Metacognitions in Symptomatic and Remitted Patients with Obsessive Compulsive Disorder: Preliminary Evidence for Metacognitive State and Trait Markers

Abstract

Background
The phenomenon of metacognition is instrumental in the conceptualization and management of obsessive compulsive disorder (OCD). Studies on the comparison between metacognitions in OCD patients and healthy controls or those with other clinical conditions have been conducted. We aimed to compare metacognitions among currently symptomatic OCD (S-OCD) patients, currently remitted OCD patients (R-OCD), and healthy controls (HC).

Method
This cross-sectional research was conducted in the Department of Psychiatry of a tertiary care hospital in North India. Purposive sampling method was used to recruit 40 OCD patients, including an equal number of R-OCD and S-OCD patients, and 20 HC matched for age and education. Meta-Cognition Questionnaire and Thought Control Questionnaire were used to assess metacognitive functions.

Results
The findings showed a gradient of highest maladaptive metacognitions in the S-OCD group and lowest in HC. In the OCD subgroups, specific metacognitive beliefs (negative beliefs F = 65.52; need to control thoughts F = 61.03) and strategies (worry F = 83.55; low distraction F = 105.61) remained significantly different (P ≤ 0.001) between S-OCD and R-OCD patients. Certain other metacognitions remained consistently more or less stable between S-OCD and R-OCD patients, that is, metacognitive beliefs (cognitive confidence F = 11.43; cognitive self-consciousness F = 37.12) and strategies (punishment F = 17.45; low social control F = 12.89). This finding is further corroborated by positive correlations of severity of OCD with need to control thoughts ( r = 0.66, P < 0.001), negative beliefs ( r = 0.63, P < 0.001), and worry ( r = 0.76, P < 0.001), and negative correlations with distraction ( r = – 0.79, P < 0.001).

Conclusion
The study provides preliminary evidence for specific metacognitions distinguished as potential state and trait markers for OCD, which needs to be established on a larger sample using a longitudinal study design.

Full text

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020 1
Original Article
Mariyam Bint Meraj1, Shweta Singh2, Sujit K Kar2, Eesha Sharma3, Seema Rani Sarraf4
Keywords: Obsessive-compulsive disorder,
remitted, symptomatic, maladaptive
metacognitions, thought control strategies,
trait markers, state markers
Key Messages: Symptomatic OCD patients
have higher maladaptive metacognitions
compared to remitted OCD patients.
There is preliminary evidence for specific
metacognitions to be distinguished
as potential state and trait markers.
Identification of metacognitive markers
for OCD is useful in planning subsequent
therapeutic intervention.
Obsessive compulsive disorder
(OCD) has a heterogeneous pre-
sentation of obsessive thoughts
and compulsive acts. It is known to
have a complex biopsychosocial etiolo-
gy.
1,2
The worldwide lifetime prevalence
of OCD is around 2.3%,
3
and in India,
prevalence studies found estimates vary-
ing between 1% and 3%.
4, 5
This disorder
causes substantial impairment for both
the patient and family members.
6,7
HOW TO CITE THIS ARTICLE: Meraj MB, Singh S, Kar SK, Sharma E, Sarraf SR. Metacognitions in Symptomatic and Remitted
Patients with Obsessive Compulsive Disorder: Preliminary Evidence for Metacognitive State and Trait Markers. Indian J Psychol Med.
2020;XX:1–8.
ACCESS THIS ARTICLE ONLINE
Website: journals.sagepub.com/home/szj
DOI: 10.1177/0253717620975295
Submitted: 25 Dec. 2019
Accepted: 29 Oct. 2020
Published Online: xxxx
Address for correspondence: Shweta Singh, Dept. of Psychiatry, King George’s
Medical University, Lucknow, 226003 Uttar Pradesh, India. Email: shwetabhanu3@
gmail.com
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative
Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/)
which permits non-Commercial use, reproduction and distribution of the work without further permission
provided the original work is attributed as specified on the SAGE and Open Access pages (https://
us.sagepub.com/en-us/nam/open-access-at-sage).
