by Uzma Ilyas, PhD scholar; Sabeela Saher, MS scholar; Ayesha Ahmad Khan, MS scholar; Anam Shahid, PhD Scholar; and Zarmeen Tariq, MS

Ms. Ilyas is Senior Lecturer, Department of Psychology, Forman Christian College University in Lahore, Pakistan. Ms. Saher, Ms. Khan, and Mr. Shahid are with Department of Psychology, University of Central Punjab in Lahore, Pakistan. Mr. Tariq is Senior Publication Officer, University of Management and Technology in Lahore, Pakistan.

Funding: No funding was provided for this article.

Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Innov Clin Neurosci. 2024;21(7–9):22–26.

Abstract

Objective: This systematic review aimed to identify the effect of obsessive compulsive disorder (OCD) on cognitive processes, such as memory, executive functioning, and cognitive flexibility, among the adult populations of Asian countries.

Methods: The systematic review progressed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. It is comprised of articles sourced from Asian countries published from 2018 to 2022, and literature about deficits in memory, executive functioning, and cognitive flexibility in the OCD population was gathered from five electronic databases, including Google Scholar, PubMed, Research Gate, Science Direct, and Wiley Online Library. Full-text impact factor articles in the English language were considered in this study.

Results: This study screened 44 articles; five were included based on the eligibility criteria for the present systematic review. Four articles found cognitive deficits in the domains of executive functioning, memory, and cognitive flexibility among patients with OCD, whereas results of one article showed normal cognitive performance of the patients. Demographic variables showed no significant differences between patients with OCD and healthy controls. 

Conclusion: This systematic review indicated deficits specifically in the cognitive functioning and flexibility of patients with OCD. Despite a noticeable prevalence of OCD in Asian countries, the literature on correlates and neurological functioning is scarce. Further studies are required to examine the effects on the larger population and provide knowledge in those countries and areas where people are suffering because of minimal knowledge regarding OCD.

Keywords: Executive functioning, memory, cognitive flexibility, OCD

Obsessive compulsive disorder (OCD) is considered a severe and impairing neuropsychiatric disorder characterized by intrusive unwanted thoughts and repetitive behaviors, which can affect patient quality of life and daily activities.¹ OCD is the fourth most common mental illness and the tenth largest cause of disability globally, according to the World Health Organization (WHO).² Globally, 12-month prevalence of OCD is between 1.1 to 1.8 percent, but this varies worldwide; for example, prevalence is approximately 1.2 percent in the United States (US).³ Various studies have been conducted in different Asian regions. For example, China has a lifetime prevalence of 1.63 percent, whereas Singapore has a reported OCD prevalence of three percent.^4–6 Studies from South Asian countries revealed the prevalence rates in India range from 0.5 to 2 percent, and in Pakistan, prevalence is three percent, whereas sex-based prevalence suggests women have higher rates of OCD, compared to men.^7,8

Evidence suggests that boys are likely to develop OCD symptoms during childhood, whereas girls often develop symptoms during adolescence.⁹ Memory is considered one of the cognitive domains in OCD. Patients with OCD have shown impairment in memory, specifically in immediate, general, and working memory. Howevere, these findings may be controversial due to the inconsistent results mentioned in the literature on memory, as the literature supports both findings of significant impairments of memory and findings of no impairment in memory among patients with OCD.¹⁰

From a neuropsychological point of view, memory deficits found in patients with OCD could be mediated by impaired strategic processing problems caused by executive functioning.¹¹ A study published in 2017 stated that individuals with OCD exhibit deficits in attention control, memory, and cognitive flexibility, compared to healthy controls.¹² Another study stated that individuals suffering from OCD had impairments in cognitive flexibility compared to a control group.¹³

OCD can have a significant impact on a person’s judgment by interfering with their abilities to process information and make decisions, as it can consume a significant amount of time and mental energy, leaving little room for other thoughts and activities. One study has found that individuals with OCD exhibited impaired judgment in decision-making tasks, compared to healthy individuals.¹⁴ Another study revealed that individuals with OCD showed a bias toward negative information and a reduced ability to shift their attention away from negative stimuli, leading to a distorted view of reality.¹⁵

