Severity of subjective cognitive impairment in patients with obsessive-compulsive disorder and depression

Reduced Subjective Cognitive Concerns With Neurobehavioral Therapy in Functional Seizures and Traumatic Brain Injury

OBJECTIVE

Functional seizures are common among people with traumatic brain injury (TBI). Subjective cognitive concerns refer to a person's own perception of problems with cognitive functioning in everyday life. The authors investigated the presence and correlates of subjective cognitive concerns and the response to neurobehavioral therapy among adults with TBI and functional seizures (TBI+FS group).

METHODS

In this observational study, participants in the TBI+FS group (N=47) completed a 12-session neurobehavioral therapy protocol for seizures, while participants in the comparison group (TBI without seizures) (N=50) received usual treatment. Subjective cognitive concerns, objective cognition, mental health, and quality of life were assessed before and after treatment. Data collection occurred from 2018 to 2022.

RESULTS

Baseline subjective cognitive concerns were reported for 37 (79%) participants in the TBI+FS group and 20 (40%) participants in the comparison group. In a multivariable regression model in the TBI+FS group, baseline global mental health (β=-0.97) and obsessive-compulsive symptoms (β=-1.01) were associated with subjective cognitive concerns at baseline. The TBI+FS group had fewer subjective cognitive concerns after treatment (η2=0.09), whereas the TBI comparison group showed a nonsignificant increase in subjective cognitive concerns.

CONCLUSIONS

Subjective cognitive concerns are common among people with TBI and functional seizures and may be related to general mental health and obsessive-compulsive symptoms. Evidence-based neurobehavioral therapy for functional seizures is a reasonable treatment option to address such concerns in this population, although additional studies in culturally diverse samples are needed. In addition, people with functional seizures would likely benefit from rehabilitation specifically targeted toward cognitive functioning.

A neurotherapy protocol to remediate cognitive deficits after adjuvant chemotherapy: a pilot study

OBJECTIVES

Adjuvant chemotherapy for breast cancer is undeniably effective in increasing survival rates but many breast cancer survivors (BCS) exhibit side effects including nausea, fatigue, stress, and neurocognitive deficits, known as "chemobrain." This pilot study explored how neurotherapy, or EEG biofeedback, a non-pharmacological approach, improved neurocognitive, behavioral, and neurophysiological deficits associated with BCS who underwent chemotherapy.

METHODS

Subjects underwent 18 sessions of EEG biofeedback training, in which audio and visual feedback occurred with successful shifting of EEG patterns.

RESULTS

Quantitative EEG and assessment tests demonstrated neurophysiological, cognitive, and behavioral deficits in all nine subjects prior to training. EEG biofeedback resulted in significant improvements in neurophysiological, neurocognitive, and psychological functions in all nine subjects after training.

CONCLUSIONS

We propose that this intervention and related forms of EEG biofeedback have the potential to significantly alleviate common side effects of chemotherapy in BCS and therefore merits additional research attention.

Subjective cognitive functioning in relation to changes in levels of depression and anxiety in youth over 3 months of treatment

BACKGROUND

Subjective cognitive difficulties are common in mental illness and have a negative impact on role functioning. Little is understood about subjective cognition and the longitudinal relationship with depression and anxiety symptoms in young people.

AIMS

To examine the relationship between changes in levels of depression and anxiety and changes in subjective cognitive functioning over 3 months in help-seeking youth.

METHOD

This was a cohort study of 656 youth aged 12-25 years attending Australian headspace primary mental health services. Subjective changes in cognitive functioning (rated as better, same, worse) reported after 3 months of treatment was assessed using the Neuropsychological Symptom Self-Report. Multivariate multinomial logistic regression analysis was conducted to evaluate the impact of baseline levels of and changes in depression (nine-item Patient Health Questionnaire; PHQ9) and anxiety symptoms (seven-item Generalised Anxiety Disorder scale; GAD7) on changes in subjective cognitive function at follow-up while controlling for covariates.

RESULTS

With a one-point reduction in PHQ9 at follow-up, there was an estimated 11-18% increase in ratings of better subjective cognitive functioning at follow-up, relative to stable cognitive functioning. A one-point increase in PHQ9 from baseline to follow-up was associated with 7-14% increase in ratings of worse subjective cognitive functioning over 3 months, relative to stable cognitive functioning. A similar attenuated pattern of findings was observed for the GAD7.