Copyright © 2020 Indian Psychiatric Society - South Zonal Branch
1Clinical Psychologist, Independent Researcher, Riyadh, Saudi Arabia 2Dept. of Psychiatry, George’s Medical University, Lucknow, Uttar Pradesh, India. 3Dept. of
Child and Adolescent Psychiatry, NIMHANS, Bengaluru, Karnataka, India. 4Dept. of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India.
S-OCD group and lowest in HC. In the OCD
subgroups, specific metacognitive beliefs
(negative beliefs F = 65.52; need to control
thoughts F = 61.03) and strategies (worry F
= 83.55; low distraction F = 105.61) remained
significantly different (P ≤ 0.001) between
S-OCD and R-OCD patients. Certain other
metacognitions remained consistently more
or less stable between S-OCD and R-OCD
patients, that is, metacognitive beliefs
(cognitive confidence F = 11.43; cognitive
self-consciousness F = 37.12) and strategies
(punishment F = 17.45; low social control F
= 12.89). This finding is further corroborated
by positive correlations of severity of OCD
with need to control thoughts (r = 0.66, P <
0.001), negative beliefs (r = 0.63, P < 0.001),
and worry (r = 0.76, P < 0.001), and negative
correlations with distraction (r = – 0.79, P <
0.001).
Conclusion: The study provides preliminary
evidence for specific metacognitions
distinguished as potential state and
trait markers for OCD, which needs to be
established on a larger sample using a
longitudinal study design.
Metacognitions in Symptomatic and Remitted
Patients with Obsessive Compulsive Disorder:
Preliminary Evidence for Metacognitive State
and Trait Markers
ABSTRACT
Background: The phenomenon of
metacognition is instrumental in the
conceptualization and management of
obsessive compulsive disorder (OCD).
Studies on the comparison between
metacognitions in OCD patients and
healthy controls or those with other
clinical conditions have been conducted.
We aimed to compare metacognitions
among currently symptomatic OCD (S-OCD)
patients, currently remitted OCD patients
(R-OCD), and healthy controls (HC).
Method: This cross-sectional research was
conducted in the Department of Psychiatry
of a tertiary care hospital in North India.
Purposive sampling method was used to
recruit 40 OCD patients, including an equal
number of R-OCD and S-OCD patients,
and 20 HC matched for age and education.
Meta-Cognition Questionnaire and Thought
Control Questionnaire were used to assess
metacognitive functions.
Results: The findings showed a gradient of
highest maladaptive metacognitions in the

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020
2
Meraj et al.
Recently, the construct of meta-
cognition has gained interest in the
conceptualization and management of
OCD. Commonly described as “thinking
about thinking,” metacognition refers to
the knowledge (beliefs), cognitive pro-
cesses, and strategies used to appraise,
monitor, and control thoughts. Wells
proposed
8–10
the metacognitive theory for
OCD, based on the self-regulatory execu-
tive function (S-REF) model.
11
This model
suggests that beliefs about thinking
comprise three metacognitive compo-
nents: (a) beliefs about the significance
of thoughts, (b) interpretation and expe-
riential perspectives on those thoughts,
and (c) beliefs about the need to control
thoughts and cope with them.
12
The S-REF theory postulates that the
processes of metacognition become mal-
adaptive in psychological disorders. These
maladaptive metacognitions result in
“cognitive-attentional syndrome (CAS).”
CAS is a crucial etiopathological and
maintaining style of thinking for OCD.
The identification of cognitive markers
of OCD has a significant preventive and
therapeutic implication. A trait marker
has a causal and predisposing role in a
disorder and remains more or less stable
across different phases of illness. In con-
trast, a state marker reflects dynamic
changes in cognition in various stages
of the disease. For instance, the neuro-
cognitive deficits in OCD are shown to
be stable trait markers as they remain
relatively unchanged in different phases
of OCD.
13–17
Comparative studies on metacog-
nition in OCD have been conducted
with a healthy control group and other
clinical conditions. These studies show
that beliefs about the uncontrollabil-
ity of thoughts, excessive focus on the
awareness of thinking, low cognitive
confidence, positive beliefs about worry,
and negative beliefs about worry are ele-
vated specifically in OCD.
