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 Table of Contents  
BRIEF COMMUNICATION
Year : 2017  |  Volume : 22  |  Issue : 1  |  Page : 55-60

Visuospatial memory in patients with obsessive-compulsive disorder


1 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
2 Central Institute of Psychiatry, Ranchi, Jharkhand, India

Date of Web Publication14-Jul-2017

Correspondence Address:
Anamika Sahu
Room No. 4089, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_37_16

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  Abstract 

Background: Obsessive-compulsive disorder (OCD) is a clinically heterogeneous disorder. The previous studies have been conducted to elucidate visuospatial and nonverbal memory deficits in OCD patients. However, they did not reach equivocal results which need to be replicated. Objectives: The current study examines the visuospatial memory in male patients with OCD as compared to normal healthy controls. Materials and Methods: It is a cross-sectional hospital-based study, in which 15 OCD patients and 15 age-, sex-, and education-matched normal healthy controls were chosen by purposive sampling technique. All the participants underwent the Extended Complex Figure Test (ECFT) for the assessment of visuospatial memory. Results: Significant difference was found between OCD patients and normal healthy controls on various domains of ECFT. OCD patients performed poorly on copy condition (t = −4.46; P< 0.001), immediate recall (t = −5.20; P< 0.001), delayed recall (t = −5.18; P< 0.001), recognition task (P < 0.001), and matching task (P < 0.001) than the controls. Conclusion: Visuospatial memory was significantly impaired in OCD that included disturbed encoding and impaired visuospatial functioning. Hence, it is important to understand the significance of visuospatial memory in the pathophysiology for OCD diagnosis and therapeutic decision.

Keywords: Nonverbal memory, obsessive-compulsive disorder, visuospatial memory


How to cite this article:
Sahu A, Das B, Gupta P. Visuospatial memory in patients with obsessive-compulsive disorder. J Mental Health Hum Behav 2017;22:55-60

How to cite this URL:
Sahu A, Das B, Gupta P. Visuospatial memory in patients with obsessive-compulsive disorder. J Mental Health Hum Behav [serial online] 2017 [cited 2020 Dec 1];22:55-60. Available from: https://www.jmhhb.org/text.asp?2017/22/1/55/210707


  Introduction Top


Obsessive-compulsive disorder (OCD) is an often disabling condition, characterized by recurrent, intrusive thoughts (i.e., obsessions) and repetitive and stereotypical rituals (i.e., compulsions) that interfere with daily functions and cause significant distress.[1] OCD is considered twice as prevalent as schizophrenia or bipolar disorder, with a worldwide prevalence of 1.5%–3%.[2],[3]

Both structural and functional neuroimaging studies suggested the involvement of neurobiological abnormalities in the pathogenesis of OCD. A neurobiological model of OCD, i.e., frontostriatal model, provides evidence for an abnormal neuronal activity in the orbitofrontal cortex, anterior cingulate cortex, dorsolateral prefrontal cortex, caudate nucleus, and thalamus.[4],[5],[6] In addition, neuropsychological impairments in individual with OCD have been documented in previous studies, for example, problem with memory,[7],[8],[9],[10],[11],[12],[13],[14] visuospatial skills,[7],[15],[16],[17],[18],[19],[20],[21] visual attention,[14],[22] and selective executive functions.[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33]

Impaired visuospatial and nonverbal memory play a crucial role in the pathogenesis of OCD.[34],[35],[36] Visuospatial disturbance may stem from alteration of the right hemisphere, i.e. detected in neuroimaging studies of OCD [37] and organizational difficulties.[19] Furthermore, primary and acquired focal dysfunctions in the right hemisphere and the subcortex are implicated in the pathogenesis of OCD [38] which can produce isolated dysfunction in some components of visuospatial memory.[39]

