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Association of Metacognitive Beliefs, Obsessive Beliefs and Symptom Severity With Quality of Life in Obsessive–Compulsive Patients

Published:September 02, 2014DOI:https://doi.org/10.1016/j.apnu.2014.08.005

      Abstract

      The aim of this study was to evaluate the association of obsessive beliefs, obsessive–compulsive disorder severity and metacognitive beliefs to the quality of life in patients with obsessive–compulsive disorder (OCD). Sixty one adults with a principal diagnosis of OCD were recruited for the study. Participants were assessed by trained clinicians using an unstructured clinical interview, the Obsessive Beliefs Questionnaire, the Yale–Brown Obsessive–Compulsive Scale, the Metacognitive Beliefs Questionnaire and the WHO Quality of Life Questionnaire. Data were analyzed using Pearson's of correlation coefficients and multiple regression analyses. Findings indicate that obsessive beliefs, severity total OCD and metacognitive beliefs were associated with total quality of life scores. Regression analysis revealed that while OCD total severity explained 40.1% of the variance in total quality of life, obsessive beliefs (perfectionism/certainty domain) and metacognitions (cognitive self-consciousness and negative beliefs about thoughts in general) explained an additional 13.7%, 7.7% and 5.4% of the variance in QoL. Findings indicate that the metacognitive beliefs associated with OCD symptom severity are different from that associated with quality of life. The implications are that metacognitive therapy aimed at symptom reduction may not necessarily result in improved QoL in OCD patients.
      Obsessive–Compulsive disorder (OCD) is a severely debilitating and usually chronic psychiatric disorder characterized by intrusive and unwanted thoughts, images or urges that are often accompanied by repetitive behaviors or mental acts. A 12-month prevalence of OCD in international settings is estimated to be 1.1% to 1.8% (
      • American Psychiatric Association
      Diagnostic and statistical manual of mental disorders: DSM-5®.
      ).
      This multidimensional mental disorder is associated with significant functional impairment across various life domains, including reduced physical functioning, increased use of healthcare services, financial difficulty, and lower overall quality of life (QoL) (
      • Vorstenbosch V.
      • Hood H.K.
      • Rogojanski J.
      • Antony M.M.
      • Summerfeldt L.J.
      • McCabe R.E.
      Exploring the relationship between OCD symptom subtypes and domains of functional impairment.
      ).
      • Hou S.Y.
      • Yen C.F.
      • Huang M.F.
      • Wang P.W.
      • Yeh Y.C.
      Quality of life and its correlates in patients with obsessive-compulsive disorder.
      compared QoL (which was assessed through WHOQoL-BREF) of OCD and non-OCD patients. Their results show that the group with OCD had worse QoL in the general, physical, psychological and social relationships domains than the control group. However, no difference was found between the two groups for the environmental domain.
      Some studies have found that QoL in patients with OCD is as bad as (
      • Moritz S.
      A review on quality of life and depression in obsessive-compulsive disorder.
      ), if not worse than (
      • Stengler-Wenzke K.
      • Kroll M.
      • Riedel-Heller S.
      • Matschinger H.
      • Angermeyer M.C.
      Quality of life in obsessive-compulsive disorder: The different impact of obsessions and compulsions.
      ), that of patients with schizophrenia and even lower in comparison with people with severe depression, heroin addicts (
      • Bobes J.
      • González M.P.
      • Bascarán M.T.
      • Arango C.
      • Sáiz P.A.
      • Bousoño M.
      Quality of life and disability in patients with obsessive-compulsive disorder.
      ) and chronic medical disease like diabetes (
      • Srivastava S.
      • Bhatia M.S.
      • Thawani R.
      • Jhanjee A.
      Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India.
      ).
      The QoL of patients with OCD has often been addressed by comparing the extent of impairment they experience in various domains of functioning. In such a consideration, QoL was found to be significantly lower in the physical, psychological well-being and social domains in OCD patients as compared to healthy controls (
      • Fontenelle I.S.
      • Fontenelle L.F.
      • Borges M.C.
      • Prazeres A.M.
      • Range B.P.
      • Mendlowicz M.V.
      • et al.
      Quality of life and symptom dimensions of patients with obsessive-compulsive disorder.
      ,
      • Srivastava S.
      • Bhatia M.S.
      • Thawani R.
      • Jhanjee A.
      Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India.
      ). Other studies have specifically explored the possible association between QoL and obsessive–compulsive symptoms. These studies have provided robust empirical evidence illustrating a correlation between different predominant symptoms of OCD and different domains of QoL in patients with OCD (
      • Fontenelle I.S.
      • Fontenelle L.F.
      • Borges M.C.
      • Prazeres A.M.
      • Range B.P.
      • Mendlowicz M.V.
      • et al.
      Quality of life and symptom dimensions of patients with obsessive-compulsive disorder.
      ,
      • Kugler B.B.
      • Lewin A.B.
      • Phares V.
      • Geffken G.R.
      • Murphy T.K.
      • Storch E.A.
      Quality of life in obsessive-compulsive disorder: The role of mediating variables.
      ,
      • Vorstenbosch V.
      • Hood H.K.
      • Rogojanski J.
      • Antony M.M.
      • Summerfeldt L.J.
      • McCabe R.E.
      Exploring the relationship between OCD symptom subtypes and domains of functional impairment.
      ). An inverse association between QoL and obsessive–compulsive symptom severity and number of symptoms (
      • Eisen J.L.
      • Mancebo M.A.
      • Pinto A.
      • Coles M.E.
      • Pagano M.E.
      • Stout R.
      • et al.
      Impact of obsessive-compulsive disorder on quality of life.
      ,
      • Kugler B.B.
      • Lewin A.B.