18–24
Also, OCD
patients use punishment, worry, reap-
praisal, and social control more often as
thought control strategies.
25,26
The find-
ings of these studies show the presence
of diagnostic specificity of the metacog-
nitive processes and strategies used in
OCD vis-à-vis other anxiety conditions.
Hence, there is an indication that they
are state or trait markers of OCD.
Most studies showing maladaptive
metacognitions in OCD have been con-
ducted on symptomatic patients. It is
not clear if maladaptive metacognitions
are state dependent or state indepen-
dent and if they persist in the remitted
phase of OCD. In other words, just as
neurocognitive deficits, are they stable
and remain unchanged in the remitted
phase of OCD and hence are suggestive of
“traits markers,” or are they reversible and
merely a reflection of a phase or severity
of OCD as “state markers?” If metacog-
nitive variables are “trait” characteristics,
then the course of illness, that is, the
remission phase, should not affect them
significantly. The present study aimed to
compare metacognitions (“metacognitive
beliefs” and “thought control strate-
gies”) among OCD patients who were
symptomatic, OCD patients who were
remitted, and healthy control subjects.
It was hypothesized that OCD patients
(symptomatic and remitted) would have
more maladaptive metacognitions than
healthy controls. Furthermore, it was
also hypothesized that there would be
a significant difference among all meta-
cognitions between symptomatic and
remitted OCD patients.
Materials andMethods
Study Design and Subjects
The present cross-sectional study was
carried out in a tertiary care hospital in
North India. It was conducted between
December 2015 and May 2016. The total
sample comprised of 60 subjects, with
20 participants in each of the 3 arms,
namely: Group 1—OCD patients cur-
rently symptomatic (S-OCD), Group
2—OCD patients currently remitted
(R-OCD), and Group 3—healthy controls
(HC). A priori it was planned to have at
least 20 subjects in each arm based on
a previous study by Bannon et al.
13
con-
ducted on 20 S-OCD, 20 R-OCD, and 20
panic disorder subjects that confirmed
the presence of specific executive func-
tion deficits in OCD, and indicated
deficits to be trait-like in nature. The
subjects were group matched for age and
years of education; after recruitment of
the patients, the group-matched controls
were recruited in the study.
OCD patients were recruited from the
outpatient services of the Department of
Psychiatry by using the purposive sam-
pling method. The inclusion criteria for
patients were: age 180–50 years, a diag-
nosis of OCD as per DSM-5, receiving
standard anti-obsessive pharmacother-
apy under a consulting psychiatrist, with
minimum education up to tenth stan-
dard, and having the ability to read and
write in the Hindi language. Patients
with neurological illnesses (seizures,
traumatic brain injury, stroke, or tumor)
or intellectual disability, as indicated by
history and clinical impression, were
excluded. Those with comorbid psychi-
atric disorders, undergoing any other
therapy for OCD and having any medical
condition requiring urgent intervention,
were also excluded. Patients who met the
remission criteria as defined by “Interna-
tional Expert Consensus”
27
as having a
Yale-Brown Obsessive-Compulsive Scale
(YBOCS) score of ≤ 12 for at least the last
week were placed in the R-OCD group.
HC who scored ≤ 3 on the General Health
Questionnaire-12 (GHQ-12)
28
were purpo-
sively selected from community areas
accessible to the investigator.
Measures
Mini International Neuropsychiatric
Interview version 6.0 (MINI 6)
29
: This
is a semi-structured diagnostic interview
that contains 19 modules that evaluate
17 major psychiatric disorders. MINI has
high inter-rater reliability (k > 0.75), test–
retest reliability (0.35–1.00), and validity
(> 0.60). It was used in the present study
to rule out comorbid psychiatric illness.
YBOCS
30
: This is a clinician-rated,
10-item scale commonly used in research
and clinical practice. The Y-BOCS has
good convergent validity with other
measures of OCD. It measures obsessions
and compulsions separately. YBOCS was
used to assess the severity of OCD.
