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Examination of emotional Stroop interference in obsessive–compulsive disorder
Behaviour Research and Therapy 42 (2004) 671–682 www.elsevier.com/locate/brat
Examination of emotional Stroop interference in obsessive– compulsive disorder Steffen Moritz , Dirk Jacobsen, Martin Kloss, Susanne Fricke, Michael Rufer, Iver Hand Klinik fu¨r Psychiatrie und Psychotherapie, Universita¨tsklinikum Hamburg–Eppendorf, Martinistraße 52, D-20246 Hamburg, Germany Received 1 April 2003; received in revised form ; accepted 23 June 2003
Abstract Previous research has produced conflicting findings on whether or not patients with subclinical or manifest obsessive–compulsive disorder (OCD) share an attentional bias for anxiety-related material. In the present study, 35 OCD patients were compared with 20 healthy controls on their performance in an emotional Stroop paradigm. Nine different stimulus conditions were compiled, including sets for depression-related and anxiety-related words as well as stimuli from two constructs with a potential relevance for the pathogenesis and maintenance of OCD symptomatology: responsibility and conscientiousness. Patients did not show enhanced interference for any of the conditions. Syndrome subtype and severity, avoidance and speed of information processing did not moderate results. The present study concurs with most prior research that OCD patients display no interference effect for general threat words. It deserves further consideration, that emotional interference effects in OCD as seen in other anxiety disorders occur when using idiosyncratic word material with a direct relation to the individual’s primary concerns. # 2003 Elsevier Ltd. All rights reserved. Keywords: Obsessive–compulsive disorder; Emotional Stroop; Anxiety; Depression; Mood congruency
Corresponding author. Tel.: +49-40-42803-6565; fax: +49-40-42803-2999. E-mail address: [email protected] (S. Moritz).
0005-7967/$ - see front matter # 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0005-7967(03)00190-6
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1. Introduction Within the last two decades, perhaps commencing with Bower’s visionary article ‘‘Mood and memory’’ (1981), the investigation on the processing of emotional stimuli has received growing recognition in the cognitive literature. Broad evidence has been provided that subjects with clinical or sub-clinical depression and anxiety disorders share a processing bias for moodcongruent or concern-related material (Coles & Heimberg, 2002; McNally, 1997; Williams et al., 1996). Besides implicit and explicit memory tasks employing emotional words, this line of research has made extensive use of attention tasks such as the dot probe and the emotional Stroop paradigm. Unlike the conventional Stroop paradigm (see MacLeod, 1991, for a review), where the subject is instructed to name the ink color of incongruently typed color words (e.g., the word blue written in red ink), the core conditions in the emotional Stroop task comprise words with mood-associated or mood-evocative semantic content. For major depression and a wide range of anxiety disorders, it has been found that subjects exhibit prolonged naming latencies when presented with words characterizing (words such as depressed, anxious) or symbolizing (e.g., dark, ghost) the current mood/concerns of the subject (Williams et al., 1996). This effect is typically explained by an attentional bias of anxiety and depressed patients towards mood-relevant material, problems in disengaging from such material or distraction from the primary task (color naming) via post-lexical rumination. The present study investigated emotional Stroop performance in patients diagnosed with obsessive–compulsive disorder (OCD). Along with words from three affective classes (depression, anxiety, positive), emotionally neutral words (color words written in an incongruent or congruent color; neutral words) and a non-lexical baseline condition, we presented words from two constructs with a putative relevance to obsessive–compulsive symptomatology: responsibility (see Salkovskis et al., 2000) and conscientiousness (e.g., Blais, 1997; Haigler & Widiger, 2001). The studies published so far have provided conflicting findings. While the majority of investigations do not support the hypothesis that depression- and anxiety-related Stroop stimuli are processed differently in OCD (Kyrios & Iob, 1998; McNally, Rieman, Louro, Lukach & Kim, 1992; McNally et al., 1994; McNeil, Tucker, Miranda, Lewin & Nordgren, 1999), Novara and Sanavio (2001) found enhanced reaction times for threatening words in normal subjects scoring high on a scale tapping compulsive checking. Similarly, Foa et al. (1993) found enhanced interference for general threat words in OCD patients without washing compulsions (some of them were checkers). In addition, in a study conducted by Lavy, van Oppen, and van den Hout (1994) OCD patients displayed greater Stroop interference for negative-valenced OCD-related stimuli. Although the latter study additionally reports enhanced interference in OCD for emotional words unrelated to obsessive–compulsive symptomatology, these results must be interpreted very cautiously, since greater interference in OCD patients was mainly due to faster reaction times in the baseline condition rather than slowed color naming in the emotional conditions. The present study aimed at assessing the presence of emotional interference effects in a large sample of OCD subjects. In view of the inconsistencies in the literature (see Summerfeldt & Endler, 1998), the contribution of potential moderators to this divergence was investigated carefully. Apart from OCD subtype (especially checking and washing) and the severity of OCD and co-morbid psychopathological symptoms (depression, anxiety), we focused on the impact of
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avoidance and speed of processing on emotional interference effects, since there is some evidence that both variables may influence the degree of emotional interference (Kyrios & Iob, 1998; Williams et al., 1996). It was expected that OCD patients display enhanced interference for material tapping anxiety, responsibility and conscientiousness, while no effects were expected for concern- and symptom-irrelevant stimulus dimensions.