      • Phares V.
      • Geffken G.R.
      • Murphy T.K.
      • Storch E.A.
      Quality of life in obsessive-compulsive disorder: The role of mediating variables.
      ,
      • Masellis M.
      • Rector N.A.
      • Richter M.A.
      Quality of life in OCD: Differential impact of obsessions, compulsions, and depression comorbidity.
      ,
      • Moritz S.
      • Rufer M.
      • Fricke S.
      • Karow A.
      • Morfeld M.
      • Jelinek L.
      • et al.
      Quality of life in obsessive–compulsive disorder before and after treatment.
      ) has been reported. Other studies looking at the association of QoL with obsession and compulsion severity have found greater QoL impairment either with obsession severity (
      • Eisen J.L.
      • Mancebo M.A.
      • Pinto A.
      • Coles M.E.
      • Pagano M.E.
      • Stout R.
      • et al.
      Impact of obsessive-compulsive disorder on quality of life.
      ) or with compulsion severity (
      • Moritz S.
      • Rufer M.
      • Fricke S.
      • Karow A.
      • Morfeld M.
      • Jelinek L.
      • et al.
      Quality of life in obsessive–compulsive disorder before and after treatment.
      ). QoL impairment in OCD has also been studied in association with clinical features. Current psychiatric comorbidity, such as co-morbid depression or anxiety, has been indicated as contributing to the impairment of quality of life seen in OCD (
      • Eisen J.L.
      • Mancebo M.A.
      • Pinto A.
      • Coles M.E.
      • Pagano M.E.
      • Stout R.
      • et al.
      Impact of obsessive-compulsive disorder on quality of life.
      ,
      • Fontenelle I.S.
      • Fontenelle L.F.
      • Borges M.C.
      • Prazeres A.M.
      • Range B.P.
      • Mendlowicz M.V.
      • et al.
      Quality of life and symptom dimensions of patients with obsessive-compulsive disorder.
      ;
      • Masellis M.
      • Rector N.A.
      • Richter M.A.
      Quality of life in OCD: Differential impact of obsessions, compulsions, and depression comorbidity.
      • Moritz S.
      • Rufer M.
      • Fricke S.
      • Karow A.
      • Morfeld M.
      • Jelinek L.
      • et al.
      Quality of life in obsessive–compulsive disorder before and after treatment.
      ,
      • Niederauer K.G.
      • Braga D.T.
      • Souza F.P.
      • Meyer E.
      • Cordioli A.V.
      Quality of life in individuals with obsessive–compulsive disorder: A review.
      ,
      • Stengler-Wenzke K.
      • Kroll M.
      • Riedel-Heller S.
      • Matschinger H.
      • Angermeyer M.C.
      Quality of life in obsessive-compulsive disorder: The different impact of obsessions and compulsions.
      ,
      • Rodriguez-Salgado B.
      • Dolengevich-Segal H.
      • Arrojo-Romero M.
      • Castelli-Candia P.
      • Navio-Acosta M.
      • Perez-Rodriguez M.M.
      • et al.
      Perceived quality of life in obsessive–compulsive disorder: Related factors.
      ). Furthermore, OCD characterized by poor insight, low resistance, and reduced control towards their compulsions has been found to have a deteriorative course and poor clinical outcome (
      • Kashyap H.
      • Fontenelle L.F.
      • Miguel E.C.
      • Ferrão Y.A.
      • Torres A.R.
      • Shavitt R.G.
      • et al.
      Impulsive compulsivity, in obsessive–compulsive disorder: A phenotypic marker of patients with poor clinical outcome.
      ).
      Few studies have evaluated the relationship between QoL and different dimensions of etiological factors contributing to OCD. The cognitive model of OCD suggests that dysfunctional beliefs lead to the emergence of the disorder. In this model beliefs regarding the overimportance of thoughts, need to control thoughts, overestimation of threat, perfectionism, and intolerance of uncertainty are believed to be important in the escalation of normal intrusive thoughts into clinical obsessions (
      • Calkins A.W.
      • Berman N.C.
      • Wilhelm S.
      Recent advances in research on cognition and emotion in OCD: A review.
      ,
      • Smith A.H.
      • Wetterneck C.T.
      • Hart J.M.
      • Short M.B.
      • Björgvinsson T.
      Differences in obsessional beliefs and emotion appraisal in obsessive compulsive symptom presentation.
      ,
      • Steketee G.
      Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory--part 2: Factor analyses and testing of a brief version.
      ).
      Despite their role in the development and maintenance of OCD and associated distress, cognitive appraisals have not been explored thoroughly as regards their contribution to the QoL of patients with OCD (
      • Kumar A.
      • Sharma M.P.
      • Kandavel T.
      • Janardhan R.Y.C.
      Cognitive appraisals and quality of life in patients with obsessive compulsive disorder.
      ).
      • Kumar A.
      • Sharma M.P.
      • Kandavel T.
      • Janardhan R.Y.C.
      Cognitive appraisals and quality of life in patients with obsessive compulsive disorder.
      studied cognitive appraisals and QoL in patients with OCD. Their results revealed that thought control, importance of thoughts, and inflated responsibility correlated negatively with the psychological domain of QoL, implying that different dysfunctional cognitions may affect different domains of QoL. Their findings support the hypothesis that cognitive appraisals of obsessions contribute to poor QoL even after controlling for the severity of depression and OCD and duration of illness.
      While the important role of cognitive appraisals in the development and maintenance of OCD is undeniable,
      • Wells A.
      Cognitive therapy of anxiety disorders: A practice manual and conceptual guide.
      has posited that in OCD symptomatology the role of metacognitive beliefs may be more important than cognitive beliefs, since metacognitive beliefs trigger the cognitive beliefs (
      • Solem S.
      • Myers S.G.
      • Fisher P.L.
      • Vogel P.A.
      • Wells A.
      An empirical test of the metacognitive model of obsessive-compulsive symptoms: Replication and extension.
      ).
      • Wells A.
      • Matthews G.
      Attention and emotion: A clinical perspective.