GHQ-12
28
: This is a self-administered
measure of current mental health. It
emphasizes two significant domains—
the ability to carry out normal functions
and the appearance of new and dis-
tressing experiences. This tool has good
internal consistency (Cronbach’s coef-
ficient 0.82–0.93), content validity (>
0.60), and concurrent validity (r = 0.65–
0.75).
31
In the present study, GHQ-12 was
used for HC.
Metacognition Questionnaire
(MCQ-30)
32
: The MCQ-30 is a shorter
version of the original MCQ. This self-re-
port instrument measures individual
differences in metacognitive beliefs,
judgments, and monitoring tendencies

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020
Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020 3
Original Article
significantly lower severity of OCD,
with the mean±SD Y-BOCS score being
23.55±6.62 in S-OCD and 9.10±1.77 in
R-OCD. R-OCD had a longer duration of
illness than the S-OCD group, with the
mean duration being 3.65±3.08 years in
S-OCD and 5.85±1.53 years in R-OCD.
Differences Among the
Study Groups
The differences among the three study
groups on all domains of metacogni-
tions (MCQ-30 and TCQ) are depicted by
findings of ANOVA and post hoc analysis
(Table 2, Figures 1 and 2). On MCQ-30,
compared to HC, generally, both OCD
groups scored higher on all domains.
Mostly there was a gradient in these
scores (S-OCD > R-OCD > HC), with
S-OCD scoring significantly (P < 0.001)
higher than R-OCD (high but not sig-
nificant on CC and CSC), which scored
significantly higher than HC (high but
not significant on POS).
On TCQ, OCD patients differed from
HC on all domains. While distraction,
reappraisal, and social control were sig-
nificantly highest (P < 0.001) in HC and
lowest in S-OCD (S- OCD < R-OCD <
HC), a reverse order was found for pun-
ishment and worry (S-OCD > R-OCD
> HC). However, here the differences
within the subgroups of OCD were not
significant in punishment and social
control.
Differences Between OCD
Subgroups
On conducting ANCOVA in S-OCD and
(Table 2) to study duration of illness as
a covariate and eliminate the effect of
variation in course, results showed that
the variables NEG, NC, distraction, and
worry showed a significant difference
between S-OCD and R-OCD. In contrast,
no significant difference was found on
POS, CC, CSC, punishment, reappraisal,
and social control.
Association Between
Severity of OCD and
Metacognitions
After adjusting the effect of duration, in
OCD subgroups, the correlations between
severity of illness (Y-BOCS scores) and
metacognition showed high positive
through its five subscales. The subscales
measure the domains—Factor 1: Posi-
tive beliefs about worry (positive beliefs,
POS); Factor 2: Negative beliefs about
worry concerning uncontrollability of
thoughts and danger (negative beliefs,
NEG); Factor 3: Beliefs about lack of
cognitive confidence (cognitive con-
fidence, CC); Factor 4: Beliefs about
the need to control thoughts (thought
control, NC); and Factor 5: Cognitive
self-consciousness (CSC). MCQ-30 has
good internal consistency and conver-
gent validity, with acceptable to a good
test–retest reliability level. Following
permission from the author, the Hindi
translation of MCQ was done for the
present study using the WHO-recom-
mended back-translation method.
Thought Control Questionnaire
(TCQ)
33
: This is a 30-item self-report
instrument devised to measure the effec-
tiveness of strategies used for controlling
unwanted thoughts. This questionnaire
includes five factors, rated on a four-point
Likert scale: distraction, punishment,
reappraisal, worry, and social control. The
TCQ scale is sensitive to changes associ-
ated with recovery.
34
The instrument has
high internal consistency and reliability.
For this study, the Hindi translation of
TCQ was done using the WHO-recom-
mended back-translation method after
seeking permission from the author.
Procedure
Ethical clearance was obtained from
the institutional ethics committee. The
diagnosis of OCD was established as per
DSM-5 by the treating consultant psychi-
atrist. GHQ-12 was used for recruiting
HC. After seeking written informed
consent, sociodemographic pro forma
was completed for all subjects to collect
information related to age, gender,
education, history, family history, per-
sonal history, and medical history. The
assessment was carried out at a mutu-
ally convenient time in the Department
of Psychiatry. Patients were advised not
to take benzodiazepine medication 12
h before assessment. MCQ-30 and TCQ
were applied to all subjects. Besides,
other assessment instruments, MINI,
and Y-BOCS were used for the patients.
