Pick a Card, Any Card: The

Relationship Between Anxiety,

Obsessive-Compulsive Symptoms and
Decision-Making
Angelina Leonello1 and Mairwen K. Jones2
1School of Psychology, The University of Sydney, New South Wales, Australia
2Discipline of Behavioural and Social Sciences in Health, The University of Sydney, New South Wales,
Australia

Specific deficits in decision-making have been demonstrated in patients with

obsessive-compulsive disorder (OCD). The experience of anxious arousal in
obsessive-compulsive (OC) patients has been posited to be responsible for dis-
rupting the cognitive processes that lead to efficacious decision-making (Sachdev
& Malhi, 2005). In spite of this, research has neglected to examine explicitly the
effect of anxiety on the relationship between decision-making and OCD. The cur-
rent study investigates whether decision-making differences on the Iowa Gambling
Task (IGT) occur as a function of OC symptomatology in a non-clinical sample
(n = 110). Participants were randomly allocated to either an anxiety condition
(n = 58) or control condition (n = 52). Anxious arousal was induced in the anx-
iety condition via an experimental manipulation prior to commencing the IGT.
Participants in the anxiety condition performed significantly worse than those in
the control group on the IGT. However, OC symptomatology did not significantly
predict IGT performance. The experience of anxiety did not significantly moderate
the relationship between OC symptomatology and IGT performance. These find-
ings indicate that decision-making differences do not occur as a function of OC
symptomatology in a non-clinical sample; however, they do suggest that the experi-
ence of anxiety significantly impairs decision-making performance. The theoretical
and practical applications of the findings are discussed.

 Keywords: OCD, anxiety, decision-making

Obsessive-compulsive disorder (OCD) is a psychological disorder characterised by

the presence of obsessions and/or compulsions (American Psychiatric Association
[APA], 2013). Crino, Slade, and Andrews (2005) identified the 12-month prevalence
of OCD in the Australian population as being approximately 0.6%. While OCD
affects a minority of the population, it carries a significant social and economic
burden that extends beyond individuals with the disorder to affect their partners
and families (Steketee, 1997). Consequently, research examining the pathogenesis, 27
nature, and treatment of this disorder is warranted. One area of enquiry has focused
on differences in decision-making in patients with OCD on cognitive tasks such as
the Iowa Gambling Task (IGT; Bechara, Damasio, Damasio, & Anderson, 1994).

Address for correspondence: Dr Mairwen Jones, Discipline of Behavioural and Social Sciences in Health, Faculty
of Health Sciences, The University of Sydney, PO Box 170, Lidcombe 1825 NSW, Australia.
Email: Mairwen.Jones@sydney.edu.au
Behaviour Change Volume 33 Number 1 2016 pp. 2743 
c The Author(s) 2016
doi 10.1017/bec.2016.1
 Angelina Leonello and Mairwen K. Jones

Researchers have suggested that deficits in efficacious decision-making, which are

commonly exhibited among people with OCD (Dittrich & Johansen, 2013), are the
underlying factors responsible for the obsessions and compulsions that characterise this
disorder (Starcke, Tuschen-Caffier, Markowitsch, & Brand, 2010). Specifically, it has
been suggested that OCD is a disorder of decision-making (Sachdev & Malhi, 2005,
p. 757). OCD patients have demonstrated significantly poorer decision-making capa-
bilities than their healthy counterparts on tasks such as the IGT and the Cambridge
Gambling Task (CGT; Rogers et al., 1999; e.g., Da Rocha, Alvarenga, Malloy-Diniz,
& Correa, 2011; Dittrich & Johansen, 2013; Starcke, Tuschen-Caffier, Markowitsch,
& Brand, 2010).
The CGT is commonly used as a measure of decision-making under conditions
of risk. In a recent study employing this task Dittrich and Johansen (2013) reported
that OC patients made significantly fewer rational decisions than control group par-
ticipants, signifying a predilection for risky decisions. Executive function deficits were
also found among the clinical group. The authors implicate emotional processing as a
possible explanation of the mechanisms that underlie these deficits.
Other researchers have attempted to delineate the differences in decision-making
performance on the basis of whether the decision in question is made under condi-
tions of risk or ambiguity. Starcke et al. (2010) investigated the relative performance
of OCD patients with a matched healthy control group on a battery of tasks that
tested executive function, as well as two decision-making tasks the IGT and
the Game of Dice Task (GDT; Brand et al., 2005). The IGT was posited to assess
decision-making under conditions of ambiguity, since it requires participants to select
a card from one of four decks that have stable but unstated win/loss contingencies.
Conversely, the GDT is a task with rules that are stated explicitly and would thus
reflect decision-making under conditions of risk. Starcke et al. (2010) found that OC
patients performed significantly more poorly overall than controls on the IGT only.
OC patients also exhibited a sustained preference over the five blocks of the task for
choosing cards from decks that yield higher immediate rewards but more severe long-
term losses. Furthermore, there was a significant interaction between group and block.
While the performance of the control group eventually improved over the course of
the task, improvements in performance among OC patients were significantly less
evident as the task progressed. Like Dittrich and Johansen (2013), the authors also
implicated emotional processing as a possible factor in the rationalisation of their
results.
However, unlike Dittrich and Johansen (2013), the authors claimed that this study
did not demonstrate the finding of differences in decision-making under conditions
of risk, given that Starcke et al. (2010) did not recognise that the IGT incorporates
risky decision-making. This is problematic, since while the rules that govern the decks
in the IGT are never made explicit, players must arrive at an implicit understanding
of which decks will yield higher profits in the long term to prosper in the task.
28 Additionally, they must then decide to use these learned contingencies to aid their
decision-making. Consequently, once the contingencies attached to each deck are
learned, the conditions under which a decision is made shift from ambiguous to risky.
Starcke et al. (2010) attributed the failure of OC patients to demonstrate the sustained
improvements exhibited by healthy controls on the IGT to the inability of OC patients
to learn the contingencies attached to each deck. However, they did not consider the
possibility that poor performance of OC patients on the later blocks of the IGT related
to an inherent deficit in rational decision-making under conditions of risk. Given