2. Methods 2.1. Participants Thirty-five patients fulfilling DSM-IV criteria of OCD and 20 healthy controls participated in the study. Patients were tested prior to a cognitive-behavioral intervention program performed at the University Hospital for Psychiatry and Psychotherapy, Hamburg (Germany). Sixteen of the patients were medicated with psychotropic drugs (14 patients with antidepressants only, one with a neuroleptic agent alone; one patient was treated with a combination of an antidepressant and a neuroleptic agent); all other patients were free of psychotropic substances at the time of testing. Psychiatric diagnoses were determined according to DSM-IV criteria based on data collected during a semi-structured interview (Mini International Neuropsychiatric Interview, Sheehan et al., 1998). Nine patients (26%) fulfilled criteria for a current major depressive episode and eight patients (23%) were co-diagnosed with another anxiety disorder. Exclusion criteria were psychopathological symptoms incompatible or conflicting with a diagnosis of OCD (such as schizophrenia) and major neurological disturbances (e.g., stroke, epilepsy). Written informed consent was obtained from all participants prior to baseline assessment. Psychopathology was assessed using the German version of the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS; Goodman et al., 1989; translation by Hand & Bu¨ttner-Westphal, 1991) and the Hamilton Depression Rating Scale (HDRS; 17-item version; Hamilton, 1960) blind to neurocognitive status. In line with a previous confirmatory factor analytic study conducted with a large OCD sample (e.g., Moritz, Meier, Hand, Schick & Jahn, submitted for publication), the HDRS was broken down into four subscales (core depressive symptoms, anxiety, sleep and gastrointestinal problems). Y-BOCS subscales were computed according to an algorithm proposed recently by Moritz, Kloss, Jacobsen, et al. (2002), again on the basis of a confirmatory factor analysis (severity of obsessions: items 1, 2 and 3; severity of compulsions: items 6, 7 and 8; resistance against symptoms: items 4 and 9). We also administered the Hamburg Obsessional Compulsive Inventory (HOCI; Klepsch, Zaworka, Hand, Lu¨nenschloss, & Jauernig, 1991), a self-rating instrument that assesses 72 core obsessions (e.g., thoughts of doing harm to oneself/others) and compulsions (e.g., checking) along six scales. 2.2. Experimental task A computerized task was constructed using SuperLab1 software for Macintosh. Subsequent to a practice task with six items, subjects were presented stimuli from nine different conditions incorporating 15 stimuli each. The initial pool of words consisted of stimuli which were used in prior studies and share known emotion-evocative properties. Words for each condition were
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Table 1 Sociodemographic, psychopathological and cognitive characteristics of the OCD and the healthy participants Variable
OCD (n ¼ 35)
Healthy controls (n ¼ 20) Statistics
Sociodemographic Sex (male/female) Age Years of school education Verbal intelligence HDRS 17-Item Years of illness Number of admissions Y-BOCS total HOCI total
9/26 29.20 (7.55) 12.00 (1.75) 107.46 (11.63) 9.71 (5.31) 9.12 (8.56) 1.23 (1.42) 23.12 (7.37) 22.61 (9.28)
5/15 26.60 (5.35) 12.65 (1.46) 112.83 (12.38) 1.94 (2.26) – – – –
v2 ð1Þ ¼ 0:00; p > 0:9 tð53Þ ¼ 1:49; p > 0:1 tð53Þ ¼ 1:47; p > 0:1 tð53Þ ¼ 1:56; p > 0:1 tð53Þ ¼ 7:36; p < 0:001 – – – –
178.18 (115.68) 66.85 (57.45) 61.62 (60.00) 80.64 (51.64) 60.15 (49.70) 73.36 (71.31) 16.91 (69.32) 48.32 (63.34)
tð53Þ ¼ 0:98; p > 0:3 tð53Þ ¼ 1:70; p ¼ 0:09 tð53Þ ¼ 0:85; p > 0:3 tð53Þ ¼ 1:69; p ¼ 0:1 tð53Þ ¼ 0:47; p > 0:6 tð53Þ ¼ 0:38; p > 0:7 tð53Þ ¼ 0:87; p > 0:3 tð53Þ ¼ 0:87; p > 0:3
Emotional Stroop difference scores in msa Stroop 208.05 (104.31) Neutral 94.71 (59.08) Anxiety 78.62 (76.78) Depression 111.42 (83.04) Positive 68.24 (66.63) Conscientiousness 80.26 (59.52) Facilitation 1.67 (58.18) Responsibility 64.14 (65.35) a
RT experimental minus baseline conditions; reaction times for the different conditions can be computed by adding the baseline condition reaction time to the difference scores (OCD patients: 629.46 ms (118.27); healthy controls: 578.66 ms (64.36)).
compiled after consensus ratings provided by six experienced clinicians. The stimuli are listed in Appendix A. The final set of items was determined after matching according to word length and word frequency (all contrasts p > 0:2). The emotional and personality word conditions were as follows: anxiety (e.g., attack, persecutor), depression (e.g., weakness, loneliness), responsibility (e.g., responsibility, guilt), conscientiousness (e.g., rank, status) and positive (e.g., beauty, success). There were three affect-neutral word conditions: neutral (e.g., bag, button), Stroop interference (e.g., incongruently written color words) and Stroop facilitation (e.g., congruently written color words). Naming of horizontal color bars served as baseline condition. Color words were written lowercase in the following colors and were distributed evenly across conditions: red (German: rot), green (gru¨n), yellow (gelb) and blue (blau). After a small fixation point (300 ms), which was followed by a 200 ms blank trial, the target stimulus (font 30, type Geneva) appeared on the screen until the voice-key was triggered via microphone. Subsequently, the experimenter pressed a button to denote correct (i.e., ‘‘C’’) and incorrect (i.e., ‘‘X’’) responses. This key press triggered the following stimulus. Participants were instructed to respond as fast as possible without making too many mistakes. Reaction time latencies were recorded only for correct trials. Experimental trials were presented in random order.
