Title of the paper: Cognitive retraining on prospective memory and

neuropsychological functions in obsessive-compulsive disorder: A single case

study.

Details of the authors:

Names of the authors:* Lisha P. Balan, **Neelima Ranjith.

*Research Scholar, ** Assistant Professor

Affiliation: Department of Psychology, Union Christian College (Affiliated to Mahatma

Gandhi University), Aluva, Kerala, India.

Name and address: Lisha.P.Balan, Pathiyil House, Kechery (P.O), Thrissur,

Kerala, 680501, India.

Contact Number: 9539115973

Email addresses: lish7esp@gmail.com

neelimaranjith@uccollege.edu.in

1
 Neuropsychological Functions in Obsessive-
Compulsive Disorder: A Single Case Study.
Lisha P. Balan *1, Neelima Ranjith *2.
*1 Research Scholar *1 Assistant Professor

Affiliation: Department of Psychology, Union Christian College (Affiliated to Mahatma Gandhi University), Aluva,
Kerala, India.
Email addresses: lish7esp@gmail.com ; neelimaranjith@uccollege.edu.in

ABSTRACT

Several researches have demonstrated cognitive impairments in Obsessive-Compulsive Disorder (OCD)

and also contributed to the possibility of cognitive retraining. The present study aimed to explore the effectiveness
of a 2-month cognitive retraining program on prospective memory and other neuropsychological functions in OCD.
It is a single case study. The patient was assessed using Obsessive-Compulsive Inventory- Revised (OCI-R), Royal
Prince Alfred Prospective Memory Test (RPA-ProMem) and NIMHANS Neuropsychological battery. The patient
was assessed before and after the cognitive retraining program (3-month and 6-month follow-up sessions were also
assessed). The results reveal that the patient has benefitted from cognitive retraining program and showed
improvement in both prospective memory and its associated neuropsychological functions. The patient also showed
improvement in the clinical symptoms of OCD.

KEYWORDS: Cognitive impairment, obsessive-compulsive disorder, effectiveness, cognitive retraining,

prospective memory, neuropsychological functions.

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a chronic disorder combined with obsessions (intrusive,

distressing and rapid thoughts or images) and compulsions (repetitive behaviours and recurrent mental acts to relieve
anxiety). The lifetime prevalence of OCD is 2.5% [American Psychiatric Association (APA), 2000]. There are
different subtypes of OCD: contamination/washing, harm/checking, hoarding, & symmetry/ ordering (Mckay et al.,
2004). Although OCD is associated with poor social, personal, and occupational functioning (Ruiz, et al., 2017)
there were several researches suggesting impaired neuropsychological functions in OCD (Chamberlain et al., 2006;
Kuelz et al., 2004). The cognitive areas which were studied in OCD are memory, attention, set shifting-ability and
executive function. Literature reviews depict memory failures as a general feature of patients with OCD (Olley et
al., 2007; Muller & Robert, 2005; Cuttler & Graf, 2007, 2008, 2009; Harris et al., 2010). Several researchers have
found deficits in working memory (Chamberlain et al., 2007; Purcell et al., 1998a) , prospective memory
( Nedelijkovic et al., 2009; Harris et al., 2010; Jaafari et al., 2013., Bhat et l., 2018), verbal learning and memory
(Sawamura et al., 2005) and visual learning memory (Savage et al., 1999; Savage et al., 2000; Shin et al., 2014).
Deficits in executive functions with respect to OCD was also studied (Omori et l., 2007; van der Linden et al., 2005)
and studies have demonstrated deficits in response inhibition (Abramovitch et al., 2011; Sottocorno et al., 2011;
Morein-Zamir et al., 2010; Page et al., 2009; Chamberlain et al., 2007,2006), Planning ( Cavedini et al., 2010;
Diamond, 2013; van Passel et al., 2016; van den Heuvel et al., 2005) and set-shifting ability (Miyake et al., 2000;
Goodwin & Sher, 1992; Omori et al., 2007; Okasha et al., 2000) are common in patients with OCD.

2
 Prospective memory refers to the ability to recall certain intentions or actions which have to be executed in
the future without any explicit reminder (Barba, 1994). Prospective memory is event- and time-based (Einstein &
McDaniel, 1996). There were studies suggesting prospective memory impairment in OCD (Sardaripour & Shamami,
2015; Bhat et al., 2018; Harris& Cranney, 2012). Prospective memory is regarded as more important for everyday
functioning and independent living than retrospective memory because many everyday activities require carrying
out of an intended action at the right time or in the right context (Shum et al., 2001). Because of the patient’s
difficulty in dealing intrusive thoughts he or she will end up doing things like checking things repeatedly, hoarding,
ordering, and washing repeatedly. Thus the patient with OCD has trouble in executing actions or intentions that has
to be done in the near future, for example, while going out they will check repeatedly whether they took the purse or
not or repeatedly check whether the gas is off after the use, or repeatedly check the door locks while going to sleep.
The reasons for the same can be the patient’s inability to suppress irrelevant or interfering stimuli or difficulty in
shifting flexibly from one activity to another. The patient with OCD has difficulty to do certain events after finishing
the activity, for instance, the patient often finds it difficult to stop washing even if the things are clean. This can be
explained as event-based prospective memory failures due to the patient’s uncertainty as to whether a specific action
has been undertaken (Palmer et al., 2015). These findings suggest the association of prospective memory failures
with deficits in other neuropsychological functions such as attention, retrospective memory, verbal learning and
memory, visual learning and memory, visuo-constructive ability, and executive functions like response inhibition,
planning, and problem-solving, mental set, set-shifting ability, and working memory (Jaafari et al., 2013; Diamond,
2013; Abramovitch et al.,2011; Cavedini et al.,2010; Cuttler & Graf, 2007.2008.).

