The metacognitive paradox of OCD: confidence is globally reduced but shows increased sensitivity to local evidence

Confidence is a critical metacognitive signal that guides behavior. Biases in confidence, such as excessive doubt, are hallmark features of mental health disorders, especially obsessive-compulsive disorder (OCD). Yet the underlying neurocognitive mechanisms and how they link to learning and decision-making remain elusive.

We asked patients with OCD and matched healthy controls to perform a novel rule-shifting task that incorporated trial-by-trial confidence ratings. Using a Bayesian observer model as a benchmark, we identified two distinct confidence characteristics: while patients with OCD indicated lower overall confidence, their trial-by-trial confidence ratings more accurately tracked task-relevant information, rendering their confidence reports more closely aligned with the Bayesian benchmark than those of controls. These findings challenge the idea of a simple, unified metacognitive impairment in OCD.

Instead, they suggest that OCD is linked to an enhanced responsiveness to environmental evidence and feedback during decision-making. We thank the entire team of the Yale OCD Research Clinic for their support with recruitment and clinical evaluation. We also thank Bastien Blain for helpful discussions.

This work was supported in part by the Department of Mental Health and Addiction Services of the State of Connecticut, USA, through its support of the Ribicoff Research Facilities at the Connecticut Mental Health Center in New Haven, Connecticut. The views expressed in this paper are those of the authors and do not reflect the position of the Department of Mental Health and Addiction Services or of the State of Connecticut. AML was a pre-doctoral fellow of the International Max Planck Research School on Computational Methods in Psychiatry and Ageing Research (IMPRS COMP2PSYCH) and the Yale-UCL Collaborative Student Exchange Programme during the completion of this project.

The participating institutions of the IMPRS programme are the Max Planck Institute for Human Development, Berlin, Germany, and University College London, London, UK. For more information, see: https://www.mps-ucl-centre.mpg.de/comp2psych. BAZ was supported by a Young Investigator Grant from the Brain & Behavior Research Foundation.

BAZ, HP, ASM, CB, and CP were supported by National Institute of Mental Health grant R01MH116038 (PIs: Pittenger and Anticevic). HP was additionally supported by NIMH grants R03MH128847 and R21MH115394 (PIs: Pushkarskaya and Pittenger). CP was additionally supported by NIMH grant K24MH121571 (PI: Pittenger).