      have explained this process. In their metacognitive model of obsessive–compulsive disorder, self-regulatory executive function (S-REF), they propose that obsessive thoughts are negatively interpreted as a result of metacognitive beliefs. The metacognitive model considers three types of metacognitive knowledge: thought–fusion beliefs, beliefs about the need to perform rituals, and stop signals or criteria for terminating the rituals. In the metacognitive model, interpretation of an intrusion depends upon the activation of thought–fusion beliefs, which fall into three domains: thought–action fusion (TAF), thought–event fusion (TEF) and thought–object fusion (TOF). In Wells' model, TAF refers to the fusion between thoughts and actions, TEF refers to the belief that a thought can cause an event or can be in itself evidence that an event has occurred, and TOF refers to the belief that thoughts, feelings or memories can be passed to other people or into objects (
      • Önen S.
      • Karakaş Uğurlu G.
      • Çayköylü A.
      The relationship between metacognitions and insight in obsessive–compulsive disorder.
      ). According to the S-REF model, a thought or intrusion triggers the fusion beliefs leading to negative appraisals which in turn activate beliefs about rituals. Beliefs about rituals are assumptions regarding the need to perform rituals and neutralizing actions in response to intrusions. The rituals and neutralizing behaviors are carried out until some internal subjective criteria, or stop signals, are met (
      • Wells A.
      Emotional disorders and metacognition: Innovative cognitive therapy.
      ). So metacognitive beliefs about the meaning and danger associated with having specific thoughts lead to obsessive thoughts (
      • Önen S.
      • Karakaş Uğurlu G.
      • Çayköylü A.
      The relationship between metacognitions and insight in obsessive–compulsive disorder.
      ).
      • Cartwright-Hatton S.
      • Wells A.
      Beliefs about worry and intrusions: The Meta-Cognitions Questionnaire and its correlates.
      described five empirically distinct and relative dimensions of metacognition: 1) positive beliefs about worry, 2) negative beliefs about the controllability of thoughts and corresponding danger, 3) cognitive confidence, 4) negative beliefs about thoughts in general, and 5) cognitive self-consciousness. In the metacognitive model, metacognitive beliefs about thoughts and thought processes are a critical component of the dysfunctional cognitive process that drives OCD symptoms.
      Patients with OCD have been characterized by their metacognitive functioning.
      • Papageorgiou C.
      • Wells A.
      Process and meta‐cognitive dimensions of depressive and anxious thoughts and relationships with emotional intensity.
      and
      • Hermans D.
      • Engelen U.
      • Grouwels L.
      • Joos E.
      • Lemmens J.
      • Pieters G.
      Cognitive confidence in obsessive–compulsive disorder: Distrusting perception, attention and memory.
      demonstrated that OCD patients lack confidence in their cognitions, which augments doubts and ultimately compulsions.
      • Exner C.
      • Kohl A.
      • Zaudig M.
      • Langs G.
      • Lincoln T.M.
      • Rief W.
      Metacognition and episodic memory in obsessive–compulsive disorder.
      pointed out that patients with OCD possess a metacognitive characteristic termed cognitive self-consciousness, a heightened tendency to focus on their own mental processes, which makes them vulnerable to obsessions.
      • Solem S.
      • Myers S.G.
      • Fisher P.L.
      • Vogel P.A.
      • Wells A.
      An empirical test of the metacognitive model of obsessive-compulsive symptoms: Replication and extension.
      identified the metacognitive need to control thoughts as triggering OCD symptoms, while
      • Moritz S.
      • Peters M.J.
      • Laroi F.
      • Lincoln T.M.
      Metacognitive beliefs in obsessive-compulsive patients: A comparison with healthy and schizophrenia participants.
      reported negative beliefs about the malleability of worry as well as high need to control thoughts as features of patients with OCD.
      Although there is a large body of research providing support for the association of metacognitions and cognitions with OCD symptoms, no study has explored the role of these concepts as regards the QoL of OCD patients. Substantial impairment in QOL appears to persist in OCD patients even after successful reduction of symptoms with treatment (
      • Bystritsky A.
      • Saxena S.
      • Maidment K.
      • Vapnik T.
      • Tarlow G.
      • Rosen R.
      Quality-of-life changes among patients with obsessive–compulsive disorder in a partial hospitalization program.
      ). We hypothesize that this is possibly due to persisting negative cognitive appraisals and, metacognitions. As diminished QoL is characteristic of most persons with OCD, treatment of OCD should consider improvements in QoL as a desirable outcome for which a thorough understanding of the complete clinical picture of OCD is essential. Therefore, the aim of this study was to examine the relative contributions of cognitions, metacognitions and symptom severity to the quality of life in OCD patients. Although a broad construct, QoL is often defined by two primary components: an individual’s functional status and an individual’s subjective determination of how their health impacts their life (
      • Rapaport M.H.
      • Clary C.
      • Fayyad R.
      • Endicott J.
      Quality-of-life impairment in depressive and anxiety disorders.
      ). Since measures of QoL generally depend on self-report, estimates of functional status are also a function of the individual’s subjective experience of impairment. For the purposes of this study, QoL is defined as an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. QoL is a broad ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment (
      • World Health Organization
      Measuring Quality of Life: The World Health Organization Quality of Life instruments (the WHOQOL-100 and the WHO-BREF) Geneva.
      ).