CONCLUSIONS

A clear association exists between subjective cognitive functioning outcomes and changes in self-reported severity of affective symptoms in young people over the first 3 months of treatment. Understanding the timing and mechanisms of these associations is needed to tailor treatment.

Subjective Cognitive Impairment in 55-65-Year-Old Adults Is Associated with Negative Affective Symptoms, Neuroticism, and Poor Quality of Life

Although subjective cognitive impairment (SCI) is increasingly recognized clinically and in research as a risk factor for mild cognitive impairment and dementia (particularly Alzheimer’s disease), it is etiologically heterogeneous and potentially treatable. Compared to mild cognitive impairment and Alzheimer’s disease, SCI however remains poorly characterized with debate continuing regarding its clinical relevance. The primary aim of this study was to improve the characterization of SCI within the general public by investigating functions sometimes omitted clinically or in research, namely visual attention-related information processing speed (RT) and its intra-individual variability (IIV_RT), general cognition, depression, anxiety, memory, quality of life (QOL), and neuroticism. Compared to individuals without SCI, those with SCI were more likely to reveal higher scores of anxiety, depression, and neuroticism and poorer perceived physical, psychological, and environmental QOL. Within-group analysis identified no significant relationships between any of the above variables for the non-SCI group whereas for the SCI group, poorer Cognitive Change Index scores were significantly correlated with slower RT, raised IIV_RT, poorer memory, negative affective symptoms, higher neuroticism scores, and poorer QOL. This indicates that reports of perceived memory changes in SCI can also be associated with other characteristics, namely objectively measured detrimental change in other aspects of brain function and behavior. This outcome emphasizes the importance of a multi-function approach to characterizing and understanding SCI. Thus, although the effect of RT and IIV_RT is not strong enough to differentiate SCI from non-SCI at group level, slowing and raised IIV_RT do appear to characterize some people with SCI.

Subjective cognitive function in hoarding disorder

The aim of the present study was to examine subjective cognitive impairment among adult patients with hoarding disorder (HD). Eighty-three patients with HD and 46 age- and gender-matched healthy control (HC) participants received a diagnostic interview and completed measures of subjective cognitive functioning and motivations for saving behavior, as well as measures of hoarding severity, depression, anxiety, stress, and obsessive-compulsive disorder (OCD) symptoms. The HD group reported more impairment than did the HC group in domains of memory, distractibility, blunders, memory for names, and inattention. These differences generally remained significant when controlling for comorbid symptoms. In the HD group, the degree of cognitive impairment was significantly correlated with severity of saving and acquiring behaviors, although results were attenuated when controlling for comorbid symptoms (overall HD severity, but not saving behavior specifically, remained significantly correlated with cognitive impairment). Subjective cognitive impairment was further associated with a desire to save possessions in order to avoid forgetting, and these results remained significant when controlling for comorbid symptoms. These results comport with current behavioral models of HD that emphasize decision-making deficits, as well as clinician observations suggestive of impaired cognitive function, and complement a growing body of neuropsychological testing studies.

Prospective memory in obsessive compulsive disorder

Studies on the nature and extent of prospective memory impairment in patients with obsessive-compulsive disorder are relatively scarce. The present study examined prospective memory in patients with obsessive-compulsive disorder in comparison to patients with schizophrenia and healthy controls. Prospective memory was assessed using Memory for Intentions Screening Test (MIST). Further, the participants were administered Delis-Kaplan Executive Function System Tower Test, Wisconsin Card Sorting Test, and Stroop Test for assessing their planning ability, mental flexibility and cognitive inhibition, respectively. Monitoring was assessed by frequency of clock checking. Results indicated that as compared to healthy controls, the patients with obsessive-compulsive disorder performed poorly on both time- and event-based prospective memory tasks, whereas, patients with schizophrenia performed poorly on time-based prospective memory task only. Further, both the patient groups had comparable performance across time- and event-based tasks. Results of error analysis indicated that patients with obsessive-compulsive disorder mainly committed no response and task substitution errors, whereas patients with schizophrenia committed no response errors. Except monitoring, none of the neurocognitive variables correlated with time or event-based prospective memory in any group. The findings are discussed in the light of their implications for retraining of prospective memory deficits in patients with obsessive-compulsive disorder and schizophrenia.