Cognitive retraining is considered an effective treatment to reduce cognitive deficits and its improvement
would reduce clinical symptoms and enhance psychosocial functioning (McGurk et al., 2007; Medalia et al., 2009).
Cognitive retraining is mainly used in traumatic head injury patients ( Diya Nangia & Keshav Kumar,2012) and it is
also used in different disorders like schizophrenia (Hedge et al.,2012; Malhotra et. al, 2009). Cognitive remediation
therapy (CRT) has been used in patients with traumatic brain injury, eating disorder (Tchanturia, 2014), ADHD
(Stevenson et al., 2002), Learning disability and schizophrenia (Wykes et al, 2011; Saperstein et al., 2015).

There is a scarcity of studies in cognitive retraining related to OCD. So far only five studies have been
reported. A single case intervention of cognitive training for neurocognitive and functional impairments in
obsessive compulsive disorder was done for 12 weeks by Kashyap et al in 2019 and significant changes were
reported on verbal fluency and planning, and smaller changes on attention and working memory were also reported.
Further, there was improvement in subjectively perceived cognitive difficulties as well as psychosocial functioning
along with simultaneous reduction on the severity of anxiety, depression, and obsessive-compulsive symptoms.
Effectiveness of CRT has investigated in OCD with Specialized attention therapy (SAT) and the results showed that
there were improvements in the clinical symptoms as well as cognitive functions (van Passel et al., 2016). In 2013,
Calkins & Otto had investigated the effect of a three-session computerized cognitive control training intervention
(CCT) on obsessive-compulsive symptoms in a community sample. The results have shown that there is no
significant difference in obsessive-compulsive scores between groups post intervention, indicting the in
effectiveness of CCT in reducing obsessive compulsive symptoms. Buhlmann et al (2006) have stated that
impairment in organization and memory in patients with OCD can be alleviated with cognitive retraining but they
did not investigate the improvement of clinical symptoms. Another study demonstrated the improvement in memory
with cognitive retraining in patients with OCD and it reported improvement in clinical symptoms (Park et al., 2006).

The present study was done with an aim to develop a cognitive retraining program focusing on enhancing
prospective memory and other neuropsychological functions associated with it in order to see the improvements in
obsessive-compulsive disorder. Early studies did not investigate neuropsychological functions in detail other than
memory and organization in OCD. So a study was needed to investigate the effectiveness of cognitive retraining of
prospective memory and other neuropsychological functions. An adequate level of monitoring by the expert was
given in order to make sure the patient doing the training properly and it helped to avoid dropouts. It was also aimed

3
to make this program partially home-based with a minimum level of monitoring by the family members as it is
difficult for the patient to come regularly. Such program also reduced the financial burden. The intervention
program would be a cost-effective treatment for OCD. The efficiency of the program was assessed by following up
the patients after 3-months and 6-months.

PROCEDURE

It is a single case study. The patient was recruited from private clinic of the researcher. The diagnosis of
OCD was made by the consultant psychiatrist based on clinical history and clinical examination. The duration of the
illness was less than 1 year. The patient was a 24-year-old married female currently living with her parents, educated
up to degree. There was no history of a mental retardation, presence of a neurosurgical condition or neurological
condition other than OCD. The patient has not undergone electroconvulsive therapy at all. The patient has not
attended proper CBT sessions. One member who was identified as the primary caregiver (mother), not having any
current psychiatric illness was included in order to monitor the patient. The research study was approved by the
ethics committee and written informed consent was obtained from the patient and the primary caregiver (mother).

The patient was assessed using Obsessive-Compulsive Inventory-Revised for OCD (OCI-R). OCI-R (Foa
et al., 1998) evaluates the frequency and distress experienced of OCD symptoms using 6 subscales: washing,
obsessing, hoarding, ordering, checking and neutralizing. It has good psychometric properties. It consists of 18
questions that a person endorses on a 5-point Likert scale. The Royal Prince Alfred Prospective Memory test (RPA-
ProMem) was administered to assess prospective memory. RPA-ProMem (Radford et al., 2011) is a brief and easily
administered time- and event- based behavioural measure of prospective memory with three alternative forms which
provide objective clinical information and it is designed to assess retention over both short and long intervals. This
measure of prospective memory should particularly useful in situations that require repeated assessment such as
evaluation of rehabilitation efforts. Other neuropsychological functions were assessed by NIMHANS
Neuropsychological battery (Rao et al., 2004). NIMHANS Neuropsychological battery consists of 19 widely used
western neuropsychological tests that have been adapted and standardized for Indian population. It has population
derived norms for ages 16-65 years and has been validated for use in many neurocognitive disorders. The scores on
the neuropsychological tests were compared with norms appropriate to that of the subject’s gender, age, and
education. Indian norms for the tests in the neuropsychological battery have been developed based on literacy
[illiterates, school-educated (1st to 10th std), and college-educated (11th std and above)], age [young adults (16–30
years), middle-aged adults (31–50 years), and older adults (51-65years)], sex (males and females). Percentile scores
were calculated for each test variable. The 15th percentile score (1 SD below the mean) was taken as the cut-off
score. The neuropsychological tests administered using NIMHANS Neuropsychological battery were: digit
vigilance test, color trails tests to assess attention; finger tapping test to assess motor speed; digit symbol substitution
to assess mental speed; animal names test , verbal N-back-Task, Stroop test, tower of London, Wisconsin card
sorting test (WSCT) to assess various executive functions; Rey’s auditory verbal learning test (RAVLT) to assess
verbal learning and memory; Rey Osterrieth Complex figure Test (CFT) to assess visuo-constructive ability and
visual memory.

