title: Counterfactual processing of economic action-outcome alternatives in obsessive-compulsive disorder: further evidence of impaired goal-directed behavior.
abstract: BACKGROUND
  Obsessive-compulsive disorder (OCD) is a disorder of automatic, uncontrollable behaviors and obsessive rumination. There is evidence that OCD patients have difficulties performing goal-directed actions, instead exhibiting repetitive stimulus-response habit behaviors. This might result from the excessive formation of stimulus-response habit associations or from an impairment in the ability to use outcome value to guide behavior. We investigated the latter by examining counterfactual decision making, which is the ability to use comparisons of prospective action-outcome scenarios to guide economic choice.
  
  
  METHODS
  We tested decision making (forward counterfactual) and affective responses (backward counterfactual) in 20 OCD patients and 20 matched healthy control subjects using an economic choice paradigm that previously revealed attenuation of both the experience and avoidance of counterfactual emotion in schizophrenia patients and patients with orbitofrontal cortex lesions.
  
  
  RESULTS
  The use of counterfactual comparison to guide decision making was diminished in OCD patients, who relied primarily on expected value. Unlike the apathetic affective responses previously shown to accompany this decision style, OCD patients reported increased emotional responsivity to the outcomes of their choices and to the counterfactual comparisons that typify regret and relief.
  
  
  CONCLUSIONS
  Obsessive-compulsive disorder patients exhibit a pattern of decision making consistent with a disruption in goal-directed forward modeling, basing decisions instead on the temporally present (and more rational) calculation of expected value. In contrast to this style of decision making, emotional responses in OCD were more extreme and reactive than control subjects. These results are in line with an account of disrupted goal-directed cognitive control in OCD.
authors: Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, United Kingdom; Department of Psychology, University of Cambridge, Cambridge, United Kingdom. Electronic address: claire.gillan@gmail.com.
authors: Claire M
authors: CM
authors: Gillan
authors: Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, United Kingdom; Department of Psychology, University of Cambridge, Cambridge, United Kingdom.
authors: Sharon
authors: S
authors: Morein-Zamir
authors: Bahcesehir University, Istanbul, Turkey; Department of Psychiatry, University of Cambridge, Cambridge.
authors: Muzaffer
authors: M
authors: Kaser
authors: Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, United Kingdom; Department of Psychiatry, Queen Elizabeth II Hospital, Welwyn Garden City, Hertfordshire; Postgraduate Medical School, University of Hertfordshire, Hatfield.
authors: Naomi A
authors: NA
authors: Fineberg
authors: Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, United Kingdom; Department of Psychiatry, University of Cambridge, Cambridge; South Essex Partnership Trust, Springhouse, Biggleswade Hospital, Bedfordshire, United Kingdom.
authors: Akeem
authors: A
authors: Sule
authors: Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, United Kingdom; Department of Psychiatry, University of Cambridge, Cambridge.
authors: Barbara J
authors: BJ
authors: Sahakian
authors: Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, United Kingdom; Department of Psychology, University of Cambridge, Cambridge, United Kingdom.
authors: Rudolf N
authors: RN
authors: Cardinal
authors: Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, United Kingdom; Department of Psychology, University of Cambridge, Cambridge, United Kingdom.
authors: Trevor W
authors: TW
authors: Robbins
mesh_terms: D000328:Adult; D002755:Choice Behavior; D003657:Decision Making; D004644:Emotions; D030141:Feedback, Psychological; D005715:Gambling; D006040:Goals; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D008960:Models, Psychological; D009771:Obsessive-Compulsive Disorder / Q000523:psychology*; D011581:Psychological Tests; D012201:Reward
keywords: Behavioral neuroscience; decision-making; goal-directed; habit; obsessive-compulsive disorder; regret