      Materials & method

      Participants

      Sixty one adults with a principal diagnosis of OCD were recruited for the study. Participants were assessed by trained clinicians using an unstructured clinical interview. All patients were selected from those seeking treatment at two private clinics. The inclusion criteria used were i) a primary diagnosis of OCD according to DSM-5 criteria; ii) patients between the ages of 20 and 55 years; iii) minimum educational level of 8th grade. Exclusion criteria were i) patients with a history of psychosis, ii) patients with severe comorbid depression or anxiety. Using these criteria, a total of 78 patients were sampled. But 17 patients did not fulfill the inclusion criteria and were excluded from the study; 4 patients had had only 5 years of schooling, 7 had severe co-morbid depression, and 1 patient refused to participate in the study. From among the 61 patients, 21 were males and 40 were females. All patients ranged in age from 20 to 52 years. Patients' education levels ranged from 8 years to 16 years of schooling.

      Instruments

      Yale–Brown Obsessive–Compulsive Scale (Y-BOCS)

      The Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) is a semi-structured interview including 10 items for the measurement of OCD severity, 5 items pertaining to compulsions and 5 items to obsessions. Items are rated on a five point Likert scale from 0 (no symptoms) to 4 (extreme symptoms). These items assess time occupied, interference with activities, distress, resistance, and control. The psychometric properties including internal consistency and interrater reliability for the Y-BOCS have been found to be satisfactory (
      • Goodman W.K.
      • Price L.H.
      • Rasmussen S.A.
      • Mazure C.
      • Delgado P.
      • Heninger G.R.
      • et al.
      The Yale-Brown obsessive compulsive scale: II. Validity.
      ,
      • Goodman W.K.
      • Price L.H.
      • Rasmussen S.A.
      • Mazure C.
      • Fleischmann R.L.
      • Hill Candy L.
      • et al.
      The Yale-Brown obsessive compulsive scale: I. Development, use, and reliability.
      ). The internal consistency (Cronbach's α) for this study was found to be .82.

      World Health Organization Questionnaire on Quality of Life (WHOQoL-BREF)

      The World Health Organization Questionnaire on Quality of Life, Short Form–Iranian version consists of 26 items rated on a five point Likert scale. WHO-QoL-BREF contains four important domains of QoL including physical health (e.g., pain, energy), psychological health (e.g., positive and negative feelings), social relationships (e.g. social support, sex) and environment (e.g., safety and security, home environment). The cross-cultural reliability and validity have been proven to be good to excellent, so WHOQoL-BREF is a valid measure of QoL (
      • Skevington S.M.
      • Lotfy M.
      • O'Connell K.A.
      The World Health Organization's WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A report from the WHOQOL group.
      ,
      • WHOQOL-BREF
      • WHO
      Introduction, administration, scoring, and generic version of the assessment.
      ).

      Obsessional Beliefs Questionnaire-44 (OBQ-44)

      The OBQ-44 consists of 44 questions and assesses obsessional beliefs in three domains of: 1) inflated responsibility and overestimation of threat, 2) perfectionism and intolerance of uncertainty, 3) over-importance and need to control thoughts. Internal consistency and convergent validity are reported to be satisfactory. The questions in OBQ-44 are rated on a seven-point Likert scale rating from 1 to 7 (
      • Obsessive Compulsive Cognitions Working Group (OCCWG)
      Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part I.
      ,
      • Steketee G.
      Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory--part 2: Factor analyses and testing of a brief version.
      ).

      Metacognitions Questionnaire-65

      Metacognitions questionnaire 65-items(MCQ-65) contains five subscales measuring five dimensions of metacognition including: 1) positive beliefs about worry, 2) negative beliefs about worry concerning uncontrollability and danger, 3) beliefs about cognitive confidence, 4) beliefs about the need to control thoughts, and 5) cognitive self-consciousness. This scale has demonstrated good α reliabilities for five subscales, internal consistency, convergent validity and moderate test–retest reliability (
      • Cartwright-Hatton S.
      • Wells A.
      Beliefs about worry and intrusions: The Meta-Cognitions Questionnaire and its correlates.
      ,
      • Wells A.
      Cognitive therapy of anxiety disorders: A practice manual and conceptual guide.
      ).

      Procedure

      From among patients seeking treatment for psychological disorders at two private clinics, those who were identified with a principal diagnosis of obsessive–compulsive disorder by the clinicians providing diagnostic and treatment services, 61 consecutive cases were selected and recruited for the study. The various questionnaires were administered to the patients on an individual basis.

      Ethics Statement

      This research protocol was approved by the Ethics Committee of the University of Mohaghegh Ardabili, Iran, and written informed consent was obtained from the study participants prior to administration of the questionnaires.

      Statistical Analyses

      In addition to the descriptive statistics of means, standard deviations and percentages, Pearson's correlation coefficients and multiple regression analyses were used to test the study hypotheses.

