A Study of Attentional Bias in Obsessive-Compulsive Disorder

A Study of Attentional Bias in Obsessive-Compulsive Disorder

Lubna Mehmood*1

*Correspondence to: Lubna Mehmood, Senior Clinical Psychologist, Mind Institute Special Needs Center, Doha Qatar.


© 2023 Lubna Mehmood. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 27 November 2023

Published: 01 December 2023

DOI: https://doi.org/10.5281/zenodo.10254292


The aim of the research is to study the Attention Bias in Obsessive-Compulsive Disorder in three variables. Three problems were formed: To study the difference in attention bias of OCD Patients and Healthy Controls. To study the difference in attention bias of Males and Females. To study the interaction effect between Type of Population and Gender. To study the mentioned problems; three hypotheses were assumed: 1-There will be significant difference in attentional bias of obsessive-compulsive disorder patients compared with healthy controls. 2-There will be significant difference in attentional bias of male and female. 3-There will be significant in interaction effect between type of population and gender in attention bias. There were two Independent Variables were taken: A- Types of Population (a1- OCD Patients and a2 Healthy Controls) B-Gender (b1-Male and b2-Females). The dependent variable was Attention Bias. In this study a 2x2 factorial design was used. The sample comprised 30 patients (15 males & 15 females) with current diagnosis of obsessive-compulsive disorder. The Yale-Brown Obsessive Compulsive Scale, sometimes referred to as Y-BOCS, is a test to rate the severity of Obsessive-Compulsive Scale (OCD) symptoms. The scale, which was designed by Goodman et.al (1989 a, b), is used extensively in research and research and clinical practice to both determine severity of OCD and to monitor improvement during treatment. The STROOP Neurological Screening Test was used to measure the dependent variable (Attention Bias). The Stroop Neuropsychological Screening Test, sometimes referred to as SNST, was developed with the goal of providing an efficient and sensitive neuropsychological screening measure based on the Stroop procedure. John Ridley Stroop introduced the basic format for the test in 1935. The results suggest that there is a significant difference in attention bias between OCD and healthy controls but there is no significant difference in attention bias in males and females.

Keywords: Obsessive-Compulsive Disorder, Attention Bias, Y-BOCS, Stroop Neurological Screening Test.

A Study of Attentional Bias in Obsessive-Compulsive Disorder



Attention is a selective process. Man lives in an environment. The stimuli from the environment are always affecting him. But these stimuli do not affect him equally. It is a common place observation that some stimuli affect us more than others. This shows that man selects out of environmental stimuli. This tendency of selection shows that there is a motivational process in him which is known as attention. It is a selective process which includes motivation, set, and selection. For example, if a student is motivated, he will attend the class lecture. Again, while a professor is delivering a lecture in the class, there are several other sounds being made in other rooms and the surroundings. The student who hears the lecture selects the professor’s voice out of the noise in the surroundings. While a student is attentively listening to the lecture, one can very well note his physical set which is also symbolic of his mental set. Receptor adjustment, bodily adjustment, postural adjustment, muscle attention, and central nervous adjustments are typical of body attitude in attention.

The word Attention seems to have many different meanings. When we talk about attending a lecture, we mean something like concentration. When we talk about attending a particular conversation in a crowded room, we mean a selection. When we talk about being able to attend to only so many things, we are referring to limits in capacity. When we talk about no longer having to attend to skills that we perform well, we are referring to automaticity.

Each of them recognizes that people cannot do an infinite number of different things at the same time. We cannot listen to a lecture on attention and think about the great party we attended on Friday night. We cannot process all the information about every conversation taking place at a party simultaneously, let alone all the sights, sounds, smells, and taste there. We all may be able to walk and chew gum, but without a lot of practice, it would be difficult to read one paragraph and take dictation about another. With a lot of practice, however, we do get better at doing different things at the same time.

