Behaviour Research and Therapy 39 (2001) 913–927www.elsevier.com/locate/bratMemory and memory confidence in obsessive–compulsivedisorderDavid F. Tolina,*, Jonathan S. Abramowitzb, Bartholomew D. Brigidic,Nader Amird, Gordon P. Streeta, Edna B. FoaaaAnxiety Disorders Center, Institute of Living, 400 Washington Street, Hartford, CA 06106, USAbCenter for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania,Philadelphia, PA 19104, USAcDepartment of Psychology, University of Vermont, VT, USAdDepartment of Psychology, University of Georgia, GA, USAReceived in revised form 9 May 2000AbstractPathological doubt, often found in individuals with obsessive–compulsive disorder (OCD), has beentheoretically linked to memory deficits, but empirical evidence for such deficits has been mixed. In contrast,many studies suggest that individuals with OCD have low confidence in their memories. The present studyaimed to build upon previous research by measuring memory accuracy and confidence in OCD usingecologically valid, idiographically-selected stimuli. Individuals with OCD (OCs), anxious controls (ACs),and nonanxious controls (NACs) were exposed to a set of objects that the OCs had identified as safe,unsafe, or neutral. Participants were then asked to recall as many objects as possible and to rate theirconfidence in each memory. This process was repeated 6 times, using the same stimuli for each trial.Contrary to hypothesis, no group differences emerged in memory accuracy. However, OCs’ memory confi-dence for unsafe objects showed a progressive decline over repeated trials. This pattern was not observedamong NACs or ACs. Furthermore, OCs with primary checking reported lower confidence in long-termmemory than did OCs without primary checking. These results suggest that when OCs are repeatedlyexposed to threat-related stimuli (such as repeated checking), their level of confidence in rememberingthese stimuli paradoxically decreases. 2001 Elsevier Science Ltd. All rights reserved.Keywords: Obsessive-compulsive disorder; Memory; Confidence; Cognition* Corresponding author. Anxiety Disorders Center, Institute of Living, 400 Washington Street, Hartford, CT 06106, USA.0005-7967/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved.PII: S0005-7967(00)00064-4914 D.F. Tolin et al. / Behaviour Research and Therapy 39 (2001) 913–9271. Memory and confidence biases in OCDPathological doubt is often observed in individuals with OCD (OCs; e.g., Rasmussen & Eisen,1989). Reed (1985) suggested that OCD-related doubt reflects uncertainty about the properties ofa stimulus, situation, or action. For example, OCs frequently report uncertainty about whetherthey have performed actions correctly, have committed infractions, have contacted contaminants,etc. In an attempt to reduce their doubt, OCs are likely to engage in compulsive behaviors suchas checking, washing, assurance-seeking, and repeating activities. Rachman and Hodgson (1980)posited a strong relationship between pathological doubt and checking rituals. In a similar vein,Rasmussen and Eisen (1992) proposed that although doubt can be found across the range of OCDsymptoms, it is “seen in its purest form” (p. 750) in patients with predominant checking rituals(e.g., driving around the block to ascertain that they did not run over anyone, returning home tomake sure that the front door is locked, and calling relatives to check that they have not beenharmed). One hypothesis about the source of doubt is that OCs have a general memory deficit(cf. Reed, 1977).Despite the intuitive appeal of a memory-deficit theory of OCD, empirical studies haveyielded mixed results. In one study, individuals with subclinical checking concerns showed nodifferences in memory for words, compared to non-checkers, but exhibited poorer recall forpreviously completed actions (Rubenstein, Peynircioglu, Chambless, & Pigott, 1993). This pat-tern appears stronger for checkers than for washers (Sher, Frost, Kushner, Crews, & Alexander,1989; Sher, Frost, & Otto, 1983). Furthermore, neuropsychological studies indicate that OCsshow deficits in nonverbal memory, compared to NACs (Boone, Ananth, Philpott, Kaur, &Djenderjian, 1991; Christensen, Kim, Dyksen, & Hoover, 1992; Cohen et al., 1996; Dirson,Bouvard, Cottraux, & Martin, 1995; Savage et al., 1996; Zielinski, Taylor, & Juzwin, 1991).Other investigations, however, have failed to find evidence of an overall memory deficit amongOCs (Abbruzzese, Bellodi, Ferri, & Scarone, 1993; Brown, Kosslyn, Breiter, Baer, & Jenike,1994; Foa, Amir, Gershuny, Molnar, & Kozak, 1997; MacDonald, Antony, MacLeod, &Richter, 1997; McNally & Kohlbeck, 1993). Thus, the literature is mixed regarding the pres-ence of a general memory deficit in OCD.An alternative to the general deficit hypothesis is the hypothesis that OCs have memory deficitsonly for threat-related stimuli or activities. For example, an individual who fears leaving the ovenon will exhibit poor memory for whether or not they had turned the oven off, but will shownormal memory performance for non-feared activities. The few studies investigating this hypoth-esis suggest a bias in the opposite direction, i.e., enhanced memory for threat-related information.Using threat-relevant and threat-irrelevant actions, Constans, Foa, Franklin and Mathews (1995)found that compared to NACs, OC checkers exhibited superior recall for previously completedactions, but only when those actions elicited anxiety. Recently, Radomsky and Rachman (1999)found similar results using a different paradigm. OC washers and NACs were asked to look ateveryday (neutral valence) objects, touched with either a clean cloth or one they were told was“probably dirty.” In a subsequent recall test, OCs recalled more “contaminated” objects than“clean” objects, and recalled fewer “clean” objects than did NACs. Thus, there are two studiessuggesting that OCs show a specific bias toward remembering threat material relevant to OCD.A third hypothesis is that OCs suffer from low confidence in their memories which leads topathological doubt. Two studies have assessed memory confidence in OCs using a “reality moni-915D.F. Tolin et al. / Behaviour Research and Therapy 39 (2001) 913–927toring” task, in which participants are asked to determine whether they had engaged in, or merelyimagined engaging in, some action. McNally and Kohlbeck (1993) found that
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