Self-Reported Cognitive Biases Are Equally Present in Patients Diagnosed With Psychotic Versus Nonpsychotic Disorders

We investigated the relation between subjective cognitive biases measured with the Dutch Davos Assessment of Cognitive Biases (DACOBS-NL) and (1) the presence of a psychotic versus nonpsychotic psychiatric disorder, (2) the current dose of antipsychotic medication and current psychotic symptoms, and (3) the Personality Inventory for the DSM-5 (PID-5) Psychoticism personality trait. Results showed that DACOBS-NL subjective cognitive biases (1) were equally present in patients diagnosed with nonpsychotic disorders compared with patients with a psychotic disorder, (2) could not be explained by the current dose of antipsychotic medication, nor by current psychotic symptoms, and (3) significantly correlated with all PID-5 Personality domains. Moreover, in predicting membership of the psychotic versus nonpsychotic psychiatric disorder group, the addition of the PID-5 domains in step 2 rendered the contribution of the DACOBS-NL subjective cognitive biases in step 1 nonsignificant. Further research is needed to clarify the interplay between cognitive biases and aberrant salience in the prediction of psychotic disorders.

Graph-theoretical analysis of resting-state fMRI in pediatric obsessive-compulsive disorder

BACKGROUND

fMRI graph theory reveals resting-state brain networks, but has never been used in pediatric OCD.

METHODS

Whole-brain resting-state fMRI was acquired at 3T from 21 children with OCD and 20 age-matched healthy controls. BOLD connectivity was analyzed yielding global and local graph-theory metrics across 100 child-based functional nodes. We also compared local metrics between groups in frontopolar, supplementary motor, and sensorimotor cortices, regions implicated in recent neuroimaging and/or brain stimulation treatment studies in OCD.

RESULTS

As in adults, the global metric small-worldness was significantly (P<0.05) lower in patients than controls, by 13.5% (%mean difference=100%X(OCD mean - control mean)/control mean). This suggests less efficient information transfer in patients. In addition, modularity was lower in OCD (15.1%, P<0.01), suggesting less granular - or differently organized - functional brain parcellation. Higher clustering coefficients (23.9-32.4%, P<0.05) were observed in patients in frontopolar, supplementary motor, sensorimotor, and cortices with lower betweenness centrality (-63.6%, P<0.01) at one frontopolar site. These findings are consistent with more locally intensive connectivity or less interaction with other brain regions at these sites.

LIMITATIONS

Relatively large node size; relatively small sample size, comorbidities in some patients.

CONCLUSIONS

Pediatric OCD patients demonstrate aberrant global and local resting-state network connectivity topologies compared to healthy children. Local results accord with recent views of OCD as a disorder with sensorimotor component.

The nature of prospective memory deficit in patients with obsessive-compulsive disorder

We comprehensively examined prospective memory (PM) performance in patients with obsessive-compulsive disorder (OCD), and explored the cognitive and psychopathological correlates of PM in this clinical population. Fifty-eight OCD patients and 58 healthy controls were assessed with computer-based PM tasks and related neurocognitive functions, and the participants also reported frequency of PM failures and compulsive behaviours in daily life. OCD patients had intact activity-based PM performance but had lower accuracy in time-based PM and longer reaction time to event-based PM cues compared to healthy controls. Among the neurocognitive functions, both the WCST (perseverative error) and the letter number span correlated with time-based PM. OCD patients reported similar number of PM failures in daily life as controls, which correlated with their intact event-based PM performance, suggesting a generally good insight into their PM functions. Neither clinician-assessed nor self-reported OCD symptoms correlated with PM performance. This study indicates that PM impairment tends to vary with the PM cue types in OCD patients. In addition, certain executive functions (i.e., mental shifting and updating) may contribute to time-based PM impairment in patients with OCD.