Behaviour Change
 Anxiety, OC Symptoms and Decision-Making

that studies such as those conducted by Dittrich and Johansen (2013), and Dittrich,
Johansen, Landro, and Fineberg (2011) have demonstrated that patients with OCD
exhibit differences in risky decision-making, interpreting the poor performance of OC
patients on the final blocks of the IGT as a failure to exhibit rational decision-making
under conditions of risk may be considered a valid and useful approach.
Additionally, these deficits have been demonstrated when OCD patients perfor-
mance has been compared with patients with other disorders such as panic disorder
(Cavedini et al., 2002) and schizophrenia (Cavallaro et al., 2003). Cavedini et al.
(2002) attribute the relatively poor performance of this patient group to an innate
preference among OC populations for immediate gratification, thereby accounting for
the lack of risk aversion exhibited by OC patients on decision-making tasks. Other
researchers have replicated the finding of decision-making impairments among OC
populations and have suggested that understanding the relationship between OCD
and decision-making impairments is an avenue that could lead to novel approaches
for treatment (e.g., Da Rocha et al., 2011).
While it is evident that the majority of research has reported a link between OCD
and decision-making impairments, results from some studies have not found this
relationship. For example, Nielen, Veltman, de Jong, Mulder, and den Boer (2002)
found no evidence of a significant difference in decision-making behaviour on the
IGT between an OC group and a control group that had been matched on gender,
age and intelligence. However, the authors note that risk-taking in the task was
significantly correlated with OCD severity, such that more severe patients exhibited
a greater propensity to make risky decisions. More recently, Boisseau, Thompson-
Brenner, Pratt, Farchione, and Barlow (2013) also reported no significant differences
in performance on the IGT between OCD patients and healthy controls. However,
the results of this study may be limited since it employed a relatively small sample of
participants comprising an OCD group (n = 19), a healthy control group (n = 21),
and a group of patients who had been diagnosed with an eating disorder (n = 17).
Additionally, all participants were female. Overall, the majority of studies published
to date have found evidence that indicate clear decision-making impairments among
OC populations.
A variety of theories have been proposed to explain the impairments in decision-
making exhibited by OC patients. Sachdev and Malhi (2005) suggest that differences
in decision-making occur as a result of the dysfunctional interaction between cognition
and emotion. Specifically, they assert that increased activation of the orbitofrontal
cortex (OFC) as a result of anxiety or arousal degrades the decision-making capability
of patients with OCD, while healthy patients do not exhibit increased activation to the
same degree under similar conditions of arousal. Furthermore, the efficacy of healthy
patients decision-making is not significantly degraded unless the anxiety experienced
surpasses a specific threshold. Dittrich and Johansen (2013) argue along similar lines.
It is perhaps surprising then that studies examining decision-making among OCD
populations have not, to our knowledge, included an explicit anxiety manipulation. 29
There have been studies that have demonstrated decision-making deficits among
individuals with high trait anxiety (e.g., De Visser et al., 2010; Miu, Heilman, &
Houser, 2008). The question of whether anxiety moderates the relationship between
OC symptoms and decision-making is one that will be addressed in the current study.
Since researchers have found executive functioning deficits that indicate orbitofrontal
impairment in nonclinical samples who score highly on OC measures (e.g., Spitznagel
& Suhr, 2002; Zhu et al., 2014), this study will employ a non-clinical sample.