The patient received a 2-month partially home-based cognitive retraining program along with drug
treatment (from consultant psychiatrist) and psychotherapy sessions (from consultant clinical psychologist) were not
attended by the patient. No proper CBT sessions were given. Three sessions of psychoeducation were given to the
patient and the primary caregiver. The tests were administered to the patient at baseline (prior to the intervention),
post-assessment (after the intervention), at 3-month follow up (1 month after the completion of the intervention),
and at 6- month follow up (4 months after the completion of the intervention).

Intervention

4
 Cognitive retraining program

The patient was seen twice in a week for the retraining session by the expert and it was explained to the
caregiver on how to perform the tasks. The patient was instructed to note down the time taken to complete each task.
The rest of the sessions in that week were performed by the patient in the home setting. The caregiver was instructed
to monitor the sessions without over-involvement. The retraining tasks were given to the patient in a graded fashion.
As the retraining progressed the difficulty of the task increased. The retraining program included tasks that could be
carried out by the patient at home, with a minimum level of monitoring by the caregiver. Completion of two-third of
the tasks given for each week, was considered as adequate compliance. A brief description of the tasks is given in
the table1. The patient has adhered to the treatment.

Table 1:

Brief description of cognitive retraining program

Cognitive domain Retraining tasks Description

Attention Number connection(1-3 weeks) Serially connecting numbers placed randomly on

an A4 sheet. The task was given in three

levels of difficulty increase in task difficulty was

achieved by increasing total numbers to be

connected

Mental speed Grain sorting (1-4 weeks) The task involved sorting of mixed grains into
piles of similar grains. The task was given at three
difficulty levels. This task has been used in
cognitive remediation program for head injured

subjects. Task difficulty was achieved by

increasing the types of grains. Decreasing the size
of grains increased the task difficulty

Motor speed Stacking the paper glasses (1- The task involved was to stack the paper glasses
2weeks) one on top of another. Note the time taken. Task
difficulty was achieved in increasing the number of
glasses.

Dexterity task (3-5 weeks) Task was to fill the hole on the board with the pins.
The task was given in two difficulty level.

Working memory Rearrangement of jumbled words (3- The task was to rearrange the letters to make a
4 weeks) meaningful word. Words chosen for this task were
simple nouns and words, having an average of four
to six letters. The task was given in one difficulty
level

5
Mental set Digit span (1-3weeks)
Verbal fluency Word generation (week4)
Planning Short essay writing(1-4weeks)
Maze completion task(5-8weeks)
Sustained attention, set shifting Letter cancellation task (4-7 weeks)
ability
Card sorting task(2-5weeks)
Response inhibition Design shading(1-6 weeks)
Verbal learning and memory Temporal encoding(2-5weeks)
6
Task was to recall the sequence in the same order
they were given. The task difficulty was increased
by increasing the sequence length. The task was
given in seven difficulty level.
Similar to Controlled Oral Association test. The
task consisted of generating as many words as
possible starting with a selected letter within a
stipulated time. The task was given in one
difficulty level
The task involved writing a short essay on a given
topic. The topics were related to activities that
pertained to patient’s interest and daily activities.
The task was given at one level of difficulty
Beginning with the start point, patient had to trace
the way out in the maze without tracing into a
blind alley. The task was given at three levels of
difficulty. Increased task difficulty was achieved
by the complexity of maze with increase in blind
alleys and the route to reach the end point
English aiphabets from the array of alphabets a-z
were randomly arranged in a number of rows on an
A4 size sheet. The task involved cancellation of
designated target alphabets. The task was given at
one difficulty level
Task was to find out similar cards from a deck of
cards that have been placed in rows and columns.
the task difficulty was achieved by increasing the
number of rows and columns.
Similar to the Coloring task from the cognitive
retraining of head-injured patients. The task
involved shading a design using pencils. The
evenness in pressure on the strokes and strokes not
crossing the borderlines of the design were
emphasized. The task was given at five levels of
difficulty. Task difficulty was increased by
increased the complexity of the design to be
colored
The task involved recalling the list of words
presented to the subject. Task difficulty was
achieved by increasing number of words in the list.
 This task has been used in cognitive remediation
program for head injured

subjects.

Visuo-constructive ability Bendor-Gestalt Test (week 5-6) The task involved construction of ten target
designs using

the cards placed on table. The task was given at a

single level of difficulty

Visuo-spatial reasoning
Corsi-Block test(week 6-8)
Task was to tap on the square shown in the screen
in the same order they were given. The task
difficulty was increased by increasing the sequence
length. The task was given in seven difficulty
level.

Visual memory Memory for designs (week7-7) The task involved drawing a given design from
memory. Each abstract design contained five to
eight components, which was exposed for 10
seconds. Patient was asked to observe the design
carefully and try to memorize the various
components. In each session, there were 10
designs. The task was given at one level of
difficulty

Prospective memory General knowledge questions (1-3 Task involved answering simple GK questions.
weeks) There was target word embedded in some
questions. The subject has to skip the questions
with target word. The task was given in one level
of difficulty.

Face-name association(4-7 weeks) Task was to recall the names of the faces shown in
the picture using its elaboration. 4 cards per
session. The task was given in one level of
difficulty.