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3. Results 3.1. Comparisons between OCD patients and healthy controls Subjects did not differ on sociodemographic background variables (see Table 1). Prior to more fine-grained analyses of the primary hypotheses, a two-way mixed ANOVA was performed with group (OCD, healthy control) as the between-subject and condition (all nine conditions in the emotional Stroop task) as the within-subject variable. Both the group (F ð1; 53Þ ¼ 4:43, p ¼ 0:04) and the condition effect (F ð8; 442Þ ¼ 52:64; p < 0:001) achieved significance. Whereas the group effect can be accounted for by greater overall retardation in the OCD group (see Table 1), the significant condition effect is attributable to greater slowing in the conventional Stroop condition relative to all other conditions and decreased response latencies in the facilitation and baseline conditions relative to all word conditions (p < 0:001). Additionally, post hoc t-tests revealed that reaction times for depression-related words were significantly slower compared to neutral words, positive words and responsibility words in both groups.1 The Greenhouse–Geisser corrected interaction of group condition failed to attain significance (p > 0:4). No t-test comparison calculated for difference scores in the emotional Stroop task (experimental RT word condition RT baseline condition) reached significance (see Table 1). At trend level, OCD patients exhibited stronger interference for the neutral and depression conditions (p ¼ 0:09 and p ¼ 0:10), which, however, did not withstand correction for multiple comparisons. OCD patients (8.07% (7.37)) committed more errors than controls (4.00% (3.86)). However, error interference scores corrected for baseline performance again yielded no significant differences. At the end of the testing, we asked subjects to rate on a five-point scale how motivated and concentrated they were during the task, which, however, did not achieve significance (p > 0:1).
3.2. Correlational analyses Except for age, which was significantly correlated with enhanced Stroop interference and less facilitation (r ¼ 0:25; p < 0:05), no sociodemographic background variable correlated with any of the difference scores. Due to an inflated likelihood of false-positive relationships, the alpha level was set at p ¼ 0:01 for all correlations involving Y-BOCS (subscore algorithm and an item measuring avoidance), HOCI and HDRS subscores (144 correlational analyses). No correlation surpassed this threshold of significance. Specifically, the relationship between checking (HOCI subscale) and anxiety-related interference did not even point in the expected direction (r ¼ 0:13); neither did the core depression and anxiety subscale of the HDRS correlate with the corresponding interference effect (r ¼ 0:07; r ¼ 0:22). In addition, medication status and a 1
It has been suggested previously that some participants may be able to strategically override the expected attentional bias effect by investing more effort to the primary task (Williams et al., 1996). The signature of this phenomenon is reduced response latency. For the present study, overall response latency did not predict emotional Stroop interference in OCD subjects (r < 0:21; NS).
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diagnosis of major depression and another anxiety disorder did not moderate any of the interference effects. 3.3. Response latencies for ‘‘soap’’ and ‘‘sink’’ (neutral condition) Shortly after data collection, we realized that two of the neutral stimuli may bear some relevance to OCD washing compulsions (soap, sink). In a post hoc analysis, we inspected whether washers show greater response latencies compared to non-washers and controls on these items. Whereas washers and non-washers displayed greater interference for sink relative to healthy controls (p ¼ 0:03; p ¼ 0:02), the contrast for soap did not reach significance (response latencies: soap: non-washers: 89.91 ms (SD: 156.21), washers: 112.65 ms (SD: 224.71), controls: 41.68 ms (SD: 141.58); sink: non-washers: 125.13 ms (SD: 115.46), washers: 160.48 ms (SD: 254.88), controls: 59.78 ms (SD: 97.73). Despite numerically greater interference for both words in washers, the difference to non-washers failed to reach significance.
4. Discussion The present study aimed at exploring interference effects in OCD patients as assessed with a modified Stroop task. Although several neuroimaging studies suggest an involvement of the anterior cingulate cortex in the pathogenesis of OCD (Saxena et al., 2001), an area implicated in the performance in the Stroop task, the present investigation did not find enhanced (neutral) interference in OCD subjects, in accordance with most prior cognitive research (e.g., Moritz, Kloss, Jacobsen, et al., 2002; Schmidtke, Schorb, Winkelmann, & Hohagen, 1998; however, see Bannon, Gonsalvez, Croft, & Boyce, 2002). Furthermore, we were unable to find any significant associations between interference elicited by emotional and personality Stroop words with group membership. In addition, severity of psychopathology and degree of avoidance did not exert any influence on the results. The latter result is consistent with a finding from Kyrios and Iob (1998), who failed to find a relationship between avoidance and emotional Stroop performance. Inconsistent with results from Novara and Sanavio (1999), no correlation emerged between checking symptoms with interference for depression and anxiety-related words. Only a small trend was obtained towards greater interference for depression-related words in OCD patients relative to controls, which, however, did not withstand correction for multiple comparisons. As mood-dependent interference effects have been demonstrated in most prior studies on nonOCD anxiety disorders (see Williams et al., 1996) and the cognitive profile of OCD patients thus seemingly deviates from that shown by other anxiety-disordered groups, it is tempting to interpret our finding as further confirmation of the widespread view that OCD is misclassified as an anxiety disorder (see Summerfeldt & Endler, 1998). However, caution is warranted in drawing such an inference. First, there are some studies that could not find mood-congruent interference effects in anxiety disorders (e.g., McNally et al., 1992). Moreover, emotional interference is no pathognomonic feature of anxiety disorders and therefore of little differential-diagnostic value. For example, paranoid patients also display enhanced interference for concern-related words (Bentall & Kaney, 1989). Third, personal relevance was not assured in most prior studies, including the present one. While not all studies have found that personally relevant material is