Behaviour Change
 Angelina Leonello and Mairwen K. Jones

In order to determine whether anxiety moderates the relationship between OC

symptoms and decision-making, participants will be allocated into two groups; an
anxiety group who undergo an experimental manipulation to induce anxiety, and a
control group. Consistent with previous research it is hypothesised that significant
overall differences in the quality of decision-making will exist as a function of the
degree of self-reported OC symptoms. It is predicted that participants in the anxiety
condition will demonstrate more impaired decision-making on the IGT compared
to the control group. Studies such as Miu et al. (2008) have demonstrated decision-
making deficits among people who had higher levels of trait anxiety. It is hypothesised
that the detrimental effect of anxious arousal on decision-making will be evident
when anxiety is induced in individuals on a state level, given that the negative effect
of anxiety on broad cognitive performance has been demonstrated at both a trait and
state level (Derakshan & Eysenck, 2009).
The experience of anxiety is hypothesised to moderate the relationship between
decision-making and OC symptomatology, such that anxious arousal will significantly
degrade the performance of participants who score higher on OC measures, while it
will have a less marked effect on those who score lower on OC measures.
It is also predicted that participants with a greater degree of self-rated OC symptoms
will fail to exhibit the shift towards advantageous decision-making when contingen-
cies in the IGT are learned. This prediction arises as a result of past research that has
examined the differential performance of OC patients and controls when decisions are
made under conditions which have shifted from ambiguous to risky on the IGT (e.g.,
Dittrich & Johansen, 2013; Starcke et al., 2010). Furthermore, it is predicted that
participants in the anxiety condition will also demonstrate continuously poor perfor-
mance on the IGT, as it has been suggested that anxious arousal sustains impairments
in decision-making (Sachdev & Malhi, 2005).

Method
Ethical Considerations
Ethical approval was obtained from the University of Sydney Human Research Ethics
Committee.

Participants
One hundred and twenty students enrolled in a first-year psychology course at the
University of Sydney volunteered to participate in this study in exchange for course
credit. Participants were randomly allocated to either the anxiety or control group.
Exclusion criteria consisted of the experience of brain trauma that had been confirmed
previously by a medical professional or a reported history of drug and substance abuse.
The final sample consisted of 110 participants. It was comprised of 41 males
and 69 females whose ages ranged from 18 to 49 (M = 19.72, SD = 4.55). Of the
30 110 participants, 58 were allocated to the anxiety condition and 52 to the control
condition.

Materials/Apparatus
Demographic questionnaire. The demographic questionnaire consisted of items used
to ascertain the gender, age, handedness of participants, and whether they had been
diagnosed with a mental illness by a medical professional. Other items required par-
ticipants to identify whether they met the exclusion criteria outlined above.

Behaviour Change
 Anxiety, OC Symptoms and Decision-Making

Iowa Gambling Task (IGT; Bechara et al., 1994). The IGT consists of 100 trials
in which participants are required to choose a card from one of four decks. Two of the
decks yield high immediate rewards, but devastating long-term losses. The other two
decks yield more modest immediate rewards; however, the losses they deal in the long
term are much lower. Participants are informed that their aim is to gain the largest
possible return from a starting capital. The IGT is a measure of decision-making under
conditions that are initially ambiguous but that shift theoretically to risky once the
contingencies accompanying deck choices are learned.

Measures
Obsessive Compulsive Inventory Revised (OCI-R; Foa et al., 2002). The OCI-R
consists of 18 items that assess obsessions and a range of compulsions. Participants are
required to rate how much the experiences listed in the scale have caused them distress
in the last month on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely).
Scores can range from 0 to 72, where higher scores signify the likely presence of OCD.
The OCI-R has been judged to be psychometrically sound in a non-clinical sample,
yielding an internal consistency estimate of .88 (Hajcak, Huppert, Simons, & Foa,
2004).
Beck Depression Inventory Second Edition (BDI-II; Beck, Steer, & Brown,
1996). The BDI-II is a self-report measure consisting of 21 items that assess the
cognitive-affective and somatic symptoms of the disorder. Items consist of a series of
four self-evaluative statements that allow a participant to indicate whether they do
not experience the symptom at all, or whether they experience it to a mild, moderate,
or debilitating degree. Individual item scores range from 0 to 3, where higher scores
indicate greater symptom severity. Scores on the total scale can range from 0 to 63.
The BDI-II has been shown to be a valid and reliable tool for measuring depression
in non-clinical college samples, with an internal consistency estimate of .90 for the
total scale (Storch, Roberti, & Roth, 2004).
State-Trait Anxiety Inventory Form Y (STAI-Form Y; Spielberger, Gorsuch,
Lushene, Vagg, & Jacobs, 1983). The STAI-Form Y consists of a 40-item self-report
measure that assesses anxiety on the two dimensions that form its subscales the
state level (STAI-S) and the trait level (STAI-T). Participants are asked to indicate
the degree to which they endorse various statements relating to both their current and
their typical level of anxiety on a 4-point Likert scale ranging from 1 (not at all) to 4
(very much so). Approximately half of the items on the scale are reverse-scored. Scores
for each subscale may range from 20 to 80, while scores on the total STAI-Form Y
may range from 40 to 160. Reported internal consistency estimates of the measure
have been high, ranging from .86 to .95 (Spielberger et al., 1983).

Procedure 31
Participants completed the experiment in groups under the supervision of the first
author. Throughout testing, participants were not seated adjacent to one another in
order to preserve the integrity of the separate experimental conditions. In all sessions,
a digital video camera was set up in plain view of all participants as they entered
the room and completed consent forms. The experiment consisted of four stages:
questionnaire completion, anxiety manipulation, IGT completion and manipulation
check. The maximum duration of the experiment was 45 minutes.

Behaviour Change
 Angelina Leonello and Mairwen K. Jones

Questionnaire Completion.Participants completed the questionnaires on a computer.

The questionnaires were presented to all participants in the following fixed order:
OCI-R, BDI-II, STAI-S, and STAI-T.

