Confidence in context in obsessive-compulsive disorder.

Obsessive-compulsive disorder is a psychiatric condition associated with
repetitive and functionally impairing actions (i.e. compulsions, such as
checking behaviors), mostly performed to alleviate distress induced by
intrusive thoughts (i.e. obsessions). Patients suffering from this disorder
compulsively engage in behavior and pathological decision-making that leads to
serious life impairments and suffering. It is important to study the underlying
behavioral processes that go together with this disorder.

With every decision we make, a feeling of confidence about that choice arises,
which is crucial for learning and guiding our future decision-making behavior.
Confidence is being defined as the subjective feeling of being accurate about a
choice or decision, and is a metacognitive construct. Studies have shown that
confidence mostly accurately maps onto performance in various tasks.
Importantly, however, abnormal confidence judgments that do not reflect reality
(i.e. one*s subjective feeling of being correct does not match with one*s
actual performance) may play a crucial role in pathological decision-making
typically seen in psychiatric disorders. Indeed, in a recent review we found
evidence for confidence abnormalities across a wide range of psychiatric
disorders, showing strong evidence for a decline in confidence in (sub)clinical
OCD. Multiple studies have shown a decline in confidence both in situations
where patients engage in typical OCD behavior, are in a neutral situations or
in a OCD-relevant context. Lastly, this review revealed a robust association
between confidence abnormalities and the severity of psychiatric symptom.

In the current study we want to further explore confidence disfunctionality in
OCD subjects by studying confidence in various contexts and as a more global
construct:

Confidence is not a unitary construct, since confidence abnormalities are
differently expressed in various contexts. Therefore, the role of context in
confidence abnormalities should be further delineated. For example, it is
possible that confidence abnormalities differ in strength when patients are in
a context related to their symptoms. Moreover, in the real world, we have to
adapt to inconsistent feedback and a volatile, ever-changing, environment and
OCD patients have shown difficulties with adapting to these types of
situations. Learning under these unstable conditions is thought to be more
reliant on well calibrated confidence judgments. Therefore, in this study, we
want to explore the relationship between learning behavior and confidence
levels in a volatile environment. Futhermore, we want to investigate whether
OCD patients show irregularities in using their confidence judgments for
regulating their behavior (i.e. metacognitive control). Lastly, global beliefs
about our competence have a role in our higher-order behavioral control, as
they influence our motivation and goals. Distortions in global self-belief have
been related with various psychiatric disorders. However, in OCD there is no
knowledge on the mechanisms that form global confidence levels and how they
relate to
local confidence levels in situations with and without immediate feedback.

Our objective is to study confidence abnormalities in OCD. We want to study:

1) Confidence abnormalitites in a symptom-related versus a neutral context,
2) Llearning-confidence coupling in a volatile environment in OCD,
3) Metacognitive monitoring (i.e. using confidence for behavioral regulation)
via changes of mind in OCD,
4) Global self-confidence and its* relationship to local confidence judgments
in OCD.

To investigate our main objectives we will use a cross-sectional study design
testing behavioral outcome measures using various computerized tasks in 30 OCD
patients and 30 healthy control (HC) subjects. The inclusion of a healthy
control group is critical to relate observed behavioral outcome measures in the
patient group with a group without psychiatric disorders. These groups will be
matches on age, sex and educational level and compared to each other. All
groups will undergo the same behavioral cognitive paradigms. These outcome
measures will be compared within the groups (i.e. related to symptom severity)
and between groups.

The duration of the study is 4 hours per participant: the computer tasks will
have a total duration of 2.5 hours and assessing questionnaires with have a
total duration of 1.5 hour.

The burden of the study entails a single visit of 4 hours of time
participation, in which the participants perform computer tasks and fill in
questionnaires. This study entails no risks and no physical discomfort. There
will be no direct clinical benefit for the participants of this study, however,
this study is expected to result in increased insight in the behavioral
mechanisms of confidence abnormalities in OCD, which will contribute to the
development of treatment alternatives, allowing for personalized therapies
focusing on individual deficits in disorder-specific context.