Rachman, S. (2002). A cognitive theory of compulsive checking. Behavior Research and Therapy, 40, 625–639 Radomsky, A.S., & Rachman, S. (1999). Memory bias in obsessive-compulsive disorder (OCD). Behaviour Research and Therapy, 37, 605-618. Retrieved from www.scopus.com. Radomsky, A.S., Rachman, S., & Hammond, D. (2001). Memory bias, confidence and responsibility in compulsive checking. Behaviour Research and Therapy, 39(7), 813–822. Retrieved from www.scopus.com.
18 Radomsky, A.S., Gilchrist, Philippe T., & Dussault, D. (2006). Repeated checking really does cause memory distrust. Behaviour Research and Therapy, 44, 305-316. doi:10.1016/j.brat.2005.02.005 Rosen, V.M., & Engle, R.W. (1997). The role of working memory capacity in retrieval. Journal of Experimental Psychology: General, 126(3), 211-217. doi:10.1037/0096-3445.126.3.211 Shavitt, R. G., de Mathis, M. A., Oki, F., Ferrao, Y. A., Fontenelle, L. F., Torres, A. R., . . . Simpson, H. B. (2014). Phenomenology of OCD: Lessons from a large multicenter study and implications for ICD-11. Journal of Psychiatric Research, 57(Complete), 141-148. doi:10.1016/j.jpsychires.2014.06.010 Sheehan, D. V., Lecrubier, Y., Harnett, K., Amorim, P., Janavs, J., Weiller, E., … Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(Suppl 20), 22–33 Wahl, K., Salkovskis, P.M., & Cotter, I. (2008). “I wash until it feels right”: The phenomenology of stopping criteria in obsessive-compulsive washing. Journal of Anxiety Disorders 22(2), 143-161. doi:10.1016/j.janxdis.2007.02.009 Thordarson, D.S., Radomsky, A.S., Rachman, S., Shafran, R., Sawchuk, C.N., & Hakstian, A.R. (2004). The Vancouver Obsessional Compulsive Inventory (VOCI). Behaviour Research and Therapy, 42, 1289-1314. doi:10.1016/j.brat.2003.08.007 van den Hout, M., & Kindt, M. (2003). Repeated checking causes memory distrust. Behaviour Research and Therapy, 41, 301-316. doi:10.1016/S0005-7967(02)00012-8
Appendix A Descriptive Statistics for All Variables
19 M
SD
n
How distressing? (%)
50.94
25.685
35
How often did you repeat?
10.84
16.27
35
How many minutes per episode?
17.09
32.14
35
What percentage of time did you mouth, whisper or speak aloud? (%)
40.79
35.235
19
How loudly? (1-7)
4.21
1.182
19
Decrease the amount of time you have to spend doing the action? (1-5)
1.83
1.150
18
Decrease the number of times you have to repeat the action? (1-5)
2.06
1.162
18
Improve your memory that it was done properly? (1-5)
2.39
1.037
18
Improve your confidence that it was done properly? (1-5)
2.67
1.328
18
Improve how vivid your memory is of the final repeat of the action? (1-5)
2.50
1.098
18
Improve how detailed your memory is of the 2.39 final repeat of the action? (1-5)
1.195
18
Help you get the "right" feeling, a sense of "completion" and/or a sense of certainty that 2.83 it is okay to stop? (1-5)
1.098
18
Increase your confidence that harm has been 2.89 avoided? (1-5)
1.183
18
Achieve the purpose you reported in the question above? (1-5)
2.95
1.268
19
OCD_CSR (1-8)
4.8571
1.167
35
VOCI_Total
81.00
31.282
33
Table 1 Types of Compulsionsa
20 Action Checking
n 12
% 34.3
Hand-washing/cleaning
7
20.0
Rearranging
5
14.3
Magical/ nonsensical
4
11.4
Body-related
4
11.4
Other
3
8.6
a
N = 35
Table 2 Thought, Image, Fear, Concern, or Preoccupation that Sparked Compulsiona Thought, image, fear, concern, or preoccupation Contamination
n
%
7
20.0
To get the right feeling
7
20.0
Losing items
5
14.3
Protect others
4
11.4
Miscellaneous
3
8.6
Personal appearance
3
8.6
Cause a fire
2
5.7
Prevent someone from
2
5.7
Being late
1
2.9
Unknown
1
2.9
breaking in
a
N = 35
Table 3 Content of Words Said Aloud during Repetitive Actiona
21 Content Reassurance
n 11
% 57.9
Prayers
2
10.5
Specific to the action (reading
2
10.5
Dangers of not doing the action
1
5.2
Questions about the
1
5.2
Concern / worry
1
5.2
Unknown
1
5.2
the time, reading words on the page)
completeness of the action
a
N = 19
Table 4 Correlations between results of verbalizing with percent of time speaking aloud Variable Improve how detailed your memory is of the final repeat of the action?
Percent of Time .589*
Improve your memory that it was done properly?
.519*
Improve how vivid your memory is of the final repeat of the action?
.511*
How distressing?
.346
Achieve the purpose you had reported in the question above?
.441
Increase your confidence that harm has been avoided?
.405
Decrease the number of times you have to repeat the action?
.354
Improve your confidence that it was done properly?
.349
22 Help you get the “right” feeling, a sense of “completion” and/or a sense of certainty that it is okay to stop? Decrease the amount of time you have to spend doing the action? VOCI_Total OCD_CSR
*
.349
.243 -.196 -.376
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
**
Highlights
Verbalizing during compulsions was common
Verbalizing most often took the form of reassurance
Verbalizing was associated with greater memory confidence
Verbalizing was associated with better memory