Anxiety Manipulation. After questionnaire completion, those who had been ran-
domly allocated to the anxiety condition were redirected to an information screen
containing the following notice:

You will now be taking part in a portion of the study that deals with testing your thinking style.
We are interested in your ability to think quickly with limited time for preparation. Research has
shown that these skills are related to your decision-making ability. For this task you must quickly
prepare and then deliver a short speech about what you like and dislike about your body while
standing in front of a video camera that will record your speech. This speech will be delivered
immediately after you complete the decision-making task. It is very important that you think
about the speech you are about to give. This has been shown to improve performance on the
decision-making task. Once the timer reaches 0, please click the button that will appear below in
order to begin the decision-making task.

A timer appearing below the notice counted down 6.5 minutes, giving participants
adequate time to read the notice and prepare their speeches. This method of inducing
anxiety is based on the work of Phillips and Giancola (2008). Following the anxiety
manipulation, participants completed a post-manipulation anxiety check. This mea-
sure consisted of a rating scale ranging from 1 to 10 and served as one part of the
manipulation check. Participants in the anxiety condition were asked: How anxious
are you about delivering the 3 minute, videotaped speech you have prepared, on a
scale from 1 to 10 (1 being not at all anxious, 10 being very anxious)?

No Anxiety Manipulation. Participants who had been allocated to the control con-
dition were given the following notice and a timer that counted down 6 minutes, as
they had a significantly shorter block of text to read:

You will now experience a 6-minute waiting period before you begin the decision-making task.
Please remain silent during this time. When the 6 minutes are up, you can begin the decision-
making task by pressing the button that will appear below.

After the allotted time had elapsed, participants in the control condition were asked:
How would you rate your current level of anxiety on a scale from 1 to 10 (1 being not
at all anxious, 10 being very anxious)?

IGT completion. Participants in both conditions were redirected to the introduction

screen of the IGT after the on-screen timer had elapsed. Participants then completed
32 the IGT.

Manipulation check. Once all participants in the session had finished the decision-
making task, those who had been allocated to the anxiety condition were not required
to deliver their prepared speeches. However, these participants were asked to indicate
yes or no on a form that asked whether they had been convinced that they would
actually be required to deliver the videotaped speech. All participants then received
a written debrief.

Behaviour Change
 Anxiety, OC Symptoms and Decision-Making

Results
Data Preparation
Participants scores on clinical measures were treated as continuous independent
variables in the analysis.
Scores on the IGT formed the basis of the dependent variable and were computed
in two ways. First, a total IGT score was calculated by subtracting the number of choices
made from advantageous decks from the number of choices made from disadvantageous
decks throughout the entire task. Second, five block scores were calculated for each
participant by applying this method to every 20 rounds of the task. Thus, higher total
and block scores indicate more disadvantageous decision-making.
All statistical analyses were completed using IBM SPSS Statistics Version 22.

Demographic variables. Chi-squared tests of independence were used to determine

whether there were significant differences between participants in the anxiety and
control conditions based on most demographic grouping variables. There were no
significant participant differences between conditions for gender, 2 (1, N = 110) =
2.04, p =. 15; dominant hand, (1, N = 110) = 1.75, p = .19; diagnosis with a
mental illness, (1, N = 110) = .26, p = .61; reported medication or substance use
at the time of testing, (1, N = 110) < .01, p = .97. An independent samples t
test was used to examine whether participants in the anxiety and control conditions
differed in terms of age. No significant difference in age was found between the two
conditions, t(108) = .27, p = .79.

Clinical measures. Independent samples t tests were conducted between the anxiety
and control conditions for scores on the clinical measures. There were no significant
differences in mean scores on the OCI-R, the BDI-II, or the STAI-S between condi-
tions. However, there was a significant difference in the mean score on the STAI-T
between the anxiety and control conditions, t(108) = 2.03, p < .05. On average,
participants in the anxiety condition scored 4.04 points higher on the STAI-T than
those in the control condition. Given that it had been planned that the depression
and anxiety measures included in the questionnaire battery would be included as co-
variates in the main analysis, in line with the recommendation of Sachdev and Malhi
(2005), the between-condition difference in STAI-T scores was not considered prob-
lematic. Information regarding the distribution of participants between conditions on
the basis of demographic variables, as well as the means, standard deviations, ranges
of scores, and their associated t tests on the age of the current sample and their scores
on the clinical measures can be seen in Tables 1 and 2.

Manipulation checks. The first manipulation check consisted of self-report ratings

of anxiety on a 10-point scale. The mean rating of self-reported anxiety across all
participants was 4.55 (SD = 2.65). Participants in the anxiety condition had a mean
rating of 5.88 (SD = 2.35) and those in the control condition reported a mean rating 33
of 3.08 (SD = 2.14). An independent samples t test revealed a significant difference
in self-reported ratings of anxiety between the two conditions, t(108) = 6.52, p <
.001.
The second manipulation check consisted of a yes/no questionnaire completed by
participants in the anxiety condition. Participants were required to indicate whether
or not they believed the anxiety manipulation. Of the 58 participants who had been
allocated to the anxiety condition, 38% reported that they did not believe the anxiety

Behaviour Change
 Angelina Leonello and Mairwen K. Jones

TABLE 1
Distribution of Demographic Characteristics Between Conditions

Condition

Control Anxiety Total

n n N

Gender Female 29 40 69
Male 23 18 41
Hand Right 47 56 103
Left 5 2 7
Diagnosed with Yes 7 6 13
a mental illness No 45 52 97
Current medication Yes 10 11 21
or substance use No 42 47 89
Note: N = 110.

