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Decision-making under uncertainty in obsessive–compulsive disorder
Open accessAbstract
Obsessive compulsive disorder (OCD) produces profound morbidity. Difficulties with decision-making and intolerance of uncertainty are prominent clinical features in many patients. The nature and etiology of these deficits are poorly understood. We used a well-validated choice task, grounded in behavioral economic theory, to investigate differences in valuation and value-based choice during decision making under uncertainty in 20 unmedicated participants with OCD and 20 matched healthy controls. Participants' choices were used to assess individual decision-making characteristics. OCD participants did not differ from healthy controls in how they valued uncertain options when outcome probabilities were known (risk) but were more likely than healthy controls to avoid uncertain options when these probabilities were imprecisely specified (ambiguity). Compared to healthy controls, individuals with OCD were less consistent in their choices and less able to identify options that should be clearly preferable. These abnormalities correlated with symptom severity. These results suggest that value-based choices during decision-making are abnormal in OCD. Individuals with OCD show elevated intolerance of uncertainty, but only when outcome probabilities are themselves uncertain. Future research focused on the neural valuation network, which is implicated in value-based computations, may provide new neurocognitive insights into the pathophysiology of OCD. Deficits in decision-making processes may represent a target for therapeutic intervention.
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“Third, previous studies reported impaired adaption of the decision strategy during a decision-making task, suggesting lower flexibility in OCD [69, 70].”
From P300 and delay-discounting in obsessive–compulsive disorder (2022) · cites this paper as [70]
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“DM has been found to be impaired in a variety of psychiatric disorders including obsessive-compulsive disorder (Dittrich and Johansen, 2013; Pushkarskaya et al., 2015), eating disorders (Wu et al., 2016) and schizophrenia (Fond et al., 2013), whereas panic disorder without comorbid depression…”
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MethodIncreased Loss Aversion in Unmedicated Patients with Obsessive–Compulsive Disorder
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The ease and sureness of a decision: evidence accumulation of conflict and uncertainty
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“Significant controversy exists with regard to whether individual risk preferences are domainspecific (e.g., risky choices about stock investments versus alcohol consumption) (Weber et al., 2002; Weber and Johnson, 2009), or stable and domain-general (Einav et al., 2012; Pushkarskaya et al., 2015).”
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Fornaro, S., & Vallesi, A. (2024) · Current Psychology · doi:10.1007/s12144-023-04312-x · Cited by 21
“Interestingly, decision-making was particularly affected in conditions of uncertainty (Banca n.d.; Pushkarskaya et al., 2015), whose intolerance seems to promote information gathering and checking behaviors, especially in OCD patients (Toffolo et al., 2016) but also in subclinical (Fradkin et al.,…”
Understanding learning through uncertainty and bias
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“For example, Pushkarskaya and colleagues (2015) reported that patients with obsessive-compulsive disorder exhibited heightened aversion to ambiguity – but not risk – during cost-benefit decision-making 40 .”
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“OCD is associated with impairments in risk taking under ambiguity but not when the explicit risk is known (Kim et al., 2015; Pushkarskaya et al., 2015; Zhang et al., 2015).”
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“Prior studies have demonstrated the relationship between aversion to ambiguous monetary options and clinical symptom severity, including anxiety [14], OCD [12] and PTSD [13], suggesting that economic preferences could influence, or be affected by, the development and maintenance of these disorders.”
BackgroundSelf-citationDistinct neural dynamics underlying risk and ambiguity during valued‐based decision making
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“) In OCD, on the other hand, behavioral studies have shown aversion both to loss (33) and to ambiguity, defined as a situation in which the probabilities of possible outcomes are themselves uncertain (29, 34, 35).”
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BackgroundUnderstanding Learning Through Uncertainty and BiasPreprint
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ResultCardiac cycle affects risky decision-making
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Self-citationPerceived decision-making styles among individuals with obsessive-compulsive and hoarding disorders
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Self-citationAction sequence learning, habits, and automaticity in obsessive-compulsive disorder
Banca, P., Herrojo Ruiz, M., Gonzalez-Zalba, M. F., Biria, M., Marzuki, A. A., Piercy, T., Sule, A., Fineberg, N. A., & Robbins, T. W. (2024) · eLife · doi:10.7554/elife.87346 · Cited by 9
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BackgroundCognitive inflexibility, obsessive-compulsive symptoms and traits and poor post-pandemic adjustment
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BackgroundInfluentialEFFECT OF PROJECT MANAGEMENT PRACTICES ON IMPLEMENTATION OF KENYA PORTS AUTHORITY FUNDED PROJECTS
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BackgroundRisking Everything in Obsessive–Compulsive Disorder: An Analogue Decision-Making Study
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“Third, previous studies reported impaired adaption of the decision strategy during a decision-making task, suggesting lower flexibility in OCD [69, 70].”