Psychoeducation Session

Three sessions of psychoeducation were given to both the patient and the caregiver at pre-assessment, post-
assessment, and 1 month after the retraining. Each session lasted about 45 minutes to 1 hour. In this session both
patient and the caregiver were given awareness about the nature of the diagnostic symptoms, age of onset,
prevalence, course of the illness, types of neuropsychological defects, and importance of emotional support to the
patient. The patient and the caregiver were given information regarding the line of treatments.

RESULT

The result of the single case study is given below. The patient was assessed before and after the cognitive
retraining program with the tools mentioned in the method. The results reveal that the patient has benefitted from the

7
two-month cognitive retraining program and showed improvement in both prospective memory and its other
neuropsychological functions such as motor speed, mental speed, attention, response inhibition, working memory,
planning, verbal learning, and memory, mental set and set-shifting ability, category fluency, visuo-constructive
ability, and visual learning and memory.

The patient’s score on OCI-R reveals that improvement occurred in the clinical symptoms of the patient
throughout the retraining period and it was maintained thereafter. The score on the pretest, post-test, 3-month
follow-up and 6-month follow-up were 33, 12, 9, & 7 (table2). This is consistent with the early studies stating that
cognitive retraining helps to ameliorate the clinical symptoms of patients with OCD (van Passel et al., 2016; Park et
al., 2006). In the patient’s result of prospective memory test, the total score on the pretest was 4 but the score on the
post-test, 3-month follow-up, and 6-month follow-up were 8, 9, & 9 respectively (table3). This indicates that the
patient has a prospective memory defect before the retraining and long-term prospective memory is better than the
short –term prospective memory. Improvement in prospective memory is possible with prospective memory
retraining tasks was proved in early researches but not related to OCD (Raskin & Sohlberg, 2009; Kinsella et al.,
2007; Guynn, 2003). In the present study, the patient’s prospective memory enhanced with a prospective memory
retraining task.

Table 2:

Patient’s result on Obsessive-Compulsive Inventory-Revised

Total score

Pre-test 33

Post-test 12

3-month follow-up 9

6-month follow-up 7

Table 3:

Patient’s result on Royal Prince Alfred Prospective Memory Test

STPM LTPM Total score

TPM EPM TPM EPM

Pretest 0 0 2 2 4

Post-test 2 2 2 2 8

3-month follow-up 2 2 3 2 9

6-month follow-up 2 2 3 2 9

Note: STPM-Short term prospective memory, LTPM- Long term prospective memory, TPM- Time-based
prospective memory, EPM- Event-based prospective memory

8
 The patient’s result on neuropsychological tests shows that there is impairment in scores on digit symbol
test, animal name test, verbal N’back test, tower of London test, Wisconsin card sorting test, Stroop test, auditory
verbal learning test, and complex figure test (copying) (table 4). This means that the patient has impairment in
mental speed, category fluency, working memory, planning, set-shifting ability, response inhibition, verbal learning
and memory and visuo-constructive ability. In the earlier studies, it was found that the patients with OCD have
deficit in working memory (Harkin & Kessler, 2011), planning (Diamond, 2013), set-shifting ability (Miyake et al.,
2000), response inhibition (Aycicegi et al., 2003), verbal learning and memory, and visuo-constructive ability. The
result is consistent with the early researches. But the patient’s scores on finger tapping test, digit vigilance, color
trails, complex figure test (immediate recall & delayed recall) were intact. That means that the patient’s motor
speed, sustained attention, focused attention, and visual learning and memory were intact on the pretest. This result
is inconsistent with early studies which showed impaired attention and visual learning and memory in patients with
OCD (Buhlmann et al., 2006). Table 5 shows a comparison between the raw scores of the patient on
neuropsychological tests on the pre-test, post-test, 3-month follow-up, and 6-month follow-up. The results show that
there is an improvement in the neuropsychological functions of the patient after the retraining program and the
patient maintained improvement in the follow-up sessions. Even though the patient’s motor speed, sustained
attention, focused attention, and visual learning and memory were intact, these functions improved with the other
neuropsychological functions after the retraining.

Table 4:

Result on neuropsychological tests: pretest

Tests Variable Raw score Percentile

Finger tapping RH 45 35

LH 33 5

Digit symbol TT 1080 below 3

Digit vigilance TT 380 74-77

NE 16 16

Colour trails-1 TT 53 22

Colour trails-2 TT 132 18

Animal name test TNW 11 12

Verbal N-back test 1 back H 9 95

E 8 below 3

2 back H 7 15-40

E 5 10

Tower of London 2 moves MT 22 7

MM 2.5 13-100

NPMM 1 5-10

9
 3 moves MT 28.25 below 6

MM 3.5 38-69

NPMM 3 50-70

4 moves MT 85.32 below 3

MM 13.5 3-6

NPMM 1 5-33

5 moves MT 141.36 below 3

MM 15.6 below 3

NPMM 0 5-10

TNPMM 5 20-40

Wisconsin card sorting test NT 128 16

NCR 82 75-80

NE 46 13-16

PNE 36 13-16

PR 22 22

PPR 17 22

PE 21 16-19

PPE 16 19

NPE 25 3-6

PNPE 20 3-6

CLR 69 60-70

PCLR 54 10-15

NCC 4 10

TTCC1 26 7-10

FMS 2 23

Stroop test SE 229 7

Auditory verbal learning test T1 6 9

10
 T2 8 11

T3 11 12

T4 12 12

T5 11 13

TC 48 below5

LB 7 30-40

IM 10 5-10

DR 10 10

LTPR 91 15-20

H 14 5-10

M 1 24

FA 0 100

Complex figure test CS 33 below 5

IRS 29 50

DRS 29 50

Note: RH- Right hand, LH- Left hand, TT- Total time, NE- Number of errors, TNW- Total new words, H- Hits, E- Errors, MT-Mean time, MM- Mean moves, NPMM-Number of problems solved with

minimum moves, TNPMM-Total number of problems with minimum moves, NT-Number of trails, NCR-Number of correct responses, NE- Number of errors, PNE- Percentage of number of errors,