Attention is the cognitive process of selectively concentrating on one aspect of the environment while ignoring other things. In other words, attention is the first step in observation. It is focusing the consciousness on a stimulus. It is a process of preferentially responding to a stimulus or a range of stimuli. Attention is one of the most intensely studied topics within psychology and cognitive neuroscience. Of the many cognitive processes associated with the human mind (decision-making, memory, emotion, etc.), attention is considered the most concrete because it is tied so closely to perception. As such it is a gateway to the rest of cognition.

"Everyone knows what attention is. Focalization, concentration, of consciousness is of its essence. It implies withdrawal from some things to deal effectively with others and is a condition which has a real opposite in the confused, dazed, scatterbrained state. "(James 1890)

"Attention is a state of sensory clearness with a margin and a focus. Attention is the aspect of consciousness that relates to the amount of effort exerted in focusing on certain aspects of an experience, so that they become relatively vivid". (Titchner)

"Attention is concentration of mental activity (Matlin, 1983)

"Attention is the term given to perceptual processes that select certain inputs for inclusion in our conscious experience or awareness at any given time (Morgan, king, Weisz & Schopler, 1986)

Conditions of attention -

As a selective act of mind, attention depends upon several conditions. These conditions may be of two types -

• Objective conditions:

Objective conditions are related to the environment. In the environment or surrounding of the individual there are several stimuli, but he does not attend to all of them at the same time, because some stimuli are stronger than others. The factors making these stimuli stronger than others are known as external determinants of attention.

• Subjective Conditions:

Besides the external conditions, the mental conditions, culture, and heredity also influence attention. Due to these internal conditions some objects attract our attention more than others. These internal factors are internal determinants of attention. The methods of achieving attention are based upon these external and internal determinants of attention.


Types of attention-

All attention is not conscious and selective, some attention is due to the nature of the stimulus, and some attention is due to habitual reaction. According to "Stout" there are three types of attention:

a.Voluntary Attention:

Voluntary attention is that which is willingly directed to an object for example, a student attends to his studies of his own account and not because of any external pressure; his attention will be called voluntary attention. An analysis reveals elements of desire and interest, aim and social adjustment in voluntary attention. The student directs his attention because of some aim like the passing of an examination, acquiring knowledge or one of a number of other goals. He takes interest in studying. Like other activities, attention is just another form of adjustment.

b.Involuntary Attention:

As has been explained above, involuntary attention is not only directed by the individual's desire or motivation, but it may also even be against it. It generally hinders the process of goal seeking. If, for example, your attention is attracted by a song while you are studying, your studies will suffer. Social adjustment is similarly obstructed by involuntary attention. The proper adjustment of a student can be the outcome only of an undisturbed attention to his studies. Because of the fact that one can pay attention to only one thing at a time, the student will not be able to attend to his studies if his attention continually wanders in other directions. Obviously, a person forgets his goal owing to involuntary attention and cannot affect his adjustment.

c.Habitual Attention:

Besides the two types mentioned above, there is a third type, habitual or non-voluntary attention. The difference between non-voluntary and in- voluntary attention is that the former type is the result of some habit or practice and the motivation is in the individual but the reason for the attention in the latter type is in the object. Habitual attention is different from voluntary attention because habitual attention has no need for a will as the latter does. But continued application of voluntary attention converts it into habitual attention. For example, a student pays voluntary attention to study in the beginning, but it is gradually transformed into habitual attention towards reading and writing. Thus, the position of habitual attention is in between voluntary and involuntary types of attention.