OCD has been linked to decreased cognitive flexibility, as research shows that people with OCD tend to exhibit rigidity in their thoughts and behaviors and might have difficulty shifting their focus or adjusting to new situations. One study found that individuals with OCD exhibited decreased cognitive flexibility, compared to healthy controls, and this impairment was associated with greater symptom severity.¹⁶ Another study found that cognitive flexibility is an important target for treatment in OCD, and exposure and response prevention therapy can improve cognitive flexibility in individuals with OCD.¹⁷

Concerning differences between male and female patients with OCD, a significant difference of obsessions and compulsions was found. For instance, female patients were more likely to report obsessions associated with contaminated thoughts or aggressive concerns, while male patients mostly reported blasphemous thoughts.¹⁸ Youths with OCD can experience severe distress and impaired functioning in critical cognitive domains, such as learning, memory, cognitive flexibility, and goal-directed behavioral control, that can affect daily functioning. They might have difficulty learning about contingencies and become less sensitive to outcome devaluation, suggesting impairment in goal-directed control and academic success. While talking about academic success, they might show significant learning and memory impairment.¹⁹

Previous neuropsychological research is still not conclusive, as there exist some inconsistent findings about OCD. This current review aimed to investigate the outcomes of OCD, which are significantly associated with issues of memory, executive functioning, judgment, and cognitive flexibility, reported in adults with a diagnosis of OCD in Asian countries.

Methods

The current study systematically reviewed articles on OCD and neuropsychological deficits in adult populations published from 2018 to 2022 in Asian countries (Figure 1). The databases used for the present review included Google Scholar, Wiley Online Library, Research Gate, Science Direct, and PubMed. The pool of articles was made by selecting all the articles about OCD and neuropsychological functioning, then screening out each article separately.

After screening, duplicate articles were removed. The articles that were published before 2018 and those including children and adolescents were excluded. Five articles^10,20–23 were included in the present systematic review; they included case-control studies,^10,22 ross-sectional studies,^21,23 and a functional magnetic resonance imaging (fMRI) study.²⁰ Information regarding demographics, including age, sex, and age of onset, and socioeconomic factors, such as marital status and education, were also sought out by the researchers. The adult age range included was 18 to 65 years. Full-text articles published in the English language and based in Asian countries were included.

By following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the key terms for the review, which included “OCD,” “executive functioning,” “memory,” “judgment,” “cognitive flexibility,” “Asia,” and “adults,” were searched. Data collected included author names, date of publication, demographics (age, sex, socioeconomic status, education, and marital status), and study design. Furthermore, the methodology and outcomes of the study were also considered. The included articles were analyzed in detail, and those not meeting the criteria of inclusion were excluded from the study.

Results

Of the 44 articles initially identified, five (11.6%) were included for analysis (Table 1).^10,20–23 The main themes extracted from the findings of these five studies included executive function, memory, cognitive flexibility, and judgment among patients with OCD.

All of the studies were comparative and consisted of samples of patients with OCD and healthy controls.^10,20–23 The ages of study participants ranged between 18 to 65 years. The Asian countries included in the study were from Iran,^10,21 China,²³ Republic of Korea,²⁰ and Egypt.²² The main themes extracted based on these five relevant articles showed no significant differences between the demographic variables (age, sex, education, and marital status) for male and female patients.

The findings showed that cognitive impairment was significantly correlated with OCD. The most prominent deficits were found in the area of executive functioning, and it was found that more preservative thinking errors had a detrimental impact on executive functioning in patients with OCD.²¹ The studies also revealed common impairments in patients in the domains of general memory, verbal memory, immediate memory, and working memory.