PR- Perseverative responses, PPR- Percentage of perseverative responses, PE-Perseverative errors, PPE- Percentage of perseverative errors, NPE- Non perseverative errors, PNPE-Percentage of non

perseverative errors, CLR- Conception level responses, PCLR-Percentage of conception level responses, NCC- Number of categories completed, TTCC1- Trail to complete category 1, FMS- Failure to

maintain set, SE-Stoop effect, T1-Trail 1 no. of correct responses, T2-Trail 2 no. of correct responses T3-Trail 3 no. of correct responses, T4-Trail 4 no. of correct responses, T5-Trail 5no.of correct

responses, TC-Total no. of correct responses LB-List B no. of correct responses, IM-Immediate recall no. of correct response, DR-delayed recall no. of correct responses, LTPR-Long term percent

retention, M- no. of misses, A- no. of false alarm, CS-Copying score, IRS- Immediate recall score, DRS- delayed recall score

Table 5:

Pretest, posttest, 3-month follow-up, and 6-month follow-up: raw scores of the patient on neuropsychological tests

Test Variable Raw score

pre-test post-test 3-month follow- 6-month

up follow-up

Finger tapping RH 45 49 48 50

LH 38 42 44 44

Digit symbol TT 1080 217 211 207

Digit vigilance TT 380 347 328 336

11
 NE 16 9 6 7

Colour trails-1 TT 53 49 45 46

Colour trails-2 TT 132 114 111 109

Animal name test TNW 11 13 15 15

Verbal N-back test 1 back\ H 9 9 9 9

E 8 2 0 0

2 back H 7 7 7 7

E 5 3 1 1

Tower of London 2 moves MT 22 10 8 8

MM 2.5 2 2 2

NPMM 1 2 2 2

3 moves MT 28.25 21.5 19 12

MM 3.5 3 3 3

NPMM 3 4 4 4

4 moves MT 85.32 51.75 42.56 39.25

MM 13.5 9 8 8

NPMM 1 1 1 2

5 moves MT 141.36 108 89 85

MM 15.6 10 11 10

NPMM 0 0 0 0

TNPMM 5 7 7 8

Wisconsin card sorting test NT 128 128 128 128

NCR 82 99 105 108

NE 46 29 23 20

PNE 36 23 18 16

PR 22 15 13 10

PPR 17 12 10 8

12
 PE 21 15 11 8

PPE 16 12 9 6

NPE 25 14 12 12

PNPE 20 11 9 9

CLR 69 73 72 73

PCLR 54 57 56 57

NCC 4 5 5 5

TTCC1 26 15 9 11

FMS 2 1 0 0

Stroop test SE 229 157 145 152

Auditory verbal learning test T1 6 8 10 12

T2 8 11 11 11

T3 11 11 13 12

T4 12 14 14 14

T5 11 14 14 15

TC 48 58 62 64

LB 7 7 9 8

IR 10 14 13 14

DR 10 13 13 14

LTPR 91 93 93 93

H 14 15 15 15

M 1 0 0 0

FA 0 0 0 0

Complex figure test CS 33 36 36 36

IRS 29 32 34 33

DRS 29 30 34 34

Note: RH- Right hand, LH- Left hand, TT- Total time, NE- Number of errors, TNW- Total new words, H- Hits, E- Errors, MT-Mean time, MM- Mean moves, NPMM-Number of problems solved with

minimum moves, TNPMM-Total number of problems with minimum moves, NT-Number of trails, NCR-Number of correct responses, NE- Number of errors, PNE- Percentage of number of errors,

PR- Perseverative responses, PPR- Percentage of perseverative responses, PE-Perseverative errors, PPE- Percentage of perseverative errors, NPE- Non perseverative errors, PNPE-Percentage of non

13
perseverative errors, CLR- Conception level responses, PCLR-Percentage of conception level responses, NCC- Number of categories completed, TTCC1- Trail to complete category 1, FMS- Failure to

maintain set, SE-Stoop effect, T1-Trail 1 no. of correct responses, T2-Trail 2 no. of correct responses T3-Trail 3 no. of correct responses, T4-Trail 4 no. of correct responses, T5-Trail 5no.of correct

responses, TC-Total no. of correct responses LB-List B no. of correct responses, IM-Immediate recall no. of correct response, DR-delayed recall no. of correct responses, LTPR-Long term percent

retention, M- no. of misses, A- no. of false alarm, CS-Copying score, IRS- Immediate recall score, DRS- delayed recall score

DISCUSSION

In the present study which was designed to explore the effectiveness of cognitive retraining in improving
prospective memory and other neuropsychological functions and alleviating clinical symptoms in patient with OCD,
we found that cognitive retraining enhanced prospective memory and other neuropsychological functions (like
motor speed, mental speed, attention, response inhibition, working memory, planning, verbal learning and memory,
mental set and set-shifting ability, category fluency, visuo-constructive ability, and visual learning and memory) of
the patient and ameliorated the clinical symptoms. The patient with OCD exhibits compulsion in order to prevent
anxiety caused by the obsession. When a person finds it difficult to discard the intrusive thoughts& recurrent mental
acts and is unable to recall relevant past actions in confidence, then an encompassing explanation for his/ her act is
that the person may have the inability to suppress irrelevant or interfering stimuli (ability related to response
inhibition), or may encounter difficulties in moving flexibly from one action to another (set-shifting ability), or
difficulty in organizing the execution of action effectively within memory (planning) or may have uncertainty as to
whether a specific action has been undertaken (ability related to different types of memory). These findings suggest
underlying cognitive deficits in patients with OCD (Palmer et al., 2015; Jaafari et al., 2013; Diamond, 2013;
Abramovitch et al.,2011; Cavedini et al.,2010; Cuttler & Graf, 2007.2008.). This may be the reason for an
improvement in clinical symptoms of OCD with cognitive retraining.