Data Analysis
Analysis was done using descriptive
statistics and making comparisons
among various groups. For the analysis
of sociodemographic characteristics,
discrete (categorical) data were summa-
rized as proportions and percentages
(%). Chi-square test was applied for the
comparision of categorical variables.
The quantitative data were repre-
sented as mean±SD, on which t-test was
used. The normality was tested by the
Shapiro–Wilk test, which is used for
small samples. The results showed that
for each parameter, at least one group
had normality of data; therefore, para-
metric tests were applied as they are
more potent.
Analysis of variance (ANOVA) and
Tukey’s post hoc test were used for com-
parison of MCQ-30 and TCQ domains
across the three groups. ANCOVA was
used in the clinical groups to eliminate
the effect of illness duration, by treating
it as a covariate. Also, a partial correlation
method was used to find an adjusted cor-
relation between the scores on severity of
OCD and metacognitions, after eliminat-
ing the effect of duration of OCD. The P
value of <0.01 and <0.001 were taken as
the significance level. The analysis was
done by using IBM-SPSS (v21) and MS
Excel.
Results
For this study, 61 OCD patients were
screened. The most common reason for
exclusion among OCD patients was a
comorbid psychiatric illness (8) (depres-
sion [4], agoraphobia [2], and social
anxiety disorder [2]). Other reasons
for exclusion were age > 50 years (2),
below the desired educational level (3),
and undergoing other therapies (5). In
total, 43 OCD subjects were taken for
assessment, and 3 did not complete the
assessment. In the control group, 25
subjects were screened, out of which 20
subjects were included. Three subjects
were below the desired education level,
and two subjects refused to give consent.
Hence, 20 in each group were taken up
for analysis.
Sociodemographic and
Clinical Characteristics
Sociodemographic characteristics were
comparable across S-OCD, R-OCD,
and HC (Table 1). Among clinical fea-
tures, as expected, the R-OCD had

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020
4
Meraj et al.
TABLE .
Sociodemographic Characteristics of Clinical Groups and Healthy Control Group
Sociodemographic
Characteristics
S-OCD
(n = 20) R-OCD (n = 20) HC (n = 20) Χ2/t
Age Mean ± SD 30.15±8.0 31.10±8.42 30.05±10.5
S-OCD vs R-OCD (P = 0.94)
S-OCD vs HC (P = 0.96)
R-OCD vs HC (P = 0.93)
Gender Male 12 (60%) 14 (70%) 13 (65%) 0.80
Female 08 (40%) 06 (30%) 07 (35%)
Education Upto10 years 02 (10%) 06 (30%) 02 (10%) 0.81
12 years 07 (35%) 05 (25%) 06 (30%)
15 years 08 (40%) 06 (30%) 07 (35%)
17 years 03 (15%) 03 (15%) 05 (25%)
Marital status Married 14 (70%) 12 (60%) 13 (65%) 0.80
Unmarried 06 (30%) 08 (40%) 07 (30%)
Occupation Unemployed 02 (10%) 01 (5%) 01 (5%) 0.99
Employed 07 (35%) 06 (30%) 08 (40%)
Homemaker 05 (25%) 06 (30%) 04 (20%)
Student 06 (30%) 07 (35%) 07 (35%)
Domicile Urban 15 (75%) 16 (80%) 18 (90%) 0.46
Rural 05 (25%) 04 (20%) 02 (10%)
Family income, per
month (INR)
< 5000 01 (5%) 01 (5%)
0
5001–10,000 03 (15%) 02 (10%) 02 (10%)
>10,000 16 (80%) 17 (85%) 18 (90%)
Y-BOCS scores Mean±SD 23.55± 6.62 9.10±1.77 –
Duration of OCD Mean±SD (in years) 3.65±3.08 5.85±1.53 –
S-OCD: symptomatic OCD patients, R-OCD: remitted OCD patients, HC: healthy controls.
TABLE .