TABLE 2
Descriptive Statistics and Results of Independent Samples T Tests for Age and Clinical
Measures

Condition

Control Anxiety Total

Variable M (SD) Range M (SD) Range M (SD) Range t df

Age 19.60 (4.06) 1845 19.83 (4.99) 1849 19.72 (4.55) 1849 .27 108
OCI-R 18.81 (12.03) 165 19.40 (8.63) 336 19.12 (10.33) 165 .30 108
BDI-II 9.94 (7.86) 041 12.21 (7.82) 033 11.14 (7.88) 041 1.51 108
STAI-S 36.62 (11.21) 2180 38.91 (10.65) 2372 37.83 (10.93) 2180 1.10 108
STAI-T 41.17 (10.21) 2261 45.21 (10.59) 2169 43.30 (10.56) 2169 2.03 108

Note: M = mean; SD = standard deviation; df = degrees of freedom; N = 110. OCI-R = Obsessive

Compulsive Inventory Revised; BDI-II = Beck Depression Inventory Second Edition; STAI-S =
State-Trait Anxiety Inventory State Subscale; STAI-T = State-Trait Anxiety Inventory Trait
Subscale.

Significant at p < .05

manipulation. In spite of this occurrence, an independent samples t test revealed no

34 significant differences in self-rated anxiety between participants who believed the
manipulation and those who did not, t(56) = .85, p = .40. However, there was a
significant difference in global performance on the IGT as a function of whether or
not participants in the anxiety condition believed the manipulation, t(56) = 2.30,
p = .03. The mean score for participants who believed the anxiety manipulation (n =
36) was 22.11 (SD = 22.11; range = 2294) on the IGT, while participants in the
anxiety condition who did not believe the experimental manipulation (n = 22) had
a mean score of .45 (SD = 44.50; range = 100100) on this task.

Behaviour Change
 Anxiety, OC Symptoms and Decision-Making

TABLE 3
Descriptive Statistics of Score on the IGT Between Conditions

Condition

Control Anxiety Total

M (SD) Range M (SD) Range M (SD) Range

Block 1 2.23 (7.42) 2018 3.79 (8.86) 2020 3.05 (8.21) 2020
Block 2 1.69 (8.43) 2020 5.03 (10.32) 2020 3.45 (9.58) 2020
Block 3 .15 (10.75) 2020 3.10 (10.17) 2020 1.56 (10.53) 2020
Block 4 1.88 (10.41) 2020 1.38 (9.52) 2020 .16 (10.04) 2020
Block 5 2.69 (10.75) 2020 .24 (9.81) 2020 1.15 (10.33) 2020
Total Score .81 (37.65) 10086 13.55 (37.59) 100100 6.76 (38.13) 100100

Note: M= mean; SD = standard deviation; N = 110.

IGT performance. An independent samples t test revealed significant differences

in total score on the IGT between the anxiety and control conditions, t(108) =
2.00, p < .05. On average, participants in the anxiety condition scored 14.36 points
higher on the IGT than those in the control condition, indicating significantly poorer
performance overall. Table 3 depicts the mean performance of participants on the
blocks of the IGT, as well as global performance on the task.

Main Analysis
Global decision-making effects.A bivariate correlation analysis was used to examine
the relationships between variables of interest in general terms, and more specifically,
whether a relationship between OC symptoms and decision-making existed in the
current sample. A four-stage hierarchical regression analysis was conducted with total
IGT score as the dependent variable to determine whether the experience of anxiety
exerts a moderating influence on this relationship. Given that a significant relationship
between condition and global IGT performance had been observed in preliminary
analyses, it was decided that experimental condition would be entered as the first step
of the model. The other main independent variable of interest, OC symptoms, was
accounted for in step 2 when total OCI-R scores were entered into the model. Step 3
consisted of the entry of clinical covariates, to determine whether any relationships
between OC symptoms and anxiety with decision-making held when these covariates
were accounted for. Consequently, scores on the BDI-II, STAI-S, and the STAI-T
were entered into the model at this stage. The fourth and final step of the regression
model consisted of the entry of a computed interaction variable to assess whether the
experience of anxiety, as a result of the experimental manipulation, moderated the 35
relationship between OC symptoms and decision-making.

Testing of regression assumptions.Scatterplots of standardised residuals indicated

that assumptions of the independence of errors, linearity and homoscedasticity were
fulfilled for total IGT score. A histogram and normal probability plot of standardised
residuals confirmed that the assumption of normally distributed errors had also been
met.

Behaviour Change
 Angelina Leonello and Mairwen K. Jones

TABLE 4
Zero Order Correlations Between the Dependent Variable, the Main Independent Variables
and Other Predictors of Interest

1. 2. 3. 4. 5. 6.