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crucial to elicit a mood-congruent interference effect (e.g., McNally et al., 1994), it cannot be ruled out that the usage of more idiosyncratic material may elicit increased emotional Stroop interference in OCD. In view of the heterogeneity of obsessive fears, material must be compiled carefully and tailored to individual concerns. For example, words like blood and germs may trigger an attentional bias in a patient with pre-occupations about blood-transmitted diseases but not in a patient with concerns about asbestos, although both can be allocated to the identical OCD subtype (i.e., fear of contamination). Likewise, one would not assume emotional interference effects in rape victims for words such as Charlie and Medevac that generate potent interference effects in Vietnam veterans. Interestingly, a secondary analysis revealed that the word sink elicited greater interference in the OCD group than in healthy controls. We would also like to raise some methodological concerns that might have prevented significant effects from occurring in the present study. An important variable not manipulated in the present study is the presentation time of the target. In line with our study, Unoki, Kasuga, Matsushima, and Ohta (1999) did not report any effect for emotional Stroop words in OCD under supraliminal conditions, while a delay of anxiety and compulsion-relevant words was measured with subliminal presentation (however, Kyrios and Iob, 1998, did not find differential subliminal emotional interference in OCD). Moreover, as outlined in the introduction, the exact cognitive mechanism underlying mood-congruent interference is still subject to debate. While the present random-presentation methodology is a sensitive paradigm to test whether patients with OCD display an attentional bias towards mood and certain personality words and/or have greater problems than controls in disengaging from such words, a rumination effect elicited by negative-valenced material is more likely to be obtained under blocked conditions allowing more intense stimulation. The present procedure allowed patients to ‘‘recover’’ from post-lexical rumination effects, because a word from a particular condition was always followed by an item from a different condition, so that rumination carry-over effects would have rather affected subsequent trials belonging to different conditions. It should be noted, however, that McNeil et al. (1999) also did not find significant interference for blockwise presented depression and anxietyrelated Stroop stimuli relative to neutral words in both a depression and an OCD sample. Significant interference for emotional stimuli was displayed solely by PTSD patients in that study. Nevertheless, it would be informative to investigate emotional Stroop interference in OCD with blockwise and random-trial procedures simultaneously. Despite these unresolved issues calling for caution in hastily dismissing the possibility of emotional interference effects in OCD, our results are clearly in line with most prior research, which has also failed to find differences between OCD patients and controls on the emotional Stroop task (see Kyrios & Iob, 1998 (under both sub- and supraliminal conditions); McNally et al., 1992, 1994; McNeil et al., 1999; Unoki et al., 1999 (supraliminal condition)). In contrast, a recent investigation conducted by Novara and Sanavio (2001) has reported greater Stroop interference in normal participants high on compulsive checking. Somewhat surprisingly, while an association between their Stroop interference index for threatening words and checking achieved significance, no such effect occurred for the state–trait anxiety inventory. The authors report that participants showed a 32 ms response delay for threatening words relative to participants low on checking, which turned out to be significant. Unfortunately, the authors do not report whether group differences would have remained significant if baseline scores (reducing the effect to 24 ms) were taken into account. Divergent results may have also originated from the fact
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that Novara and Sanavio (2001) utilized some threatening words with direct association to OCD-related preoccupations (e.g., blood, virus, urine, cancer), so that results might reflect differences in processing disease-related items, in line with Lavy et al. (1994) and Foa et al. (1993). However, it should also be noted that Unoki et al. (1999) did not find enhanced interference in OCD patients for anxiety-relevant and compulsion-relevant material using supraliminal presentation. Finally, the choice of threatening words in the study conducted by Novara and Sanavio is questionable, since this condition also comprised words like mamma, papa and dio (i.e., God), with no obvious anxiety-provoking content. In a final analysis, we considered the possibility that a failure to find a concern-related attentional bias may stem from an increased effort to obey the primary task demand (i.e., color naming; see Williams et al., 1996). The signature of such a strategy is a reduced overall naming latency. However, in the present study, no relationship was found between reduced interference and response speed, rendering a strategic override effect very unlikely.
Acknowledgements We also thank Lisa Huschka for help with an earlier version of the manuscript. The present study was supported by a grant from the German Research Foundation (MO 969/1-1).
Appendix A. Verbal stimulus sets
German
Translation
Neutral Becher Bettbezug Bushaltestelle Heizung Hut Kabel Knopf Pinnwand Polster Seife Sessel Steckdose Tasche Tastatur Waschbecken
Beaker Bedclothes Bus stop Heating Hat Cable Button Pin board Cushion Soap Armchair Power socket Bag Keyboard Sink
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Responsibility Anklage Beschu¨tzer Gericht Gesetz Gewissen Moral Pflicht Schuld Sorgfalt Strafe Su¨nde Ta¨ter Verantwortung Verfehlung Versa¨umnis
Accusation Guardian Court Law Conscience Moral Duty Guilt Accuracy Punishment Sin Offender Responsibility Misconduct Default
Consciousness Ansehen Anspruch Aussehen Bewertung Eignung Ko¨nnen Kritik Norm Rang Standard Status Stellung Vergleich Wettbewerb Ziel
Reputation Goal/aim Appearance Assessment Qualification Ability Criticism Norm Rank Standard Status Position Comparison Competition Goal
Depression Depression Einsamkeit Elend Kummer Leere Leid Schwa¨che
Depression Loneliness Misery Sorrow Emptiness Agony Weakness
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Schwermut Trauer Tru¨bsinn Unlust Verlust Vorwurf Wehmut weinen
Gloom Grief Melancholy Anhedonia Loss Accusation Woefulness/melancholy To cry
Anxiety Alarm Angst Anspannung Attacke Bedrohung Furcht Gefahr Horror Nervosita¨t Panik Phobie Schauder Unruhe Verfolger Verkrampfung
Alarm Anxiety Tension Attack Threat Fear Danger Horror Nervousness Panic Phobia Shudder Agitation Persecutor Cramp
Positive Begabung Begeisterung Energie Erfolg Euphorie Gro¨ße Held Jubel Kraft Reichtum Ruhm Scho¨nheit Schwung Sieger Tapferkeit
Talent Enthusiasm Energy Success Euphoria Greatness Hero Jubilation Strength Wealth Fame Beauty Drive Winner Bravery
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Examination of emotional Stroop interference in obsessive– compulsive disorder Steffen Moritz , Dirk Jacobsen, Martin Kloss, Susanne Fricke, Michael Rufer, Iver Hand Klinik fu¨r Psychiatrie und Psychotherapie, Universita¨tsklinikum Hamburg–Eppendorf, Martinistraße 52, D-20246 Hamburg, Germany Received 1 April 2003; received in revised form ; accepted 23 June 2003
Abstract Previous research has produced conflicting findings on whether or not patients with subclinical or manifest obsessive–compulsive disorder (OCD) share an attentional bias for anxiety-related material. In the present study, 35 OCD patients were compared with 20 healthy controls on their performance in an emotional Stroop paradigm. Nine different stimulus conditions were compiled, including sets for depression-related and anxiety-related words as well as stimuli from two constructs with a potential relevance for the pathogenesis and maintenance of OCD symptomatology: responsibility and conscientiousness. Patients did not show enhanced interference for any of the conditions. Syndrome subtype and severity, avoidance and speed of information processing did not moderate results. The present study concurs with most prior research that OCD patients display no interference effect for general threat words. It deserves further consideration, that emotional interference effects in OCD as seen in other anxiety disorders occur when using idiosyncratic word material with a direct relation to the individual’s primary concerns. # 2003 Elsevier Ltd. All rights reserved. Keywords: Obsessive–compulsive disorder; Emotional Stroop; Anxiety; Depression; Mood congruency
Corresponding author. Tel.: +49-40-42803-6565; fax: +49-40-42803-2999. E-mail address: [email protected] (S. Moritz).