One-Way ANOVA and Post Hoc of Metacognitions (MCQ-30 and TCQ) by Clinical Groups and Control
Group. ANCOVA (Duration of Illness as Covariate) and Correlations (Y- BOCS and Metacognitions) in
the Clinical Groups
Measures
S-OCD
(n = 20)
R-OCD
(n = 20) HC (n = 20) ANOVA N = 60
Post Hoc Analysis
ANCOVA (Du-
ration of Illness
as Covariate)
(S-OCD and
R-OCD) n = 40
Correlations
(Y-BOCS and
Metacognitions)
S-OCD and R-OCD)
n = 40
Mean±SD Mean±SD Mean±SD F-value Df = (2,57) F-value Df = (1,37)
MCQ-30
1POS 12.1±4.65 9.15±1.69 8.0±0.79 10.66** S-OCD vs R-OCD**
S-OCD vs HC**
R-OCD vs HC ns
3.68 0.55**
2NEG 19.8±2.68 15.75±3.59 10.2±1.05 65.52** S-OCD vs R-OCD **
S-OCD vs HC **
R-OCD vs **
14.51* 0.63*
3CC 8.70±2.66 9.35±2.7 6.2±0.41 11.43** S-OCD vs R-OCD ns
S-OCD vs HC **
R-OCD vs HC **
0.65 0.22
4 NC 17.z±3.39 12.85±4.12 6.9±0.55 61.03** S-OCD vs R-OCD **
S-OCD vs HC **
R-OCD vs HC **
12.81* 0.66**
5CSC 18.7±2.79 17.3±2.05 12.7±1.97 37.12** S-OCD vs R-OCD ns
S-OCD vs HC **
R-OCD vs HC **
3.65 0.49**
(Table 2 continued)

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020
Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020 5
Original Article
Measures
S-OCD
(n = 20)
R-OCD
(n = 20) HC (n = 20) ANOVA N = 60
Post Hoc Analysis
ANCOVA (Du-
ration of Illness
as Covariate)
(S-OCD and
R-OCD) n = 40
Correlations
(Y-BOCS and
Metacognitions)
S-OCD and R-OCD)
n = 40
Mean±SD Mean±SD Mean±SD F-value Df = (2,57) F-value Df = (1,37)
TCQ
1 Distraction 9.1±2.12 14.85±2.75 19.8±2.04 105.61** S-OCD vs R-OCD **
S-OCD vs HC **
R-OCD vs HC **
47.37** –0.79**
2 Punishment 11.6±3.70 9.45±3.75 6.15±0.36 17.45** S- OCD vs R-OCD ns
S-OCD vs HC **
R-OCD vs HC **
2.44 0.47**
3 Reappraisal 14.15±2.73 17±2.57 21.8±1.46 51.36** S-OCD vs R-OCD **
S-OCD vs HC **
R-OCD vs HC **
7.26 –0.64**
4 Worry 17.45±3.17 10.4±2.78 7.15±1.46 83.55** S-OCD vs R-OCD **
S-OCD vs HC **
R-OCD vs HC **
39.3** 0.76**
5 Social control 12.3±4.68 11.95±3.22 17±2.18 12.89** S-OCD vs R-OCD ns
S-OCD vs HC **
R-OCD vs HC **
1.21 –0.16
ns: not significant, S-OCD: symptomatic OCD patients, R-OCD: remitted OCD patients, HC: healthy controls, MCQ-30: Meta Cognition Questionnaire, TCQ: Thought Control Question-
naire, POS: positive belief, NEG: negative belief, CC: cognitive confidence, NC: thought control, CSC: cognitive self-consciousness.
**Significance at P < 0.001, *significance at P < 0.01.
FIGURE .
Metacognitions (Meta Cognition Questionnaire-30) by Clinical
Groups and Control Grou
S-OCD: Symptomatic OCD Patients; R-OCD: Remitted OCD patients; HC: Healthy controls; POS: Positive Belief, NEG:
Negative Belief, CC: (lack of) Cognitive Confidence; NC: Thought Control; CSC: Cognitive Self-Consciousness.
correlation with NC (r = 0.66, P ≤ 0.001),
NEG (r = 0.63, P ≤ 0.001), r = 0.76, P ≤
0.001). High negative correlation was
found with distraction (r = –0.79, P ≤
0.001) and reappraisal (r = –0.64, P ≤ 0.001)
(Table 2). Moderate positive correlations
were found on POS (r = 0.55, P ≤ 0.001), CSC
(r = 0.49, P ≤ 0.001), and punishment
(r = 0.47, P ≤ 0.001). There were poor cor-
relations with CC and social control.