      Results

      The demographic and clinical characteristics of the study sample are shown in Table 1. Sixty one OCD patients were recruited with the mean age of 33.4 years (SD = 11.2). 34.42% (21 out of 61) of participants were male, and 65.57% (40 out of 61) were female. 39.34% (24 out of 61) were single, and 60.65% (37 out of 61) married.
      Table 1Demographic Characteristics of Participants.
      OCD group (N = 61)
      Age in years33.4(11.2)
      Education in years11.2(3.9)
      Gender
       Male21(34.42%)
       Female40(65.57%)
      Marital status
       Single24(39.34%)
       Married37(60.65%)
      Clinical characteristics of the sample are shown in Table 2. The means and SDs of each domain from MCQ, OBQ, Y-BOCS and WHO-QoL-BREF are available in this table. The mean of Y-BOCS total is 23.48 (SD = 8.67) and is consistent with moderately severe symptoms (
      • Bobes J.
      • González M.P.
      • Bascarán M.T.
      • Arango C.
      • Sáiz P.A.
      • Bousoño M.
      Quality of life and disability in patients with obsessive-compulsive disorder.
      ).
      Table 2Mean and Standard Deviation Scores of Each of the Study Variables.
      MeanStd. deviation
      Metacognitive beliefs (MCQ)
       Total158.1026.97
       Positive worry beliefs37.879.54
       Uncontrollability & danger42.5410.55
       Beliefs about cognitive confidence24.456.95
       Negative beliefs about thoughts34.196.35
       Cognitive self-consciousness19.043.86
      Obsessive beliefs (OBQ)
       Total202.9041.12
       Overestimation of threat & responsibility76.0618.69
       Perfectionism/certainty79.0615.12
       Importance/Need to control thoughts47.7712.12
      OCD severity (Y-BOCS)
       Total23.488.67
       Compulsions12.674.67
       Obsessions10.804.61
      Quality of life (WHO-QoL-BREF)
       Total19066.10
       Physical health D157.2916.57
       Psychological health D243.5819.63
       Social relationships D340.3224.30
       Environment D447.2516.16
      Table 3 shows correlations between MCQ and Y-BOCS scores. As Table 3 shows, only the correlations between total Y-BOCS scores and total MCQ scores, domains of uncontrollability and danger and beliefs about cognitive confidence are significant.
      Table 3Correlations Between OCD Severity and Metacognitive Beliefs.
      MCQ totalPositive worry beliefsBeliefs about uncontrollability & dangerBeliefs about cognitive confidenceNegative beliefs about thoughtsCognitive self-consciousness
      Y-BOCS total.457
      P<.01.
      .291.373
      P<.05.
      .378
      P<.05.
      .273.324
      Y-BOCS compulsion.435
      P<.05.
      .288.331.310.314.349
      Y-BOCS obsession.418
      P<.05.
      .255.366
      P<.05.
      .396
      P<.05.
      .195.256
      low asterisk P < .05.
      low asterisklow asterisk P < .01.
      Correlations between OBQ and Y-BOCS scores were computed, and the findings are displayed in Table 4. Although all OBQ domains scores correlate with Y-BOCS total score, the perfectionism/certainty domain score has the highest correlation with total OCD severity as well as with the dimensions of obsession and compulsion severity.
      Table 4Correlations Between OCD Severity and Obsessive Beliefs (OBQ Scores).
      OBQ totalOverestimation of threat & responsibilityPerfectionism/CertaintyImportance of thought & need to control thought
      Y-BOCS total.698
      P<.01.
      .665
      P<.01.
      .730
      P<.01.
      .430
      P<.05.
      Y-BOCS compulsion.627
      P<.01.
      .600
      P<.01.
      .675
      P<.01.
      .361
      P<.05.
      Y-BOCS obsession.675
      P<.01.
      .642
      P<.01.
      .687
      P<.01.
      .443
      P<.05.
      low asterisk P < .05.
      low asterisklow asterisk P < .01.
      The associations of metacognitive beliefs (MCQ), cognitive appraisals (OBQ), and symptom severity (Y-BOCS) to quality of life (WHOQoL-BREF) indices are displayed in Table 5. As the table shows, OCD severity, reflected by total Y-BOCS scores, and all the cognitive appraisals, reflected by OBQ scores, correlated significantly with total quality of life (QoL) scores. However, among the metacognitive beliefs, only negative beliefs about thoughts in general correlated significantly with total QoL. An examination of the different domains of QoL revealed that overall OCD severity and total OBQ scores had significant correlations with each of the QoL domains, physical health, psychological health, social relationships and environment. But each of the OBQ domain scores correlated only with physical health QoL domain. As regards the association between metacognitive beliefs and quality of life indices, findings revealed that while MCQ total and domain scores failed to show any significant correlation with indices of quality of physical health and psychological health, total MCQ scores and scores pertaining to metacognitive beliefs about cognitive confidence correlated significantly with quality of social relationships and environment. Furthermore, negative beliefs about thoughts in general were associated with quality of social relationships.
      Table 5Correlations Between OCD Severity (Y-BOCS scores), Obsessive Beliefs (OBQ Scores) Metacognitive Beliefs (MCQ Scores) and Indices of Quality of Life (WHO-QoL-BREF).
      QOL totalPhysical healthPsychological healthSocial relationshipsEnvironment
      Y-BOCS
       Total.634
      P<.01.
      .648
      P<.01.
      .588
      P<.01.
      .485
      P<.01.
      .519
      P<.01.
       Compulsion.630
      P<.01.
      .633
      P<.01.
      .558
      P<.01.
      .511
      P<.01.
      .519
      P<.01.
       Obsession.552
      P<.01.
      .576
      P<.01.
      .539
      P<.01.
      .393
      P<.01.
      .449
      P<.05.
      OBQ
       Total.667
      P<.01.
      .665
      P<.01.
      .575
      P<.01.
      .512
      P<.01.
      .616
      P<.01.
       Responsibility/Threat530
      P<.01.
      .498
      P<.01.
      .465
      P<.01.
      .411
      P<.05.
      .515
      P<.01.
       Perfectionism/Certainty.716
      P<.01.
      .718
      P<.01.
      .684
      P<.01.
      .514
      P<.01.
      .668
      P<.01.
       Importance/Need to control thoughts.554
      P<.01.
      .593
      P<.05.
      .440
      P<.01.
      .461
      P<.01.
      .463
      P<.01.
      MCQ
       Total.342.260.162.390
      P<.05.
      .379
      P<.05.
       Positive worry beliefs.163.141.014.134.347
       Uncontrollability/Danger.258.187.200.273.229
       Cognitive confidence391
      P<.05.
      .302.259.388
      P<.05.
      .421
      P<.05.
       General cognitive beliefs.354.220.185528
      P<.01.
      .243
       Cognitive self-consciousness.006.177.113.07.02
      low asterisk P < .05.
      low asterisklow asterisk P < .01.
      To determining whether each of the parameters, metacognitive beliefs (MCQ), obsessive beliefs (OBQ) and OCD severity predicted total quality of life (QoL), a linear regression was conducted. OCD total severity and all domains of MCQ and OBQ were entered as predictors of total QOL. Our results demonstrated that OCD total severity, (β = −.34, t = 2.13, p < .05), obsessive beliefs about perfectionism/certainty, (β = −.43, t = −1.99, p < .05) and the metacognitive dimensions of cognitive self-consciousness (β = .34, t = 2.37, p < .05) and negative beliefs about thoughts in general (β = −.33, t = −2.09, p < .05) predicted 40.1%, 13.7%, 7.7% and 5.4% of the variance in total QoL.
      A similar regression was run to determine the predictors of sub-domain QoL variance. Results revealed that total OCD severity predicted 42%, (β = −.42, t = −2.16, p < .05), and obsessive beliefs about perfectionism/certainty predicted 13% (β = −.48, t = 2.07, p < .05) of the variance in quality of physical health; total OCD severity predicted 34.6%, (β = −.34, t = 2.69, p < .05), obsessive beliefs about perfectionism/certainty predicted 10.3% (β = −.51, t = −2.07, p < .05), and the metacognitive dimension of cognitive self-consciousness predicted 17.9% (β = .49, t = 3.10, p < .05) of the variance in quality of psychological health; overall OCD severity also predicted 23.5%, (β = −.11, t = 1.99, p < .05), and the metacognitive dimension of cognitive self-consciousness predicted 17.7% (β = −.58, t = −3.00, p < .05) of the variance in quality of social relationships; OCD severity, (β = −.24, t = 2.10, p < .05), obsessive beliefs about perfectionism/certainty (β = −.52, t = 1.99, p < .05), and the metacognitive dimension of cognitive self-consciousness (β = .29, t = 1.98, p < .05), accounted for 26.9%, 17.9% and 8.1% of variance in quality of environment, respectively. In other words, while OCD severity accounted for total quality of life as well as quality of physical health, psychological health, social relationships and environment, obsessive beliefs about perfectionism/certainty accounted for total quality of life as well as quality of physical health, psychological health and environment but not quality of social relationships, and the metacognitive dimension of cognitive self-consciousness accounted for total quality of life and quality of psychological health, social relationships and environment but not quality of physical health.

