Metacognition and the effect of incentive motivation in two compulsive disorders: gambling disorder and obsessive-compulsive disorder

Abstract

Compulsivity is a common phenotype amongst various psychiatric disorders, such as obsessive-compulsive disorder (OCD) and gambling disorder (GD). Deficiencies in metacognition, such as the inability to properly estimate ones own performance via well-calibrated confidence judgments could contribute to pathological decision-making in these psychiatric disorders. Earlier research has indeed suggested that OCD and GD patients reside at opposite ends of the confidence spectrum, with OCD patients exhibiting underconfidence, and GD patients exhibiting overconfidence. Recently, several studies established that motivational states (e.g. monetary incentives) influence metacognition, with gain (respectively loss) prospects increasing (respectively decreasing) confidence judgments. Here, we reasoned that the OCD and GD symptomatology might correspond to an exacerbation of this interaction between metacognition and motivational states. We hypothesized GDs overconfidence to be exaggerated during gain prospects, while OCDs underconfidence to be worsened in loss context, which we expected to see represented in ventromedial prefrontal cortex (VMPFC) blood-oxygen-level-dependent (BOLD) activity. We tested those hypotheses in a task-based functional magnetic resonance imaging (fMRI) design. Our initial analyses showed increased confidence levels for GD versus OCD patients, that could partly be explained by sex and IQ. Although our primary analyses did not support the hypothesized interaction between incentives and groups, exploratory analyses did show increased confidence in GD patients specifically in gain context. fMRI analyses confirmed a central role for VMPFC in the processing of confidence and incentives, but with no differences between the clinical samples. The trial is registered in the Dutch Trial Register (Trial NL6171, registration number: NTR6318) (https://www.trialregister.nl/trial/6171).