1. OCI-R 1
2. Condition .03 1
3. BDI-II .36 .14 1
4. STAI-S .37 .11 .70 1
5. STAI-T .31 .19 .72 .71 1
6. Total IGT Score .10 .19 .02 .03 .02 1

Note: N = 110. OCI-R = Obsessive Compulsive Inventory Revised; BDI-II = Beck Depression
Inventory Second Edition; STAI-S = State-Trait Anxiety Inventory State Subscale; STAI-T =
State-Trait Anxiety Inventory Trait Subscale.

p < .05.

Bivariate correlations.The correlations between total IGT score and the indepen-
dent variables of interest are presented in Table 4. All of the clinical measures
were significantly, and positively, related. These positive correlations were partic-
ularly high among the measures of anxiety and depression and signified that mul-
ticollinearity may have presented an issue for the analysis planned. There was a
significant relationship between scores on the STAI-T measure and experimental
condition, as discussed above. Experimental condition was also significantly associ-
ated with total IGT score. The nature of this relationship has also been delineated
previously.
Analysis of the planned model. Model 1 of the hierarchical regression examined the
efficacy of assigned experimental condition as a predictor of global IGT performance.
It was found that experimental condition accounted for 3.6% of the variance in
total IGT score. This proportion of variance explained was significant, F(1,108) =
4.00, p < .05. This first model is a simple linear regression model and it represents
the relationship between experimental condition and total IGT score, which was
discussed in the section IGT performance. Participants scores on the OCI-R were
entered into the model at step 2. Together with experimental condition, scores on
the OCI-R accounted for 4.4% of the variance in total IGT score. This proportion
was not significant, F(2,107) = 2.44, p = .09. When participants scores on the BDI-
II, STAI-S and STAI-T were entered into the model at step 3 in order to account
for clinical covariates, the resulting model explained 5.4% of the variance in total
score on the IGT. This proportion was not significant, F(5,104) = 1.18, p = .32.
Although the reported bivariate correlations between clinical predictors signified a
potential problem of multicollinearity, tolerance statistics for individual predictors
36 were in the acceptable range. The interaction term was entered into the model in
the final step. The final model accounted for 5.6% of the variance in total IGT score;
this amount was not statistically significant, F(6,103) = 1.02, p = .42. A compre-
hensive account of regression coefficients and their associated t tests is presented in
Table 5.
Trends in decision-making. A repeated measures ANOVA was used in order to
examine whether trends in decision-making differed as a function of OC symptoms and

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 Anxiety, OC Symptoms and Decision-Making

TABLE 5
Hierarchical Regression Analysis for Variables Predicting Total IGT Score

t sr2 R R2 R 2

Step 1 .19 .04 .04

Condition .19 2.00 .04
Step 2 .21 .04 .01
Condition .19 2.00 .03
OCI-R .09 .94 .01
Step 3 .23 .05 .01
Condition .20 2.00 .04
OCI-R .13 1.26 .01
BDI-II .07 .47 <.01
STAI-S .08 .57 <.01
STAI-T .05 .32 <.01
Step 4 .24 .06 <.01
Condition .20 2.00 .04
OCI-R .17 1.31 .02
BDI-II .06 .43 <.01
STAI-S .08 .56 <.01
STAI-T .04 .26 <.01
Condition x OCI-R .06 .49 <.01

Note: N = 110. OCI-R = Obsessive Compulsive Inventory Revised; BDI-II = Beck Depression
Inventory Second Edition; STAI-S = State-Trait Anxiety Inventory State Subscale; STAI-T =
State-Trait Anxiety Inventory Trait Subscale.

p < .05.

the experience of anxiety. Experimental condition was entered as the between-subjects

variable and the five block scores that combine to form total IGT score constituted
the repeated measures factor. Participants scores on the OCI-R were treated as a
covariate. Of particular interest to the current study was whether fluctuations in
performance throughout the task interacted with experimental condition, when OC
symptomatology was controlled for as a covariate.
Testing of repeated measures ANOVA assumptions.The assumptions of a contin-
uous dependent variable and a categorical independent variable that consisted of at
least two independent groups were met. An examination of extreme values in the
dataset did not indicate that there were outliers present, and a histogram showed
that the distribution of the dependent variable appeared to be normal. However,
Mauchleys test was significant, indicating that the assumption of sphericity had been 37
violated, (9) = 22.96, p = .01. Consequently, the Huynh-Feldt correction was
utilised in analysis ( = .94). It is an epsilon correction that adjusts the degrees of
freedom in order to increase the critical value, thus countering the inflated type I
error rate that violations of sphericity may result in (Muller & Barton, 1989). The
Huynh-Feldt correction was chosen specifically as a result of the assertion of Girden
(1992) that when the Greenhouse-Geisser estimate of epsilon is greater than .75, the
Huynh-Feldt correction should be used.