Studies considering visuospatial memory in OCD did not reach equivocal results. Where the majority of studies have been verified impaired visuospatial memory in OCD, others were unable to find group differences.[9],[29],[32],[40] It could be because of variation in OCD symptomatology, comorbid conditions, variation of task presentation, etc. In the Indian context, few studies have been done on neuropsychological profile and its correlates in OCD.[41],[42],[43],[44],[45],[46] However, they were limited by assessing selective executive function only and even conducted primarily from a major center of South India. In addition, it was found that male patients scored worse than female patients on copy organization as measured by Rey–Osterrieth metric.[47] Whereas, OCD samples with more male patients performed significantly better on verbal and visuospatial working memory.[23] Thus, further research is needed to corroborate visuospatial memory assessments revealing inconclusive patterns of impairments among patients with OCD that can prove to be an important avenue in better understanding and treatment of OCD. In view of this information, we aimed to study visuospatial memory in male patients with OCD.


  Materials and Methods Top


Participants

A total of 30 patients, 15 diagnosed with OCD-contamination subtype and 15 normal healthy controls, were participated in the study. Diagnosis of OCD was made according to the International Classification of Diseases-10/DCR criteria that were confirmed by consultant psychiatrists of Central Institute of Psychiatry (CIP), Ranchi, India, where the study was conducted. Inclusion criteria required all participants to be male aged between 18 and 50 years, with minimum 8 years of formal education, and intelligence quotient (IQ) >80. Patients were excluded from participating in this study based on the exclusion criteria, i.e. any comorbid psychiatric illness except mild to moderate level of depression, history of major medical condition, obtained score < 7 and >31 on Yale–

Brown Obsessive-compulsive Scale (Y-BOCS), Hamilton Rating Scale for Depression-17 (HAM-D) score >17. Healthy controls were excluded from participation if they had psychiatry illness or neurological disorder, substance abuse, major medical condition, and score >3 on the General Health Questionnaire-12 (GHQ-12).

Assessments

Clinical assessment

Y-BOCS,[48] HAM-D 17,[49] and Hamilton Rating Scale for Anxiety-14 (HAM-A)[50] were administered to assess current psychopathology and severity of OCD, depression, and anxiety, respectively. In addition, healthy controls were rated on GHQ-12.[51]

Assessment of visuospatial memory

The Extended Complex Figure Test (ECFT) is developed by Fastenau and Manning in 1992.[52] The Rey–Osterrieth Figure Test (ROFT) has three domains to assess visuospatial memory, i.e., copy of a complex figure, immediate recall after 4 min, and delayed recall after 20 min. Unlike ROFT, ECFT included recognition and matching component with copy, immediate recall, delayed recall which allows the clinician to distinguish perceptual operations and encoding processes from constructional skills and retrieval process, respectively. Age-stratified norms are provided for children (ages 6–18) and adults (ages 19–85) with good reliability and validity.

Procedures

Patients and healthy controls fulfilling the selection criteria were approached. After the informed consent, basic demographic information, and clinical characteristics, the evaluation of visuospatial memory was done. Psychiatric interviews were conducted by a trained psychiatrist, and visuospatial memory tests were administered by a trained clinical psychologist. On visuospatial memory task, participants were instructed to copy the ECFT figure with color pencils and subsequently after 3 min to draw what they remembered immediately (without intervening distraction), followed by 20-min delayed recall (other tests or interview were administered during this delay). After delayed recall, recognition and matching tasks were completed. Each interview session took approximately 40–50 min and cases were offered periodic breaks during testing. Controls for the study were unrelated attendants of patients, consenting staff members, employees of institute, and individuals from the community.

Data analysis

The data were analyzed using SPSS version 12.0 (SPSS, Chicago, IL, USA). Variables were first examined for normality using Shapiro–Wilk test. Comparison of demographic characteristics and visuospatial domains between clinical and control cases was done using independent sample t-test or Chi-square and Fisher's exact statistics as appropriate. In addition, Pearson bivariate correlation was used to identify correlations among the subdomains of Y-BOCS, HAM-A, HAM-D, and ECFT. Statistical significance was set at P< 0.05 and all tests were two-tailed.

Ethical considerations

Ethical approval for the study was obtained from the Ethics Committee of CIP and written informed consent was taken from all patients before participation.