0005-7967/$ - see front matter # 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0005-7967(03)00190-6
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1. Introduction Within the last two decades, perhaps commencing with Bower’s visionary article ‘‘Mood and memory’’ (1981), the investigation on the processing of emotional stimuli has received growing recognition in the cognitive literature. Broad evidence has been provided that subjects with clinical or sub-clinical depression and anxiety disorders share a processing bias for moodcongruent or concern-related material (Coles & Heimberg, 2002; McNally, 1997; Williams et al., 1996). Besides implicit and explicit memory tasks employing emotional words, this line of research has made extensive use of attention tasks such as the dot probe and the emotional Stroop paradigm. Unlike the conventional Stroop paradigm (see MacLeod, 1991, for a review), where the subject is instructed to name the ink color of incongruently typed color words (e.g., the word blue written in red ink), the core conditions in the emotional Stroop task comprise words with mood-associated or mood-evocative semantic content. For major depression and a wide range of anxiety disorders, it has been found that subjects exhibit prolonged naming latencies when presented with words characterizing (words such as depressed, anxious) or symbolizing (e.g., dark, ghost) the current mood/concerns of the subject (Williams et al., 1996). This effect is typically explained by an attentional bias of anxiety and depressed patients towards mood-relevant material, problems in disengaging from such material or distraction from the primary task (color naming) via post-lexical rumination. The present study investigated emotional Stroop performance in patients diagnosed with obsessive–compulsive disorder (OCD). Along with words from three affective classes (depression, anxiety, positive), emotionally neutral words (color words written in an incongruent or congruent color; neutral words) and a non-lexical baseline condition, we presented words from two constructs with a putative relevance to obsessive–compulsive symptomatology: responsibility (see Salkovskis et al., 2000) and conscientiousness (e.g., Blais, 1997; Haigler & Widiger, 2001). The studies published so far have provided conflicting findings. While the majority of investigations do not support the hypothesis that depression- and anxiety-related Stroop stimuli are processed differently in OCD (Kyrios & Iob, 1998; McNally, Rieman, Louro, Lukach & Kim, 1992; McNally et al., 1994; McNeil, Tucker, Miranda, Lewin & Nordgren, 1999), Novara and Sanavio (2001) found enhanced reaction times for threatening words in normal subjects scoring high on a scale tapping compulsive checking. Similarly, Foa et al. (1993) found enhanced interference for general threat words in OCD patients without washing compulsions (some of them were checkers). In addition, in a study conducted by Lavy, van Oppen, and van den Hout (1994) OCD patients displayed greater Stroop interference for negative-valenced OCD-related stimuli. Although the latter study additionally reports enhanced interference in OCD for emotional words unrelated to obsessive–compulsive symptomatology, these results must be interpreted very cautiously, since greater interference in OCD patients was mainly due to faster reaction times in the baseline condition rather than slowed color naming in the emotional conditions. The present study aimed at assessing the presence of emotional interference effects in a large sample of OCD subjects. In view of the inconsistencies in the literature (see Summerfeldt & Endler, 1998), the contribution of potential moderators to this divergence was investigated carefully. Apart from OCD subtype (especially checking and washing) and the severity of OCD and co-morbid psychopathological symptoms (depression, anxiety), we focused on the impact of
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avoidance and speed of processing on emotional interference effects, since there is some evidence that both variables may influence the degree of emotional interference (Kyrios & Iob, 1998; Williams et al., 1996). It was expected that OCD patients display enhanced interference for material tapping anxiety, responsibility and conscientiousness, while no effects were expected for concern- and symptom-irrelevant stimulus dimensions.