Furstenberg, A., Sompolinsky, H., & Deouell, L. Y. (2023) · iScience · doi:10.1016/j.isci.2023.106373 · Cited by 4
Christensen, E., Albertella, L., Chamberlain, S. R., Suo, C., Brydevall, M., Grant, J. E., Yücel, M., & Lee, R. S. C. (2024) · Journal of Behavioral Addictions · doi:10.1556/2006.2024.00041 · Cited by 6
“Less risk-taking under uncertainty seen here is akin to the patterns observed in individuals with obsessive-compulsive disorder (Pushkarskaya et al., 2015), and perhaps signi fi es a distinct difference between PUI and other addictive behaviors, suggesting PUI could be more characteristic of…”
George, S. A., Sheynin, J., Gonzalez, R., Liberzon, I., & Abelson, J. L. (2019) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2019.00469 · Cited by 6
“(19) showed that OCD patients had higher avoidance of uncertain options, they did not appear to differ in their attitude toward risk.”
BackgroundExternally orienting cues improve cognitive control in OCD
Bednarek, L., Glover, S., Ma, X., Pittenger, C., & Pushkarskaya, H. (2024) · Journal of Behavior Therapy and Experimental Psychiatry · doi:10.1016/j.jbtep.2024.101959 · Cited by 4
Self-citationFrom Value to Saliency: Neural Computations of Subjective Value under Uncertainty in PTSDPreprint
Jia, R., Ruderman, L., Gordon, C., Ehrlich, D. B., Horváth, M., Mirchandani, S., DeFontes, C. G., Southwick, S. M., Krystal, J. H., Harpaz‐Rotem, I., et al. (2020) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2020.04.14.041467 · Cited by 4
“Decision making under risk and ambiguity has also been studied in relation with other psychiatric disorders, including higher ambiguity aversion and choice inconsistency in individuals with Obsessive Compulsive Disorder (Pushkarskaya et al. 2015), and decreased ambiguity aversion in individuals with antisocial persona…”
BackgroundResultSelf-citationSantos, J. P. L., Versace, A., Arora, M., Bertocci, M. A., Chase, H. W., Skeba, A., Graur, S., Bonar, L. K., Maffei, C., Yendiki, A., et al. (2024) · Translational Psychiatry · doi:10.1038/s41398-024-03101-9 · Cited by 4
“…targets for ablative surgery in treatment-resistant OCD [9], given that it comprises fi bers connecting cortical and subcortical (e.g., thalamus and striatum) neural regions supporting decision-making and motor control processes in which abnormalities are reported in individuals with OCD [14 – 18].”
BackgroundVahedi, J., Bahic, A., Chaliani, I., Schilbach, L., Ciupka‐Schön, B., Bellebaum, C., Pietrowsky, R., & Peterburs, J. (2025) · Psychophysiology · doi:10.1111/psyp.70142 · Cited by 3
“This observation is also in line with various other studies reporting generally less perseveration but more choice shifting under uncertainty in OCD (e.g., Hauser et al. 2017; Kanen et al. 2019; Pushkarskaya et al. 2015).”
Rapp, A. M., Ashinoff, B. K., Baker, S. C., Simpson, H. B., & Horga, G. (2024) · Computational Psychiatry · doi:10.5334/cpsy.100 · Cited by 2
LoFaro, F. M., Gueguen, M. C. M., Kapoor, A., Alvarez, E. E., Bonagura, D., & Konova, A. B. (2025) · Journal of Neuroscience · doi:10.1523/jneurosci.0679-25.2025 · Cited by 2
“As in prior work (Levy et al., 2010; Tymula et al., 2012; Pushkarskaya et al., 2015; Ruderman et al., 2016; Konova et al., 2020), we modeled participants ’ choice data with a modi fi ed power utility model that separately parameterized known-risk and ambiguity tolerance.”
InfluentialLarge environmental changes reduce valence-dependent belief updating
Berón, J. C., Solovey, G., Ferrelli, I. A., Pedreira, M. E., & Fernández, R. S. (2024) · Scientific Reports · doi:10.1038/s41598-024-61207-y · Cited by 3
“Additionally, people with higher levels of anxiety have difficulties making decisions in risky or ambiguous situations which leads to sup-optimal decisions 49,51,52 .”