Cognitive dysfunction in postural tachycardia syndrome

Mental clouding is an almost universal complaint among patients with postural tachycardia syndrome (POTS) but remains poorly understood. Thus, we have determined whether POTS patients exhibit deficits during neuropsychological testing relative to healthy subjects. A comprehensive battery of validated neuropsychological tests was administered to 28 female POTS patients and 24 healthy subjects in a semi-recumbent position. Healthy subjects were matched to POTS patients on age and gender. Selective attention, a primary outcome measure, and cognitive processing speed were reduced in POTS patients compared with healthy subjects (Ruff 2&7 Speed t-score: 40±9 compared with 49±8; P=0.009; Symbol Digit Modalities Test t-score: 45±12 compared with 51±8; P=0.011). Measures of executive function were also lower in POTS patients (Trails B t-score: 46±8 compared with 52±8; P=0.007; Stroop Word Color t-score: 45±10 compared with 56±8; P=0.001), suggesting difficulties in tracking and mental flexibility. Measures of sustained attention, psychomotor speed, memory function or verbal fluency were not significantly different between groups. The present study provides evidence for deficits in selective attention and cognitive processing in patients with POTS, in the seated position when orthostatic stress is minimized. In contrast, other measures of cognitive function, including memory assessments, were not impaired in these patients, suggesting selectivity in these deficits. These findings provide new insight into the profile of cognitive dysfunction in POTS and provide the basis for further studies to identify clinical strategies to better manage the mental clouding associated with this condition.

Toxoplasma gondii and cognitive deficits in schizophrenia: an animal model perspective

Cognitive deficits are a core feature of schizophrenia. Epidemiological evidence indicates that microbial pathogens may contribute to cognitive impairment in patients with schizophrenia. Exposure to Toxoplasma gondii (T. gondii) has been associated with cognitive deficits in humans. However, the mechanisms whereby the parasite impacts cognition remain poorly understood. Animal models of T. gondii infection may aid in elucidating the underpinnings of cognitive dysfunction. Here, we (1) overview the literature on the association of T. gondii infection and cognitive impairment, (2) critically analyze current rodent models of cognitive deficits resulting from T. gondii infection, and (3) explore possible mechanisms whereby the parasite may affect cognitive function.

Obsessive-compulsive tendencies are related to indecisiveness and reliance on feedback in a neutral color judgment task

BACKGROUND AND OBJECTIVES

The present study was designed to test whether OC tendencies are associated with indecisiveness and increased need for objective feedback in vague decision situations. This hypothesis was tested using a neutral color judgment task that places minimal demands on working memory.

METHODS

Sixty-one participants completed several measures of OC symptoms and tendencies. Indecisiveness was tested on a novel computerized task in which participants can move along a continuum marked by two colors at the extreme ends and are instructed to choose the color they judge to be the exact mid-point on the continuum.

RESULTS

OC scores were positively correlated with indecisiveness on the task, as assessed by the amount of time it took participants to complete the task and the extent of their search through the color continuum. This association was most pronounced when feedback for performance was not routinely provided. Requests for feedback were also positively correlated with OC scores. OC scores were not associated with actual performance on the task (accuracy levels) or with confidence ratings.

LIMITATIONS

The study relies on non-clinical participants and the extent to which these results would extend to OCD patients in unknown. Some effects may be confounded by the fixed order in which the task phases were administered.

CONCLUSIONS

The findings support the hypothesis that OC tendencies are associated with general indecisiveness and reliance on external feedback.

Evidence of Impaired Event-Based Prospective Memory in Clinical Obsessive–Compulsive Checking

Based on findings from subclinical OCD checking samples (Cuttler & Graf, 2007; 2008), Cuttler and Graf (2009) suggested that checking may develop to compensate for prospective memory failures. The present study provides the first evidence of prospective memory problems in a clinical sample of OCD checkers (n = 26) compared to a group of healthy controls (n = 26). Consistent with earlier work with subclinical samples, the OCD checkers performed more poorly on an event-based, but not a time-based, prospective memory task. However, the OCD checkers did not report more subjective prospective memory failures than controls and their confidence in prospective memory accuracy was higher than that of controls. An explanation of the inconsistent findings with regard to metamemory in clinical and subclinical OCD checking is provided. Further research assessing both subjective memory performance and the strategies understood to support memory is needed to clarify the contribution of prospective memory to OCD checking.

Study of neurocognitive endophenotypes in drug-naïve obsessive-compulsive disorder patients, their first-degree relatives and healthy controls

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a debilitating heritable neuropsychiatric condition. Attempts to delineate genetic contributions in OCD have met with limited success, with an ongoing search for neurocognitive endophenotypes. In this study, an attempt has been made to study and compare the neurocognitive functioning of patients with OCD, their first-degree relatives (FDRs) and healthy controls.