There was a scarcity of studies on cognitive retraining in patients with OCD. This is the first study from
Kerala to investigate the effectiveness of prospective memory retraining in OCD. The present study explores the
effectiveness of cognitive retraining of most of the neuropsychological functions in OCD, unlike the early studies. In
the present study the effectiveness of cognitive retraining program in OCD is investigated in a clinically diagnosed
patient who has never undergone proper Cognitive Behavior therapy (CBT). The patient came with significant
distress even with medication and improved significantly after the retraining program (medication never been
changed during the period). A potential limitation of this study is that it is a single case study and we have not
included a control group to compare the effectiveness. This cognitive retraining program included programs that
have been widely used to enhance cognitive functions in head injury patients. We took a patient with OCD who had
been taking medication for at least 1 month prior to the study and whose acute symptoms had been reduced.
Therefore, in future study, the cognitive retraining should be demonstrated in patients with OCD who have never
received medication. Future studies are needed to explore the improvement in neuropsychological functions which
lead to alleviation of the symptoms of OCD in the patient. However, it should be emphasized that a significant
retraining effect was observed in this short period.

CONCLUSION

The present study is enabled to find out significant improvement in prospective memory and other
neuropsychological functions such as motor speed, mental speed, attention, response inhibition, working memory,
planning, verbal learning and memory, mental set and set-shifting ability, category fluency, visuo-constructive
ability, and visual learning and memory through cognitive retraining in the patient with OCD. Improvement in the
clinical symptoms is observed through a decrease in the severity of the obsessive-compulsive symptoms.

REFERENCES

14
Abramovitch, A., R.Dar, A .Schweiger, and H.Hermesh (2011), “Neuropsychological Impairments and Their Association

with Obsessive-Compulsive Symptom Severity in Obsessive-Compulsive Disorder”, Archives of Clinical

Neuropsychology, 26:364–376.

Aycicegi, A., W.M. Dinn, C.L. Harris, and H. Erkmen (2003), “Neuropsychological function in obsessive-compulsive

disorder: effects of comorbid conditions on task performance”, European Psychiatry, 18:241–248.

American Psychiatric Association. (2000), Diagnostic & Statistical Manual of Mental Disorders (4th ed., Text Revision),

Washington, DC: American Psychiatric Association.

Barba, D.G. (1994), “Prospective memory: a new memory system?” In Handbook of Neuropsychology,(eds.) F. Boller

and J. Cyrafman,pp.239-251. New York: Elsevier Science Publishers.

Bhat, N.A., V.Sharma and D. Kumar. (2018), “Prospective memory in obsessive-compulsive disorder”,Psychiatry

Research, 261:124–131.

Buhlmann, U., T. Deckersbach, I. Engelhard, L.M Cook, S.L Rauch, N. Kathmann, … C.R Savage. (2006), “Cognitive

retraining for organizational impairment in obsessive-compulsive disorder”, Psychiatry Research, 144( 2-

3):109–116.

Cavedini, P., C. Zorzi, M. Piccinni, M.C. Cavallini, and L. Bellodi.(2010), “ Executive Dysfunctions in Obsessive-

Compulsive Patients and Unaffected Relatives: Searching for a New Intermediate Phenotype”, Biological

Psychiatry, 67(12):1178–1184.

Chamberlain, S.R., N. A. Fineberg, A.D Blackwell, T.W.Robbins, and B.J. Sahakian. (2006),

“Motor inhibition and cognitive flexibility in obsessive-compulsive disorder and trichotillomania”, American

Journal of Psychiatry, 163:1282–1284.

Chamberlain, S.R.,N. A. Fineberg, L.A. Menzies, A.D. Blackwell, E.T. Bullmore, T.W. Robbins, and B.J. Sahakian.

(2007), “ Impaired cognitive flexibility and motor inhibition in unaffected first-degree relatives of patients with

obsessive-compulsive disorder”, American Journal of Psychiatry, 164: 335–338.

Calkins, A.W. and M.W. Otto. (2012), “Testing the Boundaries of Computerized Cognitive Control Training on

Symptoms of Obsessive Compulsive Disorder”, Cognitive Therapy and Research, 37: 587-594.

Cuttler, C., and Graf, P. (2007). Sub-clinical compulsive checkers’ prospective memory is impaired. Journal of Anxiety

Disorders, vol 21, pp 338–352.

15
Cuttler, C., and P.Graf. (2008),”Sub-clinical checking compulsions are related to impaired prospective memory

independently of depression, anxiety, and distractibility” Journal of Anxiety Disorders, 22:642–654.

Cuttler, C., and P.Graf. (2009), “Checking-in on the memory deficit and meta-memory deficit theories of compulsive

checking” Clinical Psychology Review,29:393-409.

Diamond, A. (2013),”Executive functions”,Annual Review of Psychology, 64:135–168.