Process of Attention-

Selective attention:

Selective attention refers to the differential processing of simultaneous sources of information. For example, selective attention is one in which a person can listen to a single voice in a room full of people talking at the same time, while apparently being oblivious to all other conversations. This instance of auditory selective attention was described Dy "Cherry" (1953) when he noted that while a person may have appeared to be selectively attending to only his or her own conversation while ignoring all other voices, that person sometimes noted important stimuli, such as his or her own name. Cherry referred to this so called "Cocktail-party phenomenon". Cherry did an experiment, selective attention makes cause of a dichotic listening task, in which two different auditory messages are presented simultaneously, one to each ear, via headphones. Participants are interested in attending selectively to one of the messages and repeat or shadow this relevant message quickly. Participants have little difficulty shadowing the message; that is, they can quickly and accurately repeat the relevant message in the attended ear while repeating very little, if any, of the irrelevant message in the unattended ear. Findings from modified dichotic listening task studies seem to indicate that selectivity occurs based on the spatial location of the messages, as well as on the e basis of frequency differences between the relevant and irrelevant messages.

Impairments in Selective Attention:

A person with good selective attention can ignore distractions in the environment and pay attention to important information. Impairments in this area are evident when individuals are easily distracted by surrounding noise in their environment. For example, after brain injury, a person may have difficulty paying attention to a conversation or task if traffic is going by the window, children are playing nearby, or other people are talking in the background. People with impairments in selective attention may become easily irritated and frustrated by such extraneous noise.

Sustained Attention:

Sustained attention, or vigilance, as it is more often called, refers to the state in which attention must be maintained over time. Vigilance refers to a person's ability to attend to a field of stimulation over a prolonged period, during which the person seeks to detect the appearance of a particular target stimulus of interest. Then being vigilant, the individual watchfully waits to detect a signal stimulus that may appear at an unknown time. Typically, vigilance is needed in settings where a given stimulus occurs only rarely but requires immediate attention as soon as it does occur. Military officers watching for a sneak attack are engaged in high-stakes vigilance tasks.

Training can help to increase vigilance. But in tasks requiring sustained vigilance, fatigue hinders performance. In vigilance tasks, expectations regarding location strongly affect response efficiency. In this case, efficiency involves the speed and accuracy detecting a target stimulus.

Impairments in Sustained Attention:

Sustained attention refers to the ability to stick with an activity over time. After a brain injury, individuals often have difficulty maintaining their attention or concentration on any one task. They may become easily tired or fatigued. Tasks that they carried out prior to the injury, automatically, or without much effort (such as holding a conversation, writing a sentence, driving a car), may now require a greater amount of energy and concentration to complete. Problems with sustained attention may also show up as inconsistent performance on an activity or task. There may be periods of very accurate performance, and periods where the person makes lots of mistakes - or cannot do the task at all.

Focused Attention:

Focused attention is the ability to respond discreetly to specific Visual, auditory, or tactile stimuli. Focusing attention does not mean that all other input is suppressed. Salient stimuli, like a loud sonic boom, will typically cause people to attend to them. Most salient stimuli are often extreme along a key dimension, however. For example, salient noises are typically loud.

Thus, it would not be typical to assume that very loud sounds command attention by virtue of their extremeness.


When considering how the brain allows focused attention, it's important to first describe what is referred to as the dual processing model of attention, in other words, how the brain processes information in two - ways. The model says attention is either automatic or controlled. In automatic processing cognition occurs with little effort, is automatic given a specific stimulus, and doesn't interfere with other mental processes. Controlled processing is cognitively expensive, relies mainly on serial processing and is responsible for self-regulation. Focusing attention is dependent on top-down processing while automatic attention is more focused on bottom-up processing. Bottom-up processing is mainly triggered by the presence of environmental stimuli, while top-down processing is dependent on information in memory, including expectation of what might occur while engaging in the task.

It is generally assumed these different types of processes may involve different cortical circuitry. The ability to focus attention may be affected by the presence of various sensory cues. The ability to focus attention is limited, and the more complex the sensory environment the harder it is to focus on a particular task. The amount of effort required to complete a specific task is also important when considering the implications of the attentive process. If the task is routine little effort is required, but if the task is novel or not as familiar more effort is required.