      Discussion

      The purpose of this study was to evaluate the relative contributions of symptom severity, obsessive beliefs and metacognitive beliefs to the quality of life in patients with obsessive–compulsive disorder (OCD). Data were analyzed using Pearson's correlation coefficients and multiple regression analyses. Findings indicate that severity of OCD, obsessive beliefs and metacognitive beliefs all contribute in varying degrees to the total quality of life of patients with OCD.
      A comparison of the quality of life endorsed by the patient sample to published Iranian norms revealed that the quality of life of the OCD patients was severely compromised in all the domains examined: physical health, psychological health, social relationships and environment. These results indicate that OCD symptoms negatively influence the conditions required for maintaining good quality of life in the various domains. Significant differences between OCD patients and healthy controls in domain scores of QoL have been reported earlier (
      • Bobes J.
      • González M.P.
      • Bascarán M.T.
      • Arango C.
      • Sáiz P.A.
      • Bousoño M.
      Quality of life and disability in patients with obsessive-compulsive disorder.
      ;
      • Srivastava S.
      • Bhatia M.S.
      • Thawani R.
      • Jhanjee A.
      Quality of life in patients with obsessive compulsive disorder: A longitudinal study from India.
      ,
      • Vorstenbosch V.
      • Hood H.K.
      • Rogojanski J.
      • Antony M.M.
      • Summerfeldt L.J.
      • McCabe R.E.
      Exploring the relationship between OCD symptom subtypes and domains of functional impairment.
      ), and the results of the present study are consistent with them.
      In keeping with the predictions of the cognitive model that individuals with dysfunctional beliefs would evidence more obsessive intrusions and neutralizing compulsions, findings of the present study demonstrate that OCD related dysfunctional beliefs are correlated with OCD severity. To date, a lot of evidence has accumulated to confirm the presence of elevated levels of these obsessive beliefs in many, if not all, individuals with OCD symptoms (
      • Abramowitz J.S.
      • Nelson C.A.
      • Rygwall R.
      • Khandker M.
      The cognitive mediation of obsessive-compulsive symptoms: A longitudinal study.
      • Calamari J.E.
      • Cohen R.J.
      • Rector N.A.
      • Szacun-Shimizu K.
      • Riemann B.C.
      • Norberg M.M.
      Dysfunctional belief-based obsessive-compulsive disorder subgroups.
      ,
      • Taylor S.
      • Abramowitz J.S.
      • McKay D.
      • Calamari J.E.
      • Sookman D.
      • Kyrios M.
      • et al.
      Do dysfunctional beliefs play a role in all types of obsessive–compulsive disorder?.
      ), and many investigators have attempted to use obsessive beliefs to predict OCD symptoms (
      • Julien D.
      • O’Connor K.P.
      • Aardema F.
      • Todorov C.
      The specificity of belief domains in obsessive–compulsive symptom subtypes.
      ,
      • Tenney N.H.
      • Denys D.A.
      • van Megen H.J.
      • Glas G.
      • Westenberg H.G.
      Effect of a pharmacological intervention on quality of life in patients with obsessive–compulsive disorder.
      ,
      • Tolin D.F.
      • Brady R.E.
      • Hannan S.
      Obsessional beliefs and symptoms of obsessive–compulsive disorder in a clinical sample.
      ) or dimensions (
      • Wheaton M.G.
      • Abramowitz J.S.
      • Berman N.C.
      • Riemann B.C.
      • Hale L.R.
      The relationship between obsessive beliefs and symptom dimensions in obsessive–compulsive disorder.
      ). The results of this study also provide support for the broad tenets of the cognitive model of OCD.
      An investigation of metacognitions in the present sample revealed that while metacognitive beliefs on the whole did correlate with total OCD severity, specifically only beliefs about uncontrollability and danger and beliefs about the lack of cognitive confidence were associated with obsession severity. While these results do corroborate the notion of metacognitions as generic vulnerability factors for psychological distress and disorders characterized by dysregulation of thinking (
      • Cucchi M.
      • Bottelli V.
      • Cavadini D.
      • Ricci L.
      • Conca V.
      • Ronchi P.
      • et al.
      An explorative study on metacognition in obsessive-compulsive disorder and panic disorder.
      ), they are inconsistent with previous research in which cognitive self-consciousness was identified as characteristic of individuals with obsessions (
      • Exner C.
      • Kohl A.
      • Zaudig M.
      • Langs G.
      • Lincoln T.M.
      • Rief W.
      Metacognition and episodic memory in obsessive–compulsive disorder.
      ) or the need to control thoughts and negative beliefs about worry were linked to obsession severity (
      • Moritz S.
      • Peters M.J.
      • Laroi F.
      • Lincoln T.M.
      Metacognitive beliefs in obsessive-compulsive patients: A comparison with healthy and schizophrenia participants.
      ). These differences might be due to methodological differences (use of the long versus short forms of the MCQ) or sample size and characteristics. However, other studies have noted that beliefs about uncontrollability and danger and lack of cognitive confidence are elevated in patients with OCD (
      • Hermans D.
      • Martens K.
      • De Cort K.
      • Pieters G.
      • Eelen P.
      Reality monitoring and metacognitive beliefs related to cognitive confidence in obsessive–compulsive disorder.
      ,
      • Hermans D.
      • Engelen U.
      • Grouwels L.
      • Joos E.
      • Lemmens J.
      • Pieters G.
      Cognitive confidence in obsessive–compulsive disorder: Distrusting perception, attention and memory.