METHOD

A cross-sectional design study was carried out with thirty dyads of patients with OCD, their FDRs and thirty matched healthy controls and screened using Mini International Neuropsychiatric Interview, Verbal Adult Intelligence Scale, Yale Brown Obsessive-Compulsive Scale, Montgomery Åsberg Depression Rating Scale, International Personality Disorder Examination (Anankastic personality scale).Tests of National Institute of Mental Health and Neurosciences Neuropsychological Battery were used to assess domains of attention, verbal memory, visual memory, set-shifting, response inhibition, planning and visuoconstructive abilities. spss version 14.0 was used for descriptive and analytical data analysis.

RESULTS

There were no statistically significant differences between patients with OCD and their FDRs on neurocognitive domains of delayed verbal recall, set-shifting, response inhibition and visuoconstructive abilities (P > 0.05) which were impaired compared with healthy controls. Significant differences (P < 0.05) on domains of attention, planning time and visual memory were noted between FDRs and patients.

CONCLUSION

The present study supports set-shifting and inhibitory control and proposes visuoconstructive abilities and delayed verbal recall as potential endophenotypes for OCD.

Cognitive Assessment Instrument of Obsessions and Compulsions (CAIOC-13) - a new 13-item scale for evaluating functional impairment associated with OCD

The Cognitive Assessment Instrument of Obsessions and Compulsions (CAIOC) was designed as a novel instrument for clinicians to assess the main cognitive and executive impairments that are hypothesized to underpin the impact of obsessive-compulsive symptoms on functioning in patients with obsessive-compulsive disorder (OCD). Initially, 18 items were selected based upon observation in the laboratory and clinical research setting, then refined to a definitive 13-item scale after excluding items due to statistical criteria. In a study involving two raters, 50 patients diagnosed with OCD were assessed using the self-rated and clinician-rated versions of the new scale. OCD patients' scores fell in the region of moderate severity on both clinician and self-rated versions of the CAIOC-13. Inter-rater reliability and Cronbach's alpha scores were satisfactory. Factor analysis indicated a one factor solution confirming its unidimensionality. Significantly higher scores in the OCD group compared to a depression group (n=31) and a healthy control group (n=55) were revealed. Scores on the clinician and self-rated versions of the 13-item CAIOC appear valid and reliable measures of the severity of functional impairment associated with OCD. Further validation, including research into the relationship of the CAIOC-13 with laboratory measures of cognitive impairment and evaluation of its sensitivity is indicated.

Cognitive functioning in a population-based sample of young adults with anxiety disorders

OBJECTIVE

Cognitive functioning in anxiety disorders has received little investigation, particularly among young adults and in non-clinical samples. The present study examined cognitive functioning in a population-based sample of young adults with anxiety disorders in comparison to healthy peers.

METHODS

A population-based sample of 21-35-year-olds with a lifetime history of anxiety disorders (n=75) and a random sample of healthy controls (n=71) derived from the same population were compared in terms of performance in neuropsychological tests measuring verbal and visual short-term memory, verbal long-term memory, attention, psychomotor processing speed, and executive functioning.

RESULTS

In general, young adults with anxiety disorders did not have major cognitive impairments when compared to healthy peers. When participants with anxiety disorder in remission were excluded, persons with current anxiety disorder scored lower in visual working memory tests. Current psychotropic medication use and low current psychosocial functioning associated with deficits in executive functioning, psychomotor processing speed, and visual short-term memory.

CONCLUSION

Lifetime history of anxiety disorders is not associated with cognitive impairment among young adults in the general population. However, among persons with anxiety disorders, current psychotropic medication use and low psychosocial functioning, indicating more severe symptoms, may associate with cognitive impairments.

Comparable performance of patients with obsessive-compulsive disorder (OCD) and healthy controls for verbal and nonverbal memory accuracy and confidence: time to forget the forgetfulness hypothesis of OCD?