BackgroundLempert, K. M., Huber, B. D., Batistuzzo, M. C., Sheshachala, K., Hezel, D. M., de Joode, N. T., Marincowitz, C., Löchner, C., Stein, D. J., Narayanaswamy, J. C., et al. (2024) · Clinical Psychological Science · doi:10.1177/21677026241289927 · Cited by 2
“…that individuals with OCD are more avoidant of risky options (Pushkarskaya et al., 2017; Sip et al., 2016; Sohn et al., 2014) but usually only when the probabilities of those options are unknown or ambiguous (Kim et al., 2015; Pushkarskaya et al., 2015; Starcke et al., 2010; Zhang et al., 2015).”
Murayama, K., Tomiyama, H., Ohono, A., Kato, K., Matsuo, A., Kang, M., & Nakao, T. (2024) · Journal of Neuropsychology · doi:10.1111/jnp.12407 · Cited by 2
“Individuals with OCD seek immediate relief from negative emotions by compulsion, being less sensitive to the negative long-term consequences of their choice (Cavedini et al., 2006; Kim et al., 2015; Pushkarskaya et al., 2015; Sachdev & Malhi, 2005).”
When radical uncertainty is too much: Clinical aspects of Conviction Narrative Theory
Linkovski, O., & Eitan, R. (2023) · Behavioral and Brain Sciences · doi:10.1017/s0140525x2200259x · Cited by 2
Compulsiveness Drives Evidence Accumulation During AmbiguityPreprint
Mandali, A., Gillan, C. M., & Voon, V. (2021) · Research Square · doi:10.21203/rs.3.rs-140450/v1 · Cited by 2
Action-sequence learning, habits and automaticity in obsessive-compulsive disorderPreprint
Banca, P., Ruiz, M. H., González-Zalba, M. F., Biria, M., Marzuki, A. A., Piercy, T., Sule, A., Fineberg, N. A., & Robbins, T. W. (2023) · medRxiv · doi:10.1101/2023.02.23.23286338 · Cited by 2
Jacoby, R. J., Klare, D. L., Armstrong, C. H., Hoeppner, S. S., Lerner, J. S., & Wilhelm, S. (2025) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2025.100955 · Cited by 1
Sen, P., Koch, K., Schmitz‐Koep, B., Gürsel, D. A., & Knolle, F. (2025) · NeuroImage · doi:10.1016/j.neuroimage.2025.121358 · Cited by 1
“Additionally, compulsions in OCD are also shown to arise from this core difficulty of regulating actions and thoughts in a goal-directed manner (Gillan, 2017; Nestadt et al., 2016; Pushkarskaya et al., 2015; Robbins, 2022).”
Appel, H., Mattes, A., & Gerlach, A. L. (2026) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2026.2618137 · Cited by 1
“From a broader perspective, the findings are in line with a general tendency in OCD (Tolin et al., 2003) and anxiety disorders (Carleton, 2012) to strive for absolute certainty, for example, when making judgments or decisions (Jacoby et al., 2014; Pushkarskaya et al., 2015).”
Smithson, M. J. (2026) · doi:10.1093/9780198960614.001.0001 · Cited by 1
Hauschildt, M., & Dar, R. (2017) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2017.12.010 · Cited by 1
Aboulomania, a Mental Disorder Characterized by Pathological Indecisiveness
Bistas, K. G., & Tabet, J. P. (2023) · Cureus · doi:10.7759/cureus.41592 · Cited by 1
“Individuals with OCD show elevated intolerance of uncertainty, but only when outcome probabilities are themselves uncertain [17].”
BackgroundNeuroimaging of Reward Processing in Anxiety and Obsessive-Compulsive Disorders
Couto, M. B., & Morgado, P. F. (2024) · Springer eBooks · doi:10.1007/978-3-031-32035-4_14-1 · Cited by 1
When uncertainty is a symptom: intolerance of uncertainty in OCD and ‘irrational’ preferences
Smith, J. N. (2023) · Journal of Medical Ethics · doi:10.1136/jme-2023-109378 · Cited by 1
Does the cardiac cycle affect decision-making under uncertainty?Preprint
Kimura, K., Kanayama, N., & Katahira, K. (2022) · Research Square · doi:10.21203/rs.3.rs-1208345/v1 · Cited by 1
“We assessed each participant’s choice of uncertain options and estimated their risk and ambiguity aversion scores (e.g., Fujino et al, 2017; Pushkarskaya et al., 2015).”