2. Methods 2.1. Participants Thirty-five patients fulfilling DSM-IV criteria of OCD and 20 healthy controls participated in the study. Patients were tested prior to a cognitive-behavioral intervention program performed at the University Hospital for Psychiatry and Psychotherapy, Hamburg (Germany). Sixteen of the patients were medicated with psychotropic drugs (14 patients with antidepressants only, one with a neuroleptic agent alone; one patient was treated with a combination of an antidepressant and a neuroleptic agent); all other patients were free of psychotropic substances at the time of testing. Psychiatric diagnoses were determined according to DSM-IV criteria based on data collected during a semi-structured interview (Mini International Neuropsychiatric Interview, Sheehan et al., 1998). Nine patients (26%) fulfilled criteria for a current major depressive episode and eight patients (23%) were co-diagnosed with another anxiety disorder. Exclusion criteria were psychopathological symptoms incompatible or conflicting with a diagnosis of OCD (such as schizophrenia) and major neurological disturbances (e.g., stroke, epilepsy). Written informed consent was obtained from all participants prior to baseline assessment. Psychopathology was assessed using the German version of the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS; Goodman et al., 1989; translation by Hand & Bu¨ttner-Westphal, 1991) and the Hamilton Depression Rating Scale (HDRS; 17-item version; Hamilton, 1960) blind to neurocognitive status. In line with a previous confirmatory factor analytic study conducted with a large OCD sample (e.g., Moritz, Meier, Hand, Schick & Jahn, submitted for publication), the HDRS was broken down into four subscales (core depressive symptoms, anxiety, sleep and gastrointestinal problems). Y-BOCS subscales were computed according to an algorithm proposed recently by Moritz, Kloss, Jacobsen, et al. (2002), again on the basis of a confirmatory factor analysis (severity of obsessions: items 1, 2 and 3; severity of compulsions: items 6, 7 and 8; resistance against symptoms: items 4 and 9). We also administered the Hamburg Obsessional Compulsive Inventory (HOCI; Klepsch, Zaworka, Hand, Lu¨nenschloss, & Jauernig, 1991), a self-rating instrument that assesses 72 core obsessions (e.g., thoughts of doing harm to oneself/others) and compulsions (e.g., checking) along six scales. 2.2. Experimental task A computerized task was constructed using SuperLab1 software for Macintosh. Subsequent to a practice task with six items, subjects were presented stimuli from nine different conditions incorporating 15 stimuli each. The initial pool of words consisted of stimuli which were used in prior studies and share known emotion-evocative properties. Words for each condition were
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Table 1 Sociodemographic, psychopathological and cognitive characteristics of the OCD and the healthy participants Variable
OCD (n ¼ 35)
Healthy controls (n ¼ 20) Statistics
Sociodemographic Sex (male/female) Age Years of school education Verbal intelligence HDRS 17-Item Years of illness Number of admissions Y-BOCS total HOCI total
9/26 29.20 (7.55) 12.00 (1.75) 107.46 (11.63) 9.71 (5.31) 9.12 (8.56) 1.23 (1.42) 23.12 (7.37) 22.61 (9.28)
5/15 26.60 (5.35) 12.65 (1.46) 112.83 (12.38) 1.94 (2.26) – – – –
v2 ð1Þ ¼ 0:00; p > 0:9 tð53Þ ¼ 1:49; p > 0:1 tð53Þ ¼ 1:47; p > 0:1 tð53Þ ¼ 1:56; p > 0:1 tð53Þ ¼ 7:36; p < 0:001 – – – –
178.18 (115.68) 66.85 (57.45) 61.62 (60.00) 80.64 (51.64) 60.15 (49.70) 73.36 (71.31) 16.91 (69.32) 48.32 (63.34)
tð53Þ ¼ 0:98; p > 0:3 tð53Þ ¼ 1:70; p ¼ 0:09 tð53Þ ¼ 0:85; p > 0:3 tð53Þ ¼ 1:69; p ¼ 0:1 tð53Þ ¼ 0:47; p > 0:6 tð53Þ ¼ 0:38; p > 0:7 tð53Þ ¼ 0:87; p > 0:3 tð53Þ ¼ 0:87; p > 0:3
Emotional Stroop difference scores in msa Stroop 208.05 (104.31) Neutral 94.71 (59.08) Anxiety 78.62 (76.78) Depression 111.42 (83.04) Positive 68.24 (66.63) Conscientiousness 80.26 (59.52) Facilitation 1.67 (58.18) Responsibility 64.14 (65.35) a
RT experimental minus baseline conditions; reaction times for the different conditions can be computed by adding the baseline condition reaction time to the difference scores (OCD patients: 629.46 ms (118.27); healthy controls: 578.66 ms (64.36)).
compiled after consensus ratings provided by six experienced clinicians. The stimuli are listed in Appendix A. The final set of items was determined after matching according to word length and word frequency (all contrasts p > 0:2). The emotional and personality word conditions were as follows: anxiety (e.g., attack, persecutor), depression (e.g., weakness, loneliness), responsibility (e.g., responsibility, guilt), conscientiousness (e.g., rank, status) and positive (e.g., beauty, success). There were three affect-neutral word conditions: neutral (e.g., bag, button), Stroop interference (e.g., incongruently written color words) and Stroop facilitation (e.g., congruently written color words). Naming of horizontal color bars served as baseline condition. Color words were written lowercase in the following colors and were distributed evenly across conditions: red (German: rot), green (gru¨n), yellow (gelb) and blue (blau). After a small fixation point (300 ms), which was followed by a 200 ms blank trial, the target stimulus (font 30, type Geneva) appeared on the screen until the voice-key was triggered via microphone. Subsequently, the experimenter pressed a button to denote correct (i.e., ‘‘C’’) and incorrect (i.e., ‘‘X’’) responses. This key press triggered the following stimulus. Participants were instructed to respond as fast as possible without making too many mistakes. Reaction time latencies were recorded only for correct trials. Experimental trials were presented in random order.