Impairments in Focused Attention:

Focused attention refers to the most basic level of attention we can observe in others. Focused attention occurs when an individual takes notice of objects or events in the environment. With this ability, one may focus on specific sensory stimuli (things that can be seen, heard, or felt). Focused attention impairments are seen mostly in people with a decreased level of consciousness, such as those emerging from coma. When individuals emerge from coma, they gradually progress from responding only to internal states (like pain or changes in body temperature) to noticing events in the external environment.

Divided Attention:

Divided attention is the task of actively paying attention to more than one task at a time, and it is both important and common in ever day life. It is rare for someone to be engaged in just one task.

Divided attention can be improved with practice. Spelke, Hirst, and Niesser (1976) studied accuracy and response time of performance by participants reading short stories and writing down dictated words. The participants' initial performance was very poor when both tasks were performed simultaneously, but after participants practiced the tasks 5 days week for 85 sessions, their performance improved for both tasks (Sternberg & Sternberg, 2012). Spelke and others have proposed that it is possible that controlled tasks can be automatized, thus using fewer attentional resources. In addition, how well people divide their attention has to do with that person's intelligence (Hunt & Lansman, 1982, as cited in Sternberg & Sternberg, 2012). According to researchers, more intelligent people can timeshare between two tasks and effectively perform two tasks better.

There have been multiple theories regarding divided attention. One, conceived by Kahneman in 1973, explains that there is a single pool of attentional resources that can be freely divided among multiple tasks. This model seems to be too oversimplified, however, due to the different modalities (e.g., visual, auditory, verbal) that we perceive (Sternberg & Sternberg, 2012). When the two tasks are from the same modality, such as listening to a radio station and writing a paper, it is much more difficult to concentrate on both because the tasks are likely to interfere with each other. The specific modality model was theorized by Navon and Gopher in 1979. Although this model is more adequate at explaining divided attention among simple tasks, resource theory is another, more accurate metaphor for explaining divided attention on complex tasks. Resource theory demonstrates that as we automatize each complex task, performing that task requires less of our limited-capacity attentional resources (Sternberg & Sternberg, 2012).

Impairments in Divided Attention:

A person with good, divided attention skills can pay attention to two or more things at the same time. Normally our brains can take in information from several sources simultaneously. For example, we can drive our cars while listening to the radio or talking with a companion. After a brain injury. A person may have difficulty paying attention to more than one thing at a time.

The Stroop Effect –

Attention can also be involved the visual processing. One of the tasks most frequently used for this purpose was first formulated by "JohnRidley Stroop, 1935". The stroop effect named is after him. The Stroop effect is a demonstration of interference in the reaction time of a task. When the name of a color (e.g., "blue," "green," or "red") is printed in a color not denoted by the name (e.g., the word "red" printed in blue ink instead of red ink), naming the color of the word takes longer and is more prone to errors than when the color of the ink matches the name of the color.

In his experiments, Stroop administered several variations of the same test for which three different kinds of stimuli were created. In the first one, the names of colors appeared in black ink. In the second, names of colors appeared in a different ink than the color named. Finally in the third one, there were squares of a given color.

In the first experiment, 1 and 2 were used (see first figure). The task required the participants to read the written color names of the words independently of the color of the ink (for example, they would have to read "purple" no matter what the color of its ink was). In the second experiment, stimuli 2 and 3 were used, and participants were required to say the color of the letters independently of the written word with the second kind of stimulus and name the color of the dot squares. If the word "purple" was written in red, they would have to say "red", but not "purple"; when the squares were shown, the participant would have to say its color. Stroop, in the third experiment, tested his participants at different stages of practice at the tasks and stimulus used in the first and second experiments, to account for the effects of association.

Stroop noted that participants took much longer to complete the color reading in the second task than they had taken to name the colors of the squares in Experiment 2. This delay had not appeared in the first experiment. Such interference was explained by the automation of reading, where the mind automatically determines the semantic meaning of the word (it reads the word "red" and thinks of the color "red"), and then must intentionally check itself and identify instead the color of the word (the ink is a color other than red), a process that is not automatized.