Discussion
The present study looked at metacog-
nitive beliefs across symptomatic and
remitted OCD patients and healthy
controls. The three groups in the study
did not differ on any sociodemographic
characteristics. Studies show that meta-
cognitions are likely to be affected by
sociodemographic characteristics.
35–37
Majority of the participants in the
present study belonged to the age group
of 18–30 years, similar to most studies
that report higher prevalence of OCD in
young adults.
38
Differences Among the
Study Groups
Our findings of ANOVA and post hoc
(Table 2, Figures 1 and 2) of MCQ-30
and TCQ suggest that generally there
were higher unhelpful metacognitions
in both OCD subgroups. S-OCD scored
higher than R-OCD who scored higher
than HC (S-OCD > R-OCD > HC) in NEG
“negative beliefs about worry concern-
ing uncontrollability of thoughts and
danger,” NC “need to control thoughts,”
and “worry” and the reverse was found
in “distraction” and “reappraisal” (
S-OCD < R-OCD < HC). This finding
is consistent with Well’s S-REF model,
which proposes that CAS, a pattern of
thinking involving negative metacog-
nitive beliefs regarding dangerousness
and significance of intrusive thoughts,
may be the causal and maintaining
factor for OCD.
39
These findings are also
(Table 2 continued)

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020
6
Meraj et al.
because the mean duration of OCD was
different for the symptomatic and remit-
ted groups. This observation agrees with
a common reflection that patients take a
longer time to reach the remitted phase.
A closer look at post hoc analysis
and ANCOVA shows that differences
between specific metacognitions (higher
CSC, CC, punishment, and lower social
control) remain “not significant” after
post hoc and ANCOVA . On the other
hand, certain other metacognitions
(increased NEG, NC, worry, and lower
distraction) were significantly different
between the two OCD subgroups. This is
further supported by our findings of the
partial correlational analysis, which was
used to assess the adjusted correlation
between the severity of OCD and meta-
cognitions. The correlations between
severity of illness (YBOCS scores) and
metacognition showed a high positive
association with NC, NEG, and worry;
a high negative correlation with distrac-
tion; and poor correlation with CC and
social control; this further supports the
above findings. Post hoc and ANCOVA
findings are not consistent on POS and
reappraisal, and hence, their role is ques-
tionable.
Trait and State
Metacognitions and Phase
of OCD
The role of trait and state metacogni-
tions in OCD can be understood in terms
of a vicious cycle (Figure 1). Our find-
ings imply that persons with OCD have
higher traits of “cognitive self-conscious-
ness” (“I think a lot about my thoughts”),
“lack of cognitive confidence” (“I have
little confidence in my memory for
words and names”), “punishment”
(“I get angry at myself for having the
thought”), and deficits in “social control”
(“I talk to a friend about the thoughts”).
These may impact other metacognitions
that are state dependent in symptomatic
phase, namely “negative beliefs about
uncontrollability and danger of worry”
(“my worry is dangerous for me”); “need
for control,” “worry” (“I focus on dif-
ferent negative thoughts”), deficits in
adaptive thought control strategies of
“distraction” (“I think about something
else”), and “reappraisal” (“I analyze the
thought rationally”). These maladaptive
FIGURE .
Metacognitions (Thought Control Questionnaire) by Clinical
Groups and Control Group
S-OCD: Symptomatic OCD patients; R-OCD: Remitted OCD patients; HC: Healthy controls.
FIGURE .
Explaining Trait and State Metacognitions in OCD (On the Basis of
Preliminary Findings of Study)
supported by studies that have focused
on the role of unhelpful metacognitions
in distinguishing OCD patients from
non-clinical controls
.40,41
Consequently,
our first hypothesis that OCD patients
(symptomatic and remitted) will have
more maladaptive metacognitive beliefs
and thought control strategies than
healthy controls was accepted.