  Results Top


[Table 1], depicting demographic profile of sample, shows that both groups were homogeneous regarding marital status (P = 0.27), occupation (P = 0.56), religion (P = 0.31), socioeconomic status (P = 1.0), and residence (P = 0.33), and the two groups were well matched for age (t = −1.09; P= 0.29), education (t = −1.94; P= 0.062), and verbal IQ (t = −1.34; P= 0.019).
Table 1: Demographic characteristics of patients with obsessive-compulsive disorder and healthy controls

Click here to view


[Table 2] shows the clinical profile of OCD patients. We can see that the mean age of onset of OCD in the patient group was 21.6 (standard deviation [SD] =7.47) years, and mean duration of illness was 5.8 (SD = 5.03) years. The mean score of Y-BOCS (23.20 ± 6.79) showed a significant presence of OCD with a higher mean score of obsession (12.40 ± 3.87) as compared to compulsion (10.80 ± 3.6). HAM-D score (8.9 ± 3.04) indicates the presence of minor depression. None of our patients had a high score HAM-A (10.67 ± 4.56) indicating the absence of anxiety among patients.
Table 2: Clinical profile of patients with obsessive-compulsive disorder group (n=15)

Click here to view


Significant between-group difference on ECFT was found as assessment of visuospatial memory [Table 3]. Our patients performed significantly worse than the controls in all 5 conditions of the test, for example, they copied the complex figure less accurately and at incorrect place (t = −4.457; P < 0.001), they reproduced it less accurately in the immediate recall (t = −5.20; P< 0.001), delayed recall (t = −5.18; P < 0.001), they recognized and matched incorrect answer on recognition task (t = −6.49; P< 0.001) and matching task (= 5.35; P < 0.001).
Table 3: Group comparison between obsessive-compulsive disorder patients and control groups on subdomains of the Extended Complex Figure Test

Click here to view


In the OCD group, the Y-BOCS, HAM-A, and HAM-D did not correlate with any subdomain of visuospatial memory except a significant negative correlation between the immediate recall and HAM-D (r = −0.562, P< 0.05) [Table 4].
Table 4: Pearson correlation coefficient among the clinical scales and subdomain of the Extended Complex Figure Test

Click here to view



  Discussion Top


The findings from our study reveal that patients with OCD performed worse than healthy controls on all the subdomains of ECFT, a measure of visuospatial memory. In other words, OCD patient copied and recalled the complex figure less accurately than the controls and took more time to copy and recall the figure that indicates poor performance on visual-spatial constructive abilities (copy a complex figure), visual memory (immediate recall), ability to retain visual-spatial material (delayed recall), adequacy of visual-spatial encoding processes (recognition), and visual-perceptual function (matching). Thus, the primary difficulty appeared to involve the ability to encode information from the copy condition. In addition, these impairments took place after controlled effects of age, education, intelligence, sociodemographic profile, and depression severity.[53]

Our finding has an agreement with the majority of studies that concluded impaired visuospatial memory in patients with OCD.[19],[20],[37],[54],[55],[56],[57],[58],[59] One study reported impairment in visuospatial analysis and synthesis, immediate visual recall, and visual discrimination in OCD patient.[15] Whereas other studies found that OCD patients show a specific pattern of spatial memory dysfunction that might occur with the limited verbal mediation of stimuli.[32],[60] Purcell et al.[32] compared thirty OCD participants, thirty patients with panic disorder, twenty unipolar depressive patients, and thirty healthy controls on a computerized neurocognitive battery. They concluded that on one hand, OCD patients had most pronounced visuospatial memory deficits and, on the other hand, they were similar to other psychiatric patients on a measure of nonverbal memory.