In addition, the studies showed that mood and anxiety disorders, mainly depression and anxiety, more specifically social anxiety, were comorbid with OCD.^10,22,23 However, patients had similar impairments in executive functioning with or without the presence of comorbidities. Moreover, in terms of medications, no significant differences were reported in cognitive performance of patients based on symptomatic severity (mild-to-moderate or severe symptoms of OCD).²³ One study showed that there were patients who were taking selective serotonin reuptake inhibitors (SSRIs), mainly citalopram, but there were no significant differences in the cognitive flexibility of patients with OCD and healthy controls following medication.²⁰ The authors reasoned it might be due to the medication effect of SSRIs. Another study included some patients who had been taking medications prior to study initiation,²² whereas a third study included patients who were on SSRIs during testing only.²³ In these two studies, one reported no significant differences between patients with OCD and healthy controls,²³ while the other reported observable differences in the executive functioning of the patients.²²

Discussion

To the best of our knowledge, current review findings showed an impaired performance of memory, executive functioning, and cognitive flexibility among patients with OCD.²⁰ There were no participants with a history of drug and alcohol abuse, head injury, or psychiatric problems included in the studies reviewed. Additionally, there were no observable differences reported in OCD symptomatology in terms of demographic variables, such as age, sex, marital status, occupation, residence, handedness, and use of medication.²¹ Based on these findings, it can be assumed that OCD symptomatology is independent of such factors or that this reflects a scarcity of research from Asian countries in this context.

Evidence suggests executive functioning is the primary factor in neuropsychological assessment of patients with OCD, while memory is secondary.²⁴ This is also reported in articles included in the current systematic review.¹⁰ The findings from one study showed that few individuals had taken medications prior to their inclusion in the study.²² Present data revealed no significant differences in the executive functioning of patients with OCD who had depression or anxiety disorder and healthy controls. This suggests that comorbidities, such as depression and anxiety, are unlikely to have an effect on executive functioning in individuals with OCD.^23,25

Research has shown a decline in the performance of patients with OCD in the nonverbal domain, visuospatial memory, and executive functioning.^26,27 Further research concluded that patients with checking OCD, which refers to the themes of compulsion where individuals are involved in checking things again and again, have distorted memory and also have impaired executive functioning.^28,29 It is worth noting that the abnormal fear of being responsible and reprimanded for not acting properly is seen as one of the key deficits contributing to abnormal moral judgment in OCD^30,31 In OCD, individuals have maladaptive patterns of repeated, inflexible thought and behavior that lead to a lack of cognitive flexibility. Much neurocognitive research has revealed behavioral and neurobiological deficits in cognitive flexibility in patients with OCD, which aligns with this clinical observation.^32–34 Although there are few studies on neuroimaging techniques in the investigation of OCD, the current research explains that both male and female patients have approximately similar levels of symptom and manifestation of OCD, compared to healthy individuals.³⁵

Research has shown that OCD is more prevalent in European countries, compared to Asian and African countries; evidence suggests that people not seeking treatment is resultant of a lack of mental health literacy, skimmed resources, and fears of stigmatization among emerging countries.³⁶ Asian countries might focus on enhancing awareness surrounding mental health and promote psychological help seeking to overcome stigmatization and curtail psychological sufferings. Another study reported there might be ethnic identity differences between Asian and American countries related to OCD.³⁷

Limitations and suggestions. The limitations of the current study are based on findings of the past five years in Asian countries. In emerging countries, there are still myths and stigmas related to OCD that contribute to people being less aware of it as a mental illness. Asian and African countries depict the least awareness of OCD and have limited studies available. Secondly, the study was not registered with any database, so it did not include articles based on randomized, controlled trials or intervention studies. Despite these limitations, this study could serve psychiatrists, neurologists, and psychologists to better understand the evolution of OCD symptomatology, especially in Asia. It is suggested that additional studies should be conducted related to OCD and common comorbidities, use of medication, or available interventions.

Conclusion

The current study showed that there are cognitive deficits among patients with OCD in the domains of executive functioning, memory, and cognitive flexibility, with no significant differences in age, sex, education, or marital status. A comparison of these studies that were purely based in Asian countries suggested differences between patients with OCD and healthy controls, except for one study. In the context of the Pakistani population, we have concluded that promoting awareness surrounding OCD and its outcomes affecting daily functioning could be helpful to the masses, in addition to research studies related to OCD and its various aspects.

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