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3. Results 3.1. Comparisons between OCD patients and healthy controls Subjects did not differ on sociodemographic background variables (see Table 1). Prior to more fine-grained analyses of the primary hypotheses, a two-way mixed ANOVA was performed with group (OCD, healthy control) as the between-subject and condition (all nine conditions in the emotional Stroop task) as the within-subject variable. Both the group (F ð1; 53Þ ¼ 4:43, p ¼ 0:04) and the condition effect (F ð8; 442Þ ¼ 52:64; p < 0:001) achieved significance. Whereas the group effect can be accounted for by greater overall retardation in the OCD group (see Table 1), the significant condition effect is attributable to greater slowing in the conventional Stroop condition relative to all other conditions and decreased response latencies in the facilitation and baseline conditions relative to all word conditions (p < 0:001). Additionally, post hoc t-tests revealed that reaction times for depression-related words were significantly slower compared to neutral words, positive words and responsibility words in both groups.1 The Greenhouse–Geisser corrected interaction of group condition failed to attain significance (p > 0:4). No t-test comparison calculated for difference scores in the emotional Stroop task (experimental RT word condition RT baseline condition) reached significance (see Table 1). At trend level, OCD patients exhibited stronger interference for the neutral and depression conditions (p ¼ 0:09 and p ¼ 0:10), which, however, did not withstand correction for multiple comparisons. OCD patients (8.07% (7.37)) committed more errors than controls (4.00% (3.86)). However, error interference scores corrected for baseline performance again yielded no significant differences. At the end of the testing, we asked subjects to rate on a five-point scale how motivated and concentrated they were during the task, which, however, did not achieve significance (p > 0:1).
3.2. Correlational analyses Except for age, which was significantly correlated with enhanced Stroop interference and less facilitation (r ¼ 0:25; p < 0:05), no sociodemographic background variable correlated with any of the difference scores. Due to an inflated likelihood of false-positive relationships, the alpha level was set at p ¼ 0:01 for all correlations involving Y-BOCS (subscore algorithm and an item measuring avoidance), HOCI and HDRS subscores (144 correlational analyses). No correlation surpassed this threshold of significance. Specifically, the relationship between checking (HOCI subscale) and anxiety-related interference did not even point in the expected direction (r ¼ 0:13); neither did the core depression and anxiety subscale of the HDRS correlate with the corresponding interference effect (r ¼ 0:07; r ¼ 0:22). In addition, medication status and a 1
It has been suggested previously that some participants may be able to strategically override the expected attentional bias effect by investing more effort to the primary task (Williams et al., 1996). The signature of this phenomenon is reduced response latency. For the present study, overall response latency did not predict emotional Stroop interference in OCD subjects (r < 0:21; NS).
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diagnosis of major depression and another anxiety disorder did not moderate any of the interference effects. 3.3. Response latencies for ‘‘soap’’ and ‘‘sink’’ (neutral condition) Shortly after data collection, we realized that two of the neutral stimuli may bear some relevance to OCD washing compulsions (soap, sink). In a post hoc analysis, we inspected whether washers show greater response latencies compared to non-washers and controls on these items. Whereas washers and non-washers displayed greater interference for sink relative to healthy controls (p ¼ 0:03; p ¼ 0:02), the contrast for soap did not reach significance (response latencies: soap: non-washers: 89.91 ms (SD: 156.21), washers: 112.65 ms (SD: 224.71), controls: 41.68 ms (SD: 141.58); sink: non-washers: 125.13 ms (SD: 115.46), washers: 160.48 ms (SD: 254.88), controls: 59.78 ms (SD: 97.73). Despite numerically greater interference for both words in washers, the difference to non-washers failed to reach significance.
4. Discussion The present study aimed at exploring interference effects in OCD patients as assessed with a modified Stroop task. Although several neuroimaging studies suggest an involvement of the anterior cingulate cortex in the pathogenesis of OCD (Saxena et al., 2001), an area implicated in the performance in the Stroop task, the present investigation did not find enhanced (neutral) interference in OCD subjects, in accordance with most prior cognitive research (e.g., Moritz, Kloss, Jacobsen, et al., 2002; Schmidtke, Schorb, Winkelmann, & Hohagen, 1998; however, see Bannon, Gonsalvez, Croft, & Boyce, 2002). Furthermore, we were unable to find any significant associations between interference elicited by emotional and personality Stroop words with group membership. In addition, severity of psychopathology and degree of avoidance did not exert any influence on the results. The latter result is consistent with a finding from Kyrios and Iob (1998), who failed to find a relationship between avoidance and emotional Stroop performance. Inconsistent with results from Novara and Sanavio (1999), no correlation emerged between checking symptoms with interference for depression and anxiety-related words. Only a small trend was obtained towards greater interference for depression-related words in OCD patients relative to controls, which, however, did not withstand correction for multiple comparisons. As mood-dependent interference effects have been demonstrated in most prior studies on nonOCD anxiety disorders (see Williams et al., 1996) and the cognitive profile of OCD patients thus seemingly deviates from that shown by other anxiety-disordered groups, it is tempting to interpret our finding as further confirmation of the widespread view that OCD is misclassified as an anxiety disorder (see Summerfeldt & Endler, 1998). However, caution is warranted in drawing such an inference. First, there are some studies that could not find mood-congruent interference effects in anxiety disorders (e.g., McNally et al., 1992). Moreover, emotional interference is no pathognomonic feature of anxiety disorders and therefore of little differential-diagnostic value. For example, paranoid patients also display enhanced interference for concern-related words (Bentall & Kaney, 1989). Third, personal relevance was not assured in most prior studies, including the present one. While not all studies have found that personally relevant material is