Einstein, G.O., and M. A.McDaniel. (1996),“Retrieval processes in prospective memory: theoretical approaches and some

new empirical findings.” In Prospective Memory: Theory &Applications, (eds.) M. Brandimonte, G.O. Einstein

and M.A. McDaniel, pp. 115-142. Mahwah: New Jersey.

Foa, EB., J.D.Huppert, S. Leiberg, R. Langner, R. Kichic, G. Hajcak, and P. Salkovskis. (1998), “The obsessive-

compulsive inventory: Development and validation of a short version”, PsychologicalAssessment, 10:206–214.

Goodwin, A.H., and K.J. Sher. (1992), “Deficits in set-shifting ability in nonclinical compulsive checkers”, Journal of

Psychopathology and Behavioral Assessment, 14(1):81–92.

Guynn, M. (2003), “A two-process model of monitoring in event-based prospective memory:

Activation/retrieval mode and checking”, International Journal of Psychology, 38:245–256.

Harkin, B., and K. Kessler. (2011), “How checking as a cognitive style influences working memory

Performance”,Applied Cognitive Psychology, 25:219–228.

Harris, L., and J. Cranney.(2012), “Event-based prospective memory and obsessive-compulsive disorder obsessional

thoughts” Australian Journal of Psychology,17:297-303.

Harris, L.M., L. Vaccaro, M.K. Jones, and G.Boots. (2010), “Prospective memory in obsessive-compulsive checking”,

Behaviour Change,27:84–92.

Hegde, S., S. Rao, A. Raguram, and B. Gangadhar. (2012), “Addition of home-based cognitive retraining to treatment as

usual in first-episode schizophrenia patients: A randomized controlled study”  Indian Journal of Psychiatry,

54:15–22.

Jaafari, N., M. Frasca, F. Rigalleau, F. Rachid, R. Gil, J.P. Oli´e, and N. Vibert. (2013),”Forgetting what you have

checked: A link between working memory impairment and checking behaviors in obsessive-compulsive

disorder” European Psychiatry, 28:87–93.

16
Kashyap, H., P. Reddy, S. Mandadi, J.Narayanaswamy, P. Sudhir, and Y.C.J. Reddy. (2019), “Cognitive training for

neurocognitive and functional impairments in obsessive compulsive disorder: A case report”, Journal of

Obsessive-Compulsive and Related Disorders, 23.

Kinsella, G., B. Ong, E. Storey, J. Wallace, and R. Hester.(2007), “ Elaborated spaced-retrieval and prospective memory

in mild Alzheimer’s disease”, Neuropsychological Rehabilitation, 17:688–706.

Kuelz, A.K., F. Hohagen, and U. Voderholzer. (2004), “Neuropsychological performance in obsessive-compulsive

disorder: A critical review”, Biological Psychology, 65,185–236.

Malhotra, S., M.S.Bhatia, G. Rajender, V. Sharma, and T.B.Singh.(2009),”Current Update on Cognitive Retraining in

Neuropsychiatric Disorders”, Delhi Psychiatry Journal, 12:213-218.

McKay, D., J. Abramowitz, J. Calamari, M. Kyrios, A. Radomsky, D. Sookman, and S. Wilhelm. (2004), “A critical

evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms”, Clinical Psychology

Review, 24:283–313.

McGurk, S.R., E.W. Twamley, D.I. Sitzer, G.J. Mchugo, and K.T. Mueser. (2007), “ A Meta-Analysis of Cognitive

Remediation in Schizophrenia”, American Journal of Psychiatry, 164:1791–1802.

Medalia, A., and J. Choi. (2009), “ Cognitive Remediation in Schizophrenia” Neuropsychology Review, 19: 353–364.

Miyake, A., N.P. Friedman, M.J. Emerson, A.H. Witzki, A. Howerter, and T.D. Wager.(2000), “ The unity and diversity

of executive functions and their contributions to complex ‘frontal lobe’ tasks: A latent variable analysis”,

Cognitive Psychology, 41: 49–100.

Morein-Zamir, S.,K.J. Craig, K.D. Ersche, S. Abbott, U. Muller, N. A. Fineberg, and T.W. Robbins (2010), “Impaired

visuospatial associative memory and attention in obsessive-compulsive disorder but no evidence for differential

dopaminergic modulation”, Psychopharmacology, 212: 357–367.

Muller, J., and J.E. Roberts. (2005), “Memory and attention in obsessive-compulsive disorder: A review”, Journal of

Anxiety Disorders,19:1–28.

Nangia, D and K. Kumar.( 2012),” Cognitive retraining in traumatic brain injury”, Neuropsychological Trends, 11: 65-74.

Nedeljkovic, M., M. Kyrios, R. Moulding, G. Doron, K. Wainwright, C. Pantelis and P. Maruff. (2009), “ Differences in

neuropsychological performance between subtypes of obsessive-compulsive disorder”, The Australian and New

Zealand Journal of Psychiatry,43:216–226.

17
Okasha, A., M. Rafaat, N. Mahallawy, G. El Nahas, A.S. El Dawla, M. Sayed, and S. El Kholi. (2000), “ Cognitive

dysfunction in obsessive-compulsive disorder”, Acta Psychiatrica Scandinavica, 101:281–285.

Olley, A., G. Malhi, and P. Sachdev. (2007), “ Memory and executive functioning in obsessive-compulsive disorder: A

selective review”, Journal of Affective Disorders, 104:15–23.

Omori, I.M., Y. Murata, T. Yamanishi, S. Nakaaki, T. Akechi, M. Mikuni, and T.A. Furukawa.

(2007), “The differential impact of executive attention dysfunction on episodic memory in

obsessive-compulsive disorder patients with checking symptoms vs. those with washing symptoms” Journal of

Psychiatric Research, 41: 776–784.