Recently, a study conducted by Tükel et al.[61] suggested that OCD patients performed significantly worse than the controls on the Benton's Line Orientation and the Wechsler Adult Intelligence Scale-R Block Design subtest (WAIS-R-BD), indicated deficits in visuoperceptual and visuoconstructional tasks. Vandborg et al.[53] have also documented group differences on the three conditions of the Rey Complex Figure Test (RCFT-copy, immediate recall, and delayed recall), a measure of visuospatial memory and organizational skills. In addition, effect sizes on between-group differences on the RCFT reported as moderate. A meta-analysis showed a small effect size for the copy component of the RCFT (d = −0.24) and for the visuospatial domain (d = −0.35) as well.[23]

Few longitudinal studies have also confirmed the persistent nature of visuospatial or nonverbal memory dysfunctions in OCD patients.[55],[62],[63] It persists even after treatment. A 1-year naturalistic study has been done by Roh et al.[58] Authors assessed cognitive dysfunction in 21 patients with OCD after the start of medications. Assessment of cognitive function was carried out on three separate occasions, i.e., baseline, after 4 months, and after 1 year. Findings suggested that significant visuospatial or nonverbal memory impairments persisted in OCD patients despite clinical improvement at the 1-year follow-up assessment. In addition, at the time of 1-year assessment, they did not found an association between impairment in the accuracy of immediate and delayed recall with OCD symptoms. With respect to subclinical OCD and OCD spectrum disorder, these patients also displayed dysfunction in visual memory and of manipulating visuospatial information.[19]

In contrast, some of the concurring studies disagreed with the visuospatial memory impairment in OCD per se. They argued that visuospatial memory dysfunction in OCD originates from organizational (executive) difficulties. Because of failure to use efficient executive strategies (organizational strategies) during encoding of the figure at the initial phase, i.e., copy the RCFT figure, OCD patients demonstrated reduced immediate and delayed recall.[19],[20],[28],[56] Savage et al.[19] proposed that dysfunction in visuospatial memory was mediated by impaired organizational strategies in OCD patients, i.e., secondary to impaired executive strategies during learning. Shin et al.[64] have examined the frontal activity (measured as electroencephalogram alpha power), correlates with visuospatial functions (as measured by RCFT) in OCD. They found a correlation between greater left frontal activation (decreased alpha power) with a poorer RCFT copy score and greater right frontal activation with a better copy score. This finding supports the notion that visuospatial dysfunction in OCD is not in the visuospatial memory per se, however, mediated by executive function deficit. In his study, Moritz et al.[40] have explored the specific elementary and complex visuospatial and nonverbal memory impairments in patients with OCD (n = 71), psychiatric control (n = 33), and healthy participants (n = 30) at two time-points (prior and subsequent to psychiatric treatment) to know the trait or state characteristics of dysfunction. In results, they did not find impaired visuospatial component in OCD patients except visuoconstruction impairment as measured by visuospatial transformation and block design performance.

On correlation analysis, it was found that the lower score on immediate recall task had a significant and negative correlation with the HAM-D score. This indicates that the severity of depression is associated with reduced immediate recall. Patients with elevated HDRS scores displayed performance deficits relative to OCD patients with low HDRS and controls.[29]

Our study findings summarized that the patients with OCD might suffer from impaired visuospatial memory and organizational skills in their everyday life that worsen OCD symptoms. Neuropsychological model also explained that impaired executive function and memory in OCD exacerbate the illness. With the help of cognitive assessments, clinician can formulate direct cognitive rehabilitation for the deficit areas that can improve visuospatial memory functions and reduce OCD symptoms as well.[65]

Furthermore, the findings of the study should be contextualized in terms of the strengths and limitations. The strength of the study includes assessing visuospatial memory by an extended form of RCFT. Some of the important limitations of our study include a small sample size with only male representation and a single measure of visuospatial memory. Furthermore, our patients were on psychotropic medication which could affect the cognition of patients. Future research needs to adapt more sophisticated neuropsychological probes that can better define elementary visuospatial deficits or the involvement of organizational strategies in it.


  Conclusion Top


To summarize the current findings, OCD patients learned significantly less information during the figure copy and found significantly impaired visuospatial functioning. Hence, it can be concluded that assessment of the various deficit areas of visuospatial memory in OCD and its incorporation into the management plan are an emerging area to be studied.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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