Rigidly Applied Rules? Revisiting Inflexibility in Obsessive Compulsive Disorder Using Multilevel Meta-Analysis

Several recent models of obsessive compulsive disorder (OCD) consider it to be a neurocognitive disorder involving inflexibility and disinhibition. Indeed, previous reviews of neuropsychological functioning in OCD suggested impaired performance in flexibility tasks. The current meta-analysis examines whether the reported differences in flexibility can be explained by general underperformance unrelated to flexibility. In addition, the role of feedback processing in inflexibility is investigated. To this end, we integrated evidence from 75 studies that compared patients with OCD with nonpsychiatric controls on at least one flexibility measure, while applying a novel approach in which task scores measuring flexibility were compared with control scores from the same tasks measuring other confounding processes. The results revealed no evidence for inflexibility in OCD, with patients' performance most parsimoniously explained by nonspecific factors. These results challenge models stressing inflexibility as an endophenotype of OCD. Methodological implications for reviewing cognitive deficits in psychopathology are discussed.