Page, L.A., K. Rubia, Q. Deeley, E. Daly, F. Toal, D. Mataix-Cols, and D.G.M. Murphy.(2009),

“A functional magnetic resonance imaging study of inhibitory control in obsessive-compulsive disorder”,

Psychiatry Research-Neuroimaging, 174:202–209.

Palmer, L.E., K. Durkin, and S.M. Rhodes. (2015), “Checking Behaviours, Prospective

Memory and Executive Functions”, Behaviour Change, 32:74–92

Park, H.S., Y.M.Shin, T.H. Ha, M.S. Shin, Y.Y. Kim, Y.H. Le, and J.S. Kwon. (2006), “ Effect of cognitive training

focusing on organizational strategies in patients with obsessive-compulsive disorder”, Psychiatry Clinical

Neurosciences, 60:18–26.

Purcell, R., P. Maruff, M. Kyrios, and C. Pantelis. (1998a), “Cognitive deficits in obsessive compulsive disorder on tests

of frontal-striatal function”, Biological Psychiatry, 43:348–357.

Radford, K. A., S. Lah, M.J. Say and Miller, L. A. (2011), “Validation of a New

Measure of Prospective Memory: The Royal Prince Alfred Prospective Memory Test”, The Clinical

Neuropsychologist, 25: 1, 127 — 140.

Rao, S.L., D.K. Suddakrishna, and K. Gopukumar. (2004), NIMHANS Neuropsychological Battery-2004 Manual (1st Ed.).

Bangalore: NIMHANS Publications.

Raskin, S.A., and M.M. Sohlberg. (2009), “Prospective Memory Intervention: A Review and Evaluation of a Pilot

Restorative Intervention”, Brain Impairment, 10:76–86.

Ruiz, P., B.J. Sadock, and V. A. Sadock. (2017), Kaplan & Sadocks comprehensive textbook of psychiatry (10th ed., Vol.

1). Philadelphia: Wolters Kluwer.

18
Saperstein, A.M., and A. Medalia. (2015), “The Role of Motivation in Cognitive Remediation for People with

Schizophrenia”, Behavioral Neuroscience of Motivation Current Topics in Behavioral Neurosciences, 27:533–

546. 

Sardaripour, M., and E.R. Shamami. (2015), “Determining the prospective (short-term) memory between normal

individuals and patients with obsessive-compulsive disorder”  International Journal of Biology, Pharmacy And

Allied Sciences,  4:223-229.

Savage, C.R., L. Baer, N.J. Keuthen, H.D. Brown, S.L. Rauch, and M.A. Jenike. (1999), “Organizational strategies

mediate nonverbal memory impairment in obsessive-compulsive disorder”, Biological Psychiatry, 45:905–16.

Savage, C.R., T. Deckersbach, S. Wilhelm, S.L. Rauch, L. Baer, T. Reid, and M.A. Jenike.(2000), “Strategic processing

and episodic memory impairment in obsessive compulsive disorder” Neuropsychology, 14:141–51.

Sawamura, K., Y. Nakashima, M. Inoue, and H. Kurita. (2005), “Short-term verbal memory

deficits in patients with obsessive‐compulsive disorder”, Psychiatry Clinical Neurosciences, 59: 527–532.

Shin, N., T. Lee, E. Kim, and J. Kwon.(2014), “Cognitive functioning in obsessive-compulsive

disorder: A meta-analysis”, Psychological Medicine , 44:1121–30.

Shum, D., J.P. Leung, G.S. Ungvari, and W.K. Tang. (2001), “Schizophrenia and Prospective Memory: A New Direction

for Clinical Practice and Research”, Hong Kong Journal of Psychiatry, 11: 23-26.

Sottocorno, S., R. Martoni, E. Galimberti, E. Fadda, and L. Bellodi. (2011), “ P01-150 - Response inhibition in the

obsessive-compulsive spectrum”, In European Psychiatry, 26:150.

Stevenson, .S., S. Whitmont, L. Bornholt, D. Livesey, and R.J. Stevenson.(2002), “ A cognitive

remediation program for adults with Attention Deficit Hyperactivity Disorder”, Australian & New Zealand Journal

of Psychiatry, 36:610–616.

Tchanturia, K. (2014), Cognitive Remediation Therapy (CRT) for Eating and Weight Disorders (1st ed.). London:

Routledge.

van den Heuvel, O.A., D.J. Veltman, H.J. Groenewegen, D.C. Cath, A. van Balkom, J. van Hartskamp, and R. van Dyck.

(2005), “ Frontal-striatal dysfunction during planning in obsessive-compulsive disorder”, Archives of General

Psychiatry, 62:301–310.

van der Linden, M., G. Ceschi, A. Zermatten, D. Dunker, and A. Perroud. (2005), “Investigation

19
 of response inhibition in obsessive-compulsive disorder using the Hayling task”, Journal of the International

Neuropsychological Society, 11:776–783.

van Passel, B., U. Danner, A. Dingemans, E. van Furth, L. Sternheim, A. van Elburg, … D. Cath.(2016), “ Cognitive

remediation therapy (CRT) as a treatment enhancer of eating disorders and obsessive-compulsive disorders:

study protocol for a randomized controlled trial”, BMC Psychiatry,16.

Wykes, T., V. Huddy, C. Cellard, S.R. McGurk, and P. Czobor. (2011), “A meta-analysis of

cognitive remediation for schizophrenia: methodology and effect sizes”, American Journal of Psychiatry,

168:472–85.

20