Behaviour Change
 Angelina Leonello and Mairwen K. Jones

4
IGT Score

0 Control
Anxiety
-2

-4

-6
1 2 3 4 5
Block

FIGURE 1
Comparison of performance on the IGT by block across condition when OCI-R scores are
accounted for.
Analysis of the repeated measures ANOVA model. A graphical depiction of the dif-
ferential performance of the anxiety and control conditions across blocks of the IGT
when OCI-R scores are accounted for appears in Figure 1. There was a significant ef-
fect of block on IGT performance, such that participants scores consistently changed
across the blocks of the task, F(3.77,403.78) = 9.29, p < .001. There was no evidence
of a significant main effect of experimental condition, F(1,107) = 3.88, p = .051, or
OCI-R score, F(1,107) = .89, p = .35, on performance across blocks. The interaction
between block and experimental condition was not significant, F(3.77,403.78) = .31,
p = .86. Nor was the interaction between block and score on the OCI-R,
F(3.77,403.78) = .31, p = .86.
There was a significant linear trend in performance across blocks, F(1,107) =
23.44, p < .001. Performance on the IGT appeared to improve across all participants,
regardless of experimental condition and score on the OCI-R, as the blocks in the
task progressed. There were no other statistically significant trends within the main
block effect, or either of the block by OCI-R score or block by experimental condition
interaction effects.
A planned interaction contrast was conducted, examining whether the difference
in performance between the first two and final two blocks of the task differed between
the two experimental conditions when OCI-R score was controlled for. Blocks were
combined in this manner to determine whether the experience gained over the first
two blocks of the task exerted the same influence over decisions in the final two blocks
38
of the task in both groups. The differential performance of participants in the anxiety
and control conditions between the first and final two blocks of the IGT were not
significantly different from one another, F(1,85) = .33, p > .05.

Discussion
This study aimed to fill the gap in the literature addressing the relationship between
decision-making and the experience of OC symptoms by explicitly examining whether

Behaviour Change
 Anxiety, OC Symptoms and Decision-Making

anxious arousal moderated this relationship. It also aimed to investigate whether there
were differences in decision-making as a function of OC symptomatology in a non-
clinical sample.
The first hypothesis that significant differences in decision-making would be found
as a function of self-reported OC symptoms was not supported, since scores on the
OCI-R did not significantly predict IGT performance. The most straightforward inter-
pretation of this finding is that decision-making differences and the OFC abnormali-
ties posited to produce them (Lawrence, Jollant, ODaly, Zelaya, & Phillips, 2009) are
simply unrelated to OC symptomatology in non-clinical participants. Findings in this
area relating to impairments in decision-making on the IGT have typically occurred
when the performance of clinical patients is compared to that of healthy controls
(e.g., Cavedini et al., 2002; Da Rocha et al., 2011; Dittrich & Johansen, 2013; Star-
cke et al., 2010). Thus, while OCD symptoms may manifest to varying degrees across
clinical and non-clinical populations, there are features of the disorder that may be
specific to clinically diagnosable OCD. This accounts for findings of decision-making
deficits in OCD clinical populations (e.g., Cavallaro et al., 2003; Cavedini et al., 2002;
Da Rocha et al., 2011; Dittrich & Johansen, 2013), but inconsistent findings among
non-clinical student samples that score highly on OCD measures (e.g., Johansen &
Dittrich, 2013; Zhu et al., 2014).
In accordance with the second hypothesis, participants in the anxiety condition
demonstrated significantly more impaired performance on the IGT than controls.
High trait anxiety has been linked to impaired decision-making on the IGT (e.g.,
De Visser et al., 2010; Miu et al., 2008). Despite this, STAI-T scores and STAI-S
scores were not correlated with IGT performance in this study. However, it is assumed
that state anxiety levels changed as a result of the experimental manipulation, as
evidenced by significantly higher levels of self-reported anxiety among participants
in the anxiety condition following the manipulation. Furthermore, participants in
the anxiety condition who reported that they believed the manipulation performed
significantly worse on the IGT than those who expressed disbelief in the terms of the
manipulation. Thus, the experience of anxious arousal appears to significantly degrade
decision-making performance in the IGT.
This result is consistent with the Somatic Marker Hypothesis (SMH; Damasio,
1996). It is theorised that incoming emotional signals disrupt cognitive appraisals
and are thus accountable for impairments in the performance of cognitive tasks such
as decision-making (Dittrich & Johansen, 2013). This experiment is the first to
explicitly test this notion and its results indicate that the anxious arousal experienced
by participants in the anxiety condition may have served to interrupt the learning
process whereby somatic markers were assigned to advantageous and disadvantageous
choices. Consequently, participants in the anxiety condition may have lacked the
assistance of somatic markers in the course of their decision-making in the IGT,
leading to their poor performance relative to controls. While the results of the current
study thus appear to support the SMH, it is necessary for this experimental paradigm 39
to be repeated while accompanied by measurements of skin conductance responses
and other signs of physiological arousal in order to confirm the validity of explaining
these results by means of the SMH.
The hypothesis that the experience of anxiety would moderate the relation-
ship between decision-making and OC symptomatology was not supported. Sachdev
and Malhi (2005) contend that anxiety results in the abnormal activation of the
OFC among people with OCD, leading to impaired decision-making. As such, the