Attention Biasness –

Attentional bias is the tendency for a particular class of stimuli to capture attention. Attentional bias can also refer to the tendency of our perception to be affected by our recurring thoughts.

Attentional bias is an occurrence wherein a person focuses more of his attention toward a specific stimulus or a sensory cue. Often, this leads to a poor sense of judgment or an incomplete recollection of a certain event or memory. Attentional biases can also lead to poor decision-making, as the person already has a bias towards one stimulus and may more likely base his decision on that preference.


Some psychologists believe that humans already tend to carry out an attention bias in some situations due to the "evolution of human intelligence" and the need to survive. For this reason, people usually give more of their attention to stimuli that pose a threat to them, such as a gun when a person is being mugged on the street. This "hyper attention" is usually associated with sensory responses such as a tunnel vision, in which the frightened person temporarily loses his peripheral vision and focuses on the threatening object. It also usually sets off some physiological responses such as an adrenaline rush and an increased heart rate, even a neurological reaction that allows the person to have a faster reflex when the situation becomes worse.

A moderate level of attentional bias may be innate in humans, but an elevated level may be a symptom or a result of a psychological disorder. One approach to measuring this bias is the "Stroop task." In this test, color- pertaining words are written out in different colors; for example, the word "blue" is written out in the color yellow. The patient is then asked to say out loud the color of the word, not the word itself; in the aforementioned example, the correct answer would be "yellow" and not "blue." A person with a high level of attentional bias may take longer to answer correctly. In some case studies, it was shown that participants who had severe anxieties and phobias had a difficult time saying the color of some suggestive words such as "spider" or "blood," as their inclination to focus on the word itself gets in the way of getting the main task done. Several types of cognitive bias occur due to attentional bias. One example occurs when a person does not examine all possible outcomes when making a judgment about a correlation or association. They may focus on one or two possibilities, while ignoring the rest.

Attentional bias has also been studied not only in relation to phobias and psychological disorders, but also in the context of alcoholism and substance abuse. In separate experiments, participants, consisting of drug users and drinkers, exhibited more responses to words or objects that implied drugs or alcohol, or had an increased craving for the substances. These results may give an explanation as to why it is helpful for recovering substance abusers to avoid any situations involving drugs or alcohol.

Attentional biases can also influence what information people are likely to focus upon. For instance, patients with anxiety disorders and chronic pain show increased attention to information representing their concerns (i.e., angry, and painful facial expressions respectively) in studies using the dot-probe paradigm. It is important to note that two different forms of attentional bias may be measured. A within-subjects bias occurs when an individual displays greater bias towards one type of information (e.g., painful faces) when compared to different types of information (e.g., neutral faces). A between-subjects bias, alternatively, occurs when one group of participants displays greater bias than another group of participants (e.g., chronic pain patients shown greater bias towards painful expressions than healthy control participants). These two types of bias therefore arise due to different mechanisms, and both are not always present in the same sample of participants. Another commonly used paradigm to measure attentional biases is the Stroop paradigm.

Neurological Basis:

Attentional bias often seen in eye tracking movements is thought to be an underlying issue of addiction. Smokers linger on smoking cues compared the orbitofrontal cortex and the amygdala when presented with smoking with neutral cues. Researchers found higher activation in the insular cortex, Ques. The orbitofrontal cortex is known to be coordinated with drug-seeking behavior and the insular cortex and amygdala are involved in the autonomic and emotional state of an individual.

Neural activity is also known to decrease upon the beginning of smoking, focusing the smokers' attention on their upcoming cigarette. Therefore, when smoking cues are nearby it is harder for a smoker to concentrate on other tasks. This is seen in the activation of the dorsal anterior cingulate cortex, known for focusing attention on relevant stimuli.

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