      ,
      • Myers S.G.
      • Wells A.
      Obsessive–compulsive symptoms: The contribution of metacognitions and responsibility.
      ). Mistrust in cognitive functioning in terms of memory and attention along with the experience of uncontrollability and danger may be a factor maintaining OCD and impeding remission (
      • Cucchi M.
      • Bottelli V.
      • Cavadini D.
      • Ricci L.
      • Conca V.
      • Ronchi P.
      • et al.
      An explorative study on metacognition in obsessive-compulsive disorder and panic disorder.
      ).
      Studies looking at QoL in OCD have identified several factors associated with QoL in OCD. In this study an attempt was made to determine the association between symptom severity, cognitive appraisals and metacognitions with indices of QoL. As expected, OCD patients with more severe symptoms, reported greater impairment in QoL. In this study the severity of both obsessions and compulsions were negatively associated with QoL in all the domains. The relationship between severity of OCD symptoms and QoL have been evaluated earlier (
      • Koran L.M.
      • Thienemann M.L.
      • Davenport R.
      Quality of life for patients with obsessive-compulsive disorder.
      ,
      • Masellis M.
      • Rector N.A.
      • Richter M.A.
      Quality of life in OCD: Differential impact of obsessions, compulsions, and depression comorbidity.
      ), and some studies have reported improvements in QoL through symptom reduction (
      • Bystritsky A.
      • Saxena S.
      • Maidment K.
      • Vapnik T.
      • Tarlow G.
      • Rosen R.
      Quality-of-life changes among patients with obsessive–compulsive disorder in a partial hospitalization program.
      • Cordioli A.V.
      • Heldt E.
      • Bochi D.B.
      • Margis R.
      • de Sousa M.B.
      • Tonello J.F.
      • et al.
      Cognitive-behavioral group therapy in obsessive–compulsive disorder: A randomized clinical trial.
      • Koran L.M.
      • Hackett E.
      • Rubin A.
      • Wolkow R.
      • Robinson D.
      Efficacy of sertraline in the long-term treatment of obsessive–compulsive disorder.
      • Moritz S.
      • Rufer M.
      • Fricke S.
      • Karow A.
      • Morfeld M.
      • Jelinek L.
      • et al.
      Quality of life in obsessive–compulsive disorder before and after treatment.
      ,
      • Tenney N.H.
      • Denys D.A.
      • van Megen H.J.
      • Glas G.
      • Westenberg H.G.
      Effect of a pharmacological intervention on quality of life in patients with obsessive–compulsive disorder.
      ). However, the association of obsession and compulsion severity with QoL is inconsistent with the findings of other researchers (
      • Eisen J.L.
      • Mancebo M.A.
      • Pinto A.
      • Coles M.E.
      • Pagano M.E.
      • Stout R.
      • et al.
      Impact of obsessive-compulsive disorder on quality of life.
      ,
      • Masellis M.
      • Rector N.A.
      • Richter M.A.
      Quality of life in OCD: Differential impact of obsessions, compulsions, and depression comorbidity.
      ) who found obsessive but not compulsive symptoms associated significantly with QoL. This discrepancy may be attributable to sample characteristics, particularly sociodemographic differences and conditions comorbid with OCD that influence QoL (
      • Fontenelle I.S.
      • Fontenelle L.F.
      • Borges M.C.
      • Prazeres A.M.
      • Range B.P.
      • Mendlowicz M.V.
      • et al.
      Quality of life and symptom dimensions of patients with obsessive-compulsive disorder.
      ). The present study also found OCD symptom severity associated with QoL in all the domains. The inverse correlation of OCD symptom severity with QoL for psychological health and social functioning has been reported previously (
      • Lewin A.B.
      • Storch E.A.
      • Conelea C.A.
      • Woods D.W.
      • Zinner S.H.
      • Budman C.L.
      • et al.
      The roles of anxiety and depression in connecting tic severity and functional Impairment.
      • Markarian Y.
      • Larson M.J.
      • Aldea M.A.
      • Baldwin S.A.
      • Good D.
      • Berkeljon A.
      • et al.
      Multiple pathways to functional impairment in obsessive–compulsive disorder.
      • Masellis M.
      • Rector N.A.
      • Richter M.A.
      Quality of life in OCD: Differential impact of obsessions, compulsions, and depression comorbidity.
      • Moritz S.
      • Rufer M.
      • Fricke S.
      • Karow A.
      • Morfeld M.
      • Jelinek L.
      • et al.
      Quality of life in obsessive–compulsive disorder before and after treatment.
      ,
      • Rapaport M.H.
      • Clary C.
      • Fayyad R.
      • Endicott J.
      Quality-of-life impairment in depressive and anxiety disorders.
      ), but the finding that OCD symptom severity may also relate to quality of physical health is contrasting. There have been few studies (
      • Albert U.
      • Maina G.
      • Bogetto F.
      • Chiarle A.
      • Mataix-Cols D.
      Clinical predictors of health-related quality of life in obsessive-compulsive disorder.
      ,
      • Eisen J.L.
      • Mancebo M.A.
      • Pinto A.
      • Coles M.E.
      • Pagano M.E.
      • Stout R.
      • et al.
      Impact of obsessive-compulsive disorder on quality of life.
      ,
      • Rodriguez-Salgado B.
      • Dolengevich-Segal H.
      • Arrojo-Romero M.
      • Castelli-Candia P.
      • Navio-Acosta M.
      • Perez-Rodriguez M.M.
      • et al.
      Perceived quality of life in obsessive–compulsive disorder: Related factors.
      ) in which impairment in the physical domains of quality of life of OCD patients has been noted. This finding might imply that OCD symptoms place the individual at risk for physical health problems or it may just reflect cultural differences in the perception of QoL. It is not uncommon for psychiatric patients in Iran to express psychological distress through the report of physical problems.