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crucial to elicit a mood-congruent interference effect (e.g., McNally et al., 1994), it cannot be ruled out that the usage of more idiosyncratic material may elicit increased emotional Stroop interference in OCD. In view of the heterogeneity of obsessive fears, material must be compiled carefully and tailored to individual concerns. For example, words like blood and germs may trigger an attentional bias in a patient with pre-occupations about blood-transmitted diseases but not in a patient with concerns about asbestos, although both can be allocated to the identical OCD subtype (i.e., fear of contamination). Likewise, one would not assume emotional interference effects in rape victims for words such as Charlie and Medevac that generate potent interference effects in Vietnam veterans. Interestingly, a secondary analysis revealed that the word sink elicited greater interference in the OCD group than in healthy controls. We would also like to raise some methodological concerns that might have prevented significant effects from occurring in the present study. An important variable not manipulated in the present study is the presentation time of the target. In line with our study, Unoki, Kasuga, Matsushima, and Ohta (1999) did not report any effect for emotional Stroop words in OCD under supraliminal conditions, while a delay of anxiety and compulsion-relevant words was measured with subliminal presentation (however, Kyrios and Iob, 1998, did not find differential subliminal emotional interference in OCD). Moreover, as outlined in the introduction, the exact cognitive mechanism underlying mood-congruent interference is still subject to debate. While the present random-presentation methodology is a sensitive paradigm to test whether patients with OCD display an attentional bias towards mood and certain personality words and/or have greater problems than controls in disengaging from such words, a rumination effect elicited by negative-valenced material is more likely to be obtained under blocked conditions allowing more intense stimulation. The present procedure allowed patients to ‘‘recover’’ from post-lexical rumination effects, because a word from a particular condition was always followed by an item from a different condition, so that rumination carry-over effects would have rather affected subsequent trials belonging to different conditions. It should be noted, however, that McNeil et al. (1999) also did not find significant interference for blockwise presented depression and anxietyrelated Stroop stimuli relative to neutral words in both a depression and an OCD sample. Significant interference for emotional stimuli was displayed solely by PTSD patients in that study. Nevertheless, it would be informative to investigate emotional Stroop interference in OCD with blockwise and random-trial procedures simultaneously. Despite these unresolved issues calling for caution in hastily dismissing the possibility of emotional interference effects in OCD, our results are clearly in line with most prior research, which has also failed to find differences between OCD patients and controls on the emotional Stroop task (see Kyrios & Iob, 1998 (under both sub- and supraliminal conditions); McNally et al., 1992, 1994; McNeil et al., 1999; Unoki et al., 1999 (supraliminal condition)). In contrast, a recent investigation conducted by Novara and Sanavio (2001) has reported greater Stroop interference in normal participants high on compulsive checking. Somewhat surprisingly, while an association between their Stroop interference index for threatening words and checking achieved significance, no such effect occurred for the state–trait anxiety inventory. The authors report that participants showed a 32 ms response delay for threatening words relative to participants low on checking, which turned out to be significant. Unfortunately, the authors do not report whether group differences would have remained significant if baseline scores (reducing the effect to 24 ms) were taken into account. Divergent results may have also originated from the fact
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that Novara and Sanavio (2001) utilized some threatening words with direct association to OCD-related preoccupations (e.g., blood, virus, urine, cancer), so that results might reflect differences in processing disease-related items, in line with Lavy et al. (1994) and Foa et al. (1993). However, it should also be noted that Unoki et al. (1999) did not find enhanced interference in OCD patients for anxiety-relevant and compulsion-relevant material using supraliminal presentation. Finally, the choice of threatening words in the study conducted by Novara and Sanavio is questionable, since this condition also comprised words like mamma, papa and dio (i.e., God), with no obvious anxiety-provoking content. In a final analysis, we considered the possibility that a failure to find a concern-related attentional bias may stem from an increased effort to obey the primary task demand (i.e., color naming; see Williams et al., 1996). The signature of such a strategy is a reduced overall naming latency. However, in the present study, no relationship was found between reduced interference and response speed, rendering a strategic override effect very unlikely.
Acknowledgements We also thank Lisa Huschka for help with an earlier version of the manuscript. The present study was supported by a grant from the German Research Foundation (MO 969/1-1).
Appendix A. Verbal stimulus sets
German
Translation
Neutral Becher Bettbezug Bushaltestelle Heizung Hut Kabel Knopf Pinnwand Polster Seife Sessel Steckdose Tasche Tastatur Waschbecken
Beaker Bedclothes Bus stop Heating Hat Cable Button Pin board Cushion Soap Armchair Power socket Bag Keyboard Sink
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Responsibility Anklage Beschu¨tzer Gericht Gesetz Gewissen Moral Pflicht Schuld Sorgfalt Strafe Su¨nde Ta¨ter Verantwortung Verfehlung Versa¨umnis
Accusation Guardian Court Law Conscience Moral Duty Guilt Accuracy Punishment Sin Offender Responsibility Misconduct Default
Consciousness Ansehen Anspruch Aussehen Bewertung Eignung Ko¨nnen Kritik Norm Rang Standard Status Stellung Vergleich Wettbewerb Ziel
Reputation Goal/aim Appearance Assessment Qualification Ability Criticism Norm Rank Standard Status Position Comparison Competition Goal
Depression Depression Einsamkeit Elend Kummer Leere Leid Schwa¨che
Depression Loneliness Misery Sorrow Emptiness Agony Weakness
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Schwermut Trauer Tru¨bsinn Unlust Verlust Vorwurf Wehmut weinen
Gloom Grief Melancholy Anhedonia Loss Accusation Woefulness/melancholy To cry
Anxiety Alarm Angst Anspannung Attacke Bedrohung Furcht Gefahr Horror Nervosita¨t Panik Phobie Schauder Unruhe Verfolger Verkrampfung
Alarm Anxiety Tension Attack Threat Fear Danger Horror Nervousness Panic Phobia Shudder Agitation Persecutor Cramp
Positive Begabung Begeisterung Energie Erfolg Euphorie Gro¨ße Held Jubel Kraft Reichtum Ruhm Scho¨nheit Schwung Sieger Tapferkeit
Talent Enthusiasm Energy Success Euphoria Greatness Hero Jubilation Strength Wealth Fame Beauty Drive Winner Bravery
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