The memory deficit or forgetfulness hypothesis of obsessive-compulsive disorder (OCD) has received considerable attention and empirical effort over the past decades. The present study aimed to provide a fair test of its various formulations: (1) memory dysfunction in OCD is ubiquitous, that is, manifests irrespective of modality and material; (2) memory dysfunction is found for nonverbal but not verbal material, (3) memory dysfunction is secondary to executive impairment; and (4) memory dysfunction affects meta-memory rather than memory accuracy. Participants comprised 43 OCD patients and 46 healthy controls who were tested on the Picture Word Memory Test (PWMT), which provides several unconfounded parameters for nonverbal and verbal memory accuracy and confidence measures across different time-points. In addition, the Trail-Making Test B was administered to test assumption number 3. Replicating earlier work of our group, samples displayed similar performance on all indices. None of the different formulations of the memory deficit hypothesis were supported. In view of waning evidence for a global memory deficit in OCD, neuropsychological research on OCD should more thoroughly investigate moderators and triggers of occasional instances of impaired performance, particularly cognitive biases such as perfectionism and an inflated sense of responsibility.

No deficits in nonverbal memory, metamemory and internal as well as external source memory in obsessive-compulsive disorder (OCD)

A large body of literature suggests that some symptoms of obsessive-compulsive disorder (OCD) result from mnemonic dysfunctions. The present study tested various formulations of the memory deficit hypothesis considering important moderators, such as depression and response slowing. Thirty-two OCD patients and 32 healthy controls were presented verbal or nonverbal instructions for actions (e.g. simple gestures). These actions should either be performed or imagined. For recognition, previously presented as well as novel actions were displayed. Decisions had to be made whether an action was previously displayed (verbally vs. nonverbally) or not and whether an action was performed or imagined (internal source memory). Moreover, both judgments required confidence ratings. Groups did not differ in memory accuracy and metamemory for verbally presented material. Patients displayed some impairment for nonverbally presented material and imagined instructions, which, however, could be fully accounted for by response slowing and depressive symptoms. The study challenges the view that primary memory deficits underlie OCD or any of its subtypes. We claim that research should move forward from the mere study of objective impairment to the assessment of cognitive performance in conjunction with personality traits such as inflated responsibility.

Enhanced perceived responsibility decreases metamemory but not memory accuracy in obsessive–compulsive disorder (OCD)

Mixed findings have been obtained in prior research with respect to the presence and severity of memory and metamemory deficits in obsessive-compulsive disorder (OCD). We tested the hypothesis that experimentally induced increments of subjective responsibility would lead to a disproportionately strong decline of memory confidence and enhanced response latencies in OCD while leaving memory accuracy unaffected. Twenty-eight OCD patients and 28 healthy controls were presented a computerized memory test framed with two different scenarios. In the neutral scenario, the participant was requested to imagine purchasing 15 items from a do-it-yourself store. In the recognition phase, the 15 needed items were presented along with 15 distractor items. The participant was asked to decide whether items were on his or her shopping list or not, graded by subjective confidence. In the responsibility scenario, the general experimental setup was analogous except that the participant now had to envision that he or she was a helper in a region recently struck by an earthquake, dispatched to provide 15 urgently needed goods from a nearby town. In line with prior work by our group, samples did not differ in either condition on memory accuracy in a subsequent recognition task. As hypothesized, OCD participants were less certain in their responses for the high responsibility condition than controls. Whereas patients and controls did not differ in their subjective estimates for memorized items, patients expressed stronger doubt that their earthquake mission was successful. The findings indicate that low memory confidence in OCD may only be elicited in situations where perceived responsibility is high and that patients may share higher performance standards ("good is not good enough") than controls when perceived responsibility is inflated.

A check on the memory deficit hypothesis of obsessive-compulsive checking

A number of recent studies have challenged the hypothesis that patients with obsessive-compulsive disorder (OCD) display global memory deficits. An alleviated form of the memory deficit hypothesis posits that OCD patients share deficits to vividly recall memory episodes. According to the latter view, checking rituals can be understood as counter-productive coping strategies to "enrich" memory episodes in order to make them more distinctive. A source memory task was administered to 27 OCD (17 checkers) and 51 healthy participants. Along with confidence judgments, a remember-know procedure was employed to assess whether OCD patients display problems with conscious/vivid recollection. Patients with or without checking compulsions did not exhibit differences to controls on source memory accuracy and meta-memory. Patients forgot more self-generated items, which, however, was related to comorbid depressive but not OCD symptoms. Findings challenge the ubiquity of memory deficits in OCD. To account for the inconclusive pattern of results in the literature, it is suggested that patients mistrust their memories and adopt checking rituals only when perceived responsibility is inflated.