Differences Between OCD
Subgroups
While trying to explore differences
between the S-OCD and R-OCD, we con-
ducted ANCOVA to establish the extent
to which the differences between the sub-
groups remain unchanged with changes
in the duration of illness. This was done

Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020
Indian Journal of Psychological Medicine | Volume XX | Issue X | XXXX-XXXX 2020 7
Original Article
strategies, such as worry and punish-
ment, may result in biased perceptions of
threatening stimuli and increase intru-
sive thoughts by an increased focus on
threatening stimuli. An increase in the
chances of detecting unwanted thoughts
and triggering intrusions may lead to
other unhelpful metacognitions.
11
Our findings are consistent with earlier
studies that also found greater use of pun-
ishment and worry in patients with OCD
when compared with HC.
42–44
They found
a reduction in the use of punishment
post-treatment; we found no difference in
punishment and social control between
symptomatic and remitted patients, that
is, at both stages of OCD, punishment
was used more and social control less
than by healthy controls.
The findings suggest that this ten-
dency for state-level metacognitions
is significantly exaggerated during
the active phase of the illness. It is
possible that these dysfunctional cog-
nitions improve with time as there is
an improvement in symptoms
45,46
and
hence contribute as state markers. Our
study shows that with the progression
in the state and phase, certain unhelp-
ful metacognitions also decline. This
suggests that treatment may have a sig-
nificant effect on the severity of OCD and
the state level metacognitions. Hence,
this provides a preliminary evidence that
certain metacognitions have a role of
trait markers while certain other meta-
cognitions have a role of state markers.
Therefore, our second hypothesis that
there will be a significant difference in all
metacognitions between symptomatic
and remitted OCD patients was rejected.
Small sample size and cross-sectional
design may have impacted the findings of
this study. Moreover, comparison to some
other anxiety conditions, such as gener-
alized anxiety disorder, may have given
more information in terms of cognitive
markers of OCD. Analysis in terms of
symptom profile of OCD may have given
further information about metacogni-
tions in this disorder. Another limitation
was that the translated scales were not
validated. It is possible that other aspects
of the illness type of treatment may have
also impacted thought control strate-
gies. However, studying these variables
was not possible with our cross-sectional
design. Future studies should look at
these phenomena in a larger sample of
patients, using a longitudinal or prospec-
tive design. Identifying these dimensions
as markers in future studies may be useful
in treatment decisions, such as the use of
metacognition-focused interventions
even in the remission phase, to moderate
the risk of relapse.
The strength of this study is that it com-
pares metacognitive beliefs and thought
control strategies between OCD patients
at two stages of the illness (namely,
symptomatic and remitted phases) and
healthy controls. We included only those
OCD patients who did not have comor-
bid psychiatric disorders; therefore,
findings were not affected by the pres-
ence of, say, depression or other anxiety
disorders. Individuals with mood and
anxiety disorders have been noted to be
different in the pattern of metacognitive
beliefs and thought control strategies.
Conclusion
The study highlights the differences
in metacognitive beliefs and thought
control strategies in individuals with
OCD and healthy controls. We found
that compared to healthy controls,
OCD patients have significantly higher
unhelpful metacognitive beliefs. These
findings showed a gradient, being
highest in the symptomatic OCD group
and lowest in healthy controls, suggest-
ing that the course of illness may impact
metacognition and thought control strat-
egies. However, certain metacognitive
beliefs (cognitive confidence and cog-
nitive self-consciousness) and thought
control strategies (punishment and low
social control) did not differ between the
phases of symptomatic and remitted
OCD. These small metacognitions may
play a role in all stages of illness, that is,
onset, recovery, and relapse. The study
provides preliminary evidence for the
possible role of certain metacognitions
to be trait and state markers of cognitive
and metacognitive therapy response.
Declaration of Conflicting Interests
The authors declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
Funding
The authors received no financial support for the
research, authorship, and/or publication of this
article.
ORCID iD
Shweta Singh https://orcid.org/0000-0001-
7469-5114
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