MethodResultBednarek, L., Glover, S. J., Ma, X., Pittenger, C., & Pushkarskaya, H. (2022) · medRxiv · doi:10.1101/2022.09.20.22279936 · Cited by 1
“A total of 97 unmedicated participants were recruited through the Yale OCD Research Clinic between 2012 and 2020 by posting flyers in the local community as a part of a larger series of investigations (Ma et al., 2021; Pushkarskaya et al., 2019; Pushkarskaya et al., 2015).”
MethodSelf-citationAction-sequence learning, habits and automaticity in obsessive-compulsive disorderPreprint
Banca, P., Ruiz, M. H., González-Zalba, M. F., Biria, M., Marzuki, A. A., Piercy, T., Sule, A., Fineberg, N. A., & Robbins, T. W. (2023) · eLife · doi:10.7554/elife.87346.1 · Cited by 1
Action-sequence learning, habits and automaticity in obsessive-compulsive disorderPreprint
Banca, P., Ruiz, M. H., González-Zalba, M. F., Biria, M., Marzuki, A. A., Piercy, T., Sule, A., Fineberg, N. A., & Robbins, T. W. (2023) · eLife · doi:10.7554/elife.87346.2 · Cited by 1
Action-sequence learning, habits and automaticity in obsessive-compulsive disorderPreprint
Banca, P., Ruiz, M. H., González-Zalba, M. F., Biria, M., Marzuki, A. A., Piercy, T., Sule, A., Fineberg, N. A., & Robbins, T. W. (2024) · eLife · doi:10.7554/elife.87346.3 · Cited by 1
Between Obsession and Optimization: A Model of Perfectionism and Non-Transitive PreferencesPreprint
Bayer, Y. M. (2025) · SSRN Electronic Journal · doi:10.20944/preprints202504.1514.v2
Perfectionism and Preference Cycles: A Behavioral Model of Deficiency-Penalized UtilityPreprint
Bayer, Y. M. (2025) · Preprints.org · doi:10.20944/preprints202504.1514.v3
Carter, W. (2025) · Preprints.org · doi:10.20944/preprints202505.1314.v1 · Cited by 1
Decision-making in OCD : when both acting and not acting result in some harm
Kindynis, Z. (2016)
Kaplan, C. M., & Solway, A. (2022) · Computational Psychiatry · doi:10.5334/cpsy.87
Murayama, K., Tomiyama, H., Ohno, A., Kato, K., Matsuo, A., Hasuzawa, S., Sashikata, K., Kang, M., & Nakao, T. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1227057 · Cited by 1
Disruption of consciousness depends on insight in OCD and on positive symptoms in schizophreniaPreprint
Tümkaya, S., Yücens, B., Gündüz, M., Maheu, M., & Berkovitch, L. (2024) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2024.01.02.571832
Between Obsession and Optimization: A Note on Perfectionism and Non-Transitive PreferencesPreprint
Bayer, Y. M. (2025) · Preprints.org · doi:10.20944/preprints202504.1514.v1
Metadata
- Authors
- Pushkarskaya, H., Tolin, D., Ruderman, L., Kirshenbaum, A., Kelly, J. M., Pittenger, C., & Levy, I.
- Affiliations
- Yale University (US)
- Hartford Hospital (US)
- Corresponding author
- Pushkarskaya, Helen
- Venue
- Journal of Psychiatric Research
- Publisher
- Elsevier BV
- Published
- 2015-10
- Volume
- 69
- Pages
- 166-173
- ISSN
- 0022-3956 (ISSN-L)
- PMC
- PMC4562025
- OpenAlex
- W2155549704
- Cited by
- 127
- References
- 34
- Citations by year
- 2026: 23 · 2025: 12 · 2024: 14 · 2023: 18 · 2022: 9 · 2021: 12 · 2020: 11 · 2019: 12 · 2018: 6 · 2017: 7 · 2016: 3
- FWCI
- 6.62
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Psychiatric Research (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (K01 MH101326-01, R01MH095790)
- National Institute on Aging (R01AG033406)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Decision Sciences › General Decision Sciences › Decision-Making and Behavioral Economics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- obsessive-compulsive disorder, decision making under uncertainty, intolerance of uncertainty, ambiguity, risk, value-based choice, behavioral economics, outcome valuation, decision consistency, symptom severity
- MeSH terms
- Attitude, Decision Making, Humans, Obsessive-Compulsive Disorder, Psychiatric Status Rating Scales, Psychological Tests, Risk-Taking, Severity of Illness Index, Uncertainty
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