Behaviour Change
 Angelina Leonello and Mairwen K. Jones

moderating effect of anxiety on the relationship between decision-making and OC

symptoms may be exclusive to patients with OCD. Given that anxiety has been shown
to affect the efficacy of decision-making in the non-clinical sample utilised in this
study, it may be a valid line of inquiry to examine its effects among a clinical pop-
ulation where impairments in decision-making have been established. Furthermore,
there have been findings which suggest that the efficacy of decision-making on the
IGT differs as a function of OCD subtype. Lawrence et al. (2006) found that poor per-
formance on the IGT was exhibited in hoarding and washing subtypes, but not others.
Thus, future research may also consider applying the experimental paradigm utilised
in this study to determine whether anxiety has a differential effect on decision-making
which is subtype specific among patients with OCD.
The final hypothesis was not supported since performance on the IGT appeared to
improve among all participants over the course of the task, regardless of their OCI-R
score or the condition to which they had been assigned. A possible explanation for
this finding is that a lack of orbitofrontal dysfunction in the current sample means that
the learning mechanisms that facilitate task performance on the IGT remained intact
among participants. Abnormalities in the OFC have been implicated repeatedly in
theories accounting for decision-making impairments among patients with OCD (e.g.,
Da Rocha et al., 2011; Sachdev & Malhi, 2005; Spitznagel & Suhr, 2002; Starcke
et al., 2010). If these abnormalities are pathology specific, non-clinical individuals
would not be affected by the interference of orbitofrontal dysfunction in the process
of learning task contingencies (Cavedini, Gorini, & Bellodi, 2006). Thus, this finding
may have implications for the clinical understanding of OCD and the mechanisms
that sustain the disorder.
The performance of participants in the anxiety condition appeared to improve
over the course of the IGT while nevertheless remaining poorer than the performance
of the control condition, overall. A possible explanation for this finding is that while
the contingencies attached to the various decks in the IGT may have been com-
prehended by those in the anxiety condition, the degree to which the knowledge of
these contingencies was utilised to inform decisions was consistently lower than in the
control group. While Miu et al. (2008) contend that anxious arousal renders affected
individuals unable to learn deck contingencies in the IGT, it instead appears that this
arousal may interfere in the adaptive application of these learned contingencies. It
may be useful for future experiments to explore this idea using a paradigm that differ-
entiates between the process of learning and the application of learned contingencies
so that the mechanisms underlying the influence of anxiety on decision-making can
be elucidated. Additionally, we suggest that future research examining how anxiety
affects the relationship between decision-making and OC symptoms should draw their
samples from clinical populations of OCD patients.
While this study explicitly attempts to address the link between cognition and
emotional processing and how this relationship affects functional decision-making,
40 it was also subject to some limitations. First, there was no selection of participants
on the basis of OCI-R scores. Given that the mean OCI-R scores of the anxiety
and control groups are similar to that of non-anxious controls reported by Foa et al.
(2002), the lack of participant selection may account for the non-significant effect
of OCI-R scores on the efficacy of decision-making. Future studies should consider
the application of this experimental paradigm to non-clinical groups with elevated
OCI-R scores. Additionally, only one task was utilised to examine cognitive deficits
in decision-making. As stated above, the IGT is a valid tool that is commonly used

Behaviour Change
 Anxiety, OC Symptoms and Decision-Making

in this research area to capture deficits in decision-making. However, the inclusion

of tasks such as the CGT or the GDT may further elucidate the specific effects of
anxiety on decision-making in OC populations. Another limitation is that galvanic
skin responses were not collected from participants as they completed the IGT. Future
studies incorporating this data would add support to findings of OFC abnormalities that
are indicated by poor performance on the IGT. Furthermore, it is unclear whether
poorer performance on the IGT by the anxiety group in the current study can be
attributed solely to anxiety, or whether distraction at the prospect of the upcoming
speech may have been a contributing factor. Finally, the fact that this sample was
drawn from a non-clinical sample limits the degree to which findings can be generalised
to the clinical experience of OCD. The use of non-clinical samples in research relating
to OCD has been justified by authors such as Wu and Cortesi (2009), who contend
that the non-clinical experience of OC symptoms is similar to the experience reported
by patients with OCD. Nevertheless, future studies wishing to explore how anxiety
affects the relationship between decision-making and OC symptoms more definitively
should draw their samples from clinical populations of OCD patients.

Conclusions
While the current study presents significant findings of the detrimental effect of anx-
ious arousal on decision-making efficacy, the experience of anxiety was not found
to moderate a relationship between differences in decision-making and OC symp-
tomatology. Evidence of a significant relationship between OC symptomatology and
decision-making performance on the IGT in a non-clinical sample was not found. Nor
was there evidence that performance over the course of the IGT differs as a function
of the degree of OC symptomatology, or whether participants were subject to the ex-
perimental manipulation. Despite some non-significant findings, the results provide a
number of theoretical implications. They expose the possibility that decision-making
deficits are implicated specifically with the clinical manifestation of OCD. The finding
that anxiety results in decision-making deficits in a non-clinical sample is important,
given that OCD patients are particularly sensitive to anxiety and distress (Sachdev &
Malhi, 2005). There are important practical implications of any significant findings
in the future of this research area. For example, if it is found that anxiety significantly
moderates the relationship between decision-making and OCD, novel treatments
that specifically target stress reduction may be integrated into treatment to aid in the
management of this debilitating disorder.

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