      Cognitive appraisals as reflected by the obsessive beliefs endorsed by the OCD patients were found to correlate negatively and significantly with QoL scores in all the domains. In published literature (
      • Belloch A.
      • Morillo C.
      • Lucero M.
      • Cabedo E.
      • Carrió C.
      Intrusive thoughts in non‐clinical subjects: The role of frequency and unpleasantness on appraisal ratings and control strategies.
      • Clark D.A.
      • Purdon C.
      • Byers E.S.
      Appraisal and control of sexual and non-sexual intrusive thoughts in university students.
      ,
      • Rowa K.
      • Purdon C.
      Why are certain intrusive thoughts more upsetting than others?.
      ), the contribution of cognitive appraisals of obsessions to psychological distress has been underscored. It is, therefore, likely that obsessive beliefs contribute to poor QoL in OCD through creating negative affect states. There has been only one study (
      • Kumar A.
      • Sharma M.P.
      • Kandavel T.
      • Janardhan R.Y.C.
      Cognitive appraisals and quality of life in patients with obsessive compulsive disorder.
      ) that has addressed the role of obsessive beliefs in the QoL of OCD patients. In the study by
      • Kumar A.
      • Sharma M.P.
      • Kandavel T.
      • Janardhan R.Y.C.
      Cognitive appraisals and quality of life in patients with obsessive compulsive disorder.
      , cognitive appraisals were found to contribute to impaired QoL even after controlling comorbid depression and illness duration. These authors concluded that apart from symptom reduction, specific belief modification interventions are required to augment the QoL of OCD patients. As the instrument used to measure cognitive appraisals differ from that used in the present study, direct comparisons are not possible. Yet, similar to the previous study, the present study found beliefs regarding the importance of thought control and inflated responsibility as contributing to QoL of OCD patients.
      This is the first study to investigate the role of metacognitions in the QoL of OCD patients. The results of this study lend support to the argument that metacognitive beliefs are important in OCD (
      • Fisher P.L.
      Obsessive compulsive disorder: a comparison of CBT and the metacognitive approach.
      ,
      • Myers S.G.
      • Wells A.
      Obsessive–compulsive symptoms: The contribution of metacognitions and responsibility.
      ,
      • Solem S.
      • Myers S.G.
      • Fisher P.L.
      • Vogel P.A.
      • Wells A.
      An empirical test of the metacognitive model of obsessive-compulsive symptoms: Replication and extension.
      ). Metacognitions were found to be associated with general Qol as well as for the social relationships and environment domains of QoL. Specifically, negative beliefs about thoughts in general and beliefs about cognitive confidence correlated with QoL in social relationships, and the former was also associated with QoL of environment. In the absence of published literature regarding the role of metacognitive beliefs in the QoL of OCD patients, the obtained findings cannot be elucidated within a reliable background and empirically robust evidence. There have been studies (
      • Fisher P.L.
      • Wells A.
      Metacognitive therapy for obsessive–compulsive disorder: A case series.
      ,
      • Rees C.S.
      • van Koesveld K.E.
      An open trial of group metacognitive therapy for obsessive–compulsive disorder.
      ) demonstrating substantial reductions in OCD severity consequent to treatment aimed at modifying metacognitive beliefs. As OCD severity does correlate with QoL (e.g.
      • Lewin A.B.
      • Storch E.A.
      • Conelea C.A.
      • Woods D.W.
      • Zinner S.H.
      • Budman C.L.
      • et al.
      The roles of anxiety and depression in connecting tic severity and functional Impairment.
      ), findings of the current study point to the relevance of the metacognitive model to the understanding and modification of QoL in OCD. As metacognitive beliefs about uncontrollability and danger have been found to be a predictor of OCD symptoms (
      • Irak M.
      • Tosun A.
      Exploring the role of metacognition in obsessive–compulsive and anxiety symptoms.
      ), and cognitive confidence has also been previously reported as being related to either OCD global severity (
      • Hermans D.
      • Engelen U.
      • Grouwels L.
      • Joos E.
      • Lemmens J.
      • Pieters G.
      Cognitive confidence in obsessive–compulsive disorder: Distrusting perception, attention and memory.
      ,
      • Nedeljkovic M.
      • Moulding R.
      • Kyrios M.
      • Doron G.
      The relationship of cognitive confidence to OCD symptoms.
      ) or depressive symptoms in OCD (
      • Moritz S.
      • Peters M.J.
      • Laroi F.
      • Lincoln T.M.
      Metacognitive beliefs in obsessive-compulsive patients: A comparison with healthy and schizophrenia participants.
      ;
      • Irak M.
      • Tosun A.
      Exploring the role of metacognition in obsessive–compulsive and anxiety symptoms.
      ), the role of these metacognitive beliefs in the impaired QoL of OCD patients, as found in this study, is justified.
      Regression analysis revealed that OCD total severity, obsessive beliefs (perfectionism/certainty domain) and metacognitions (cognitive self-consciousness and negative beliefs about thoughts in general) were able to predict QoL in OCD. These findings are in harmony with previous findings which demonstrated that total, compulsion and obsession scores of Y-BOCS were significantly correlated with total score of Sheehan Disability Scale (
      • Diefenbach G.J.
      • Abramowitz J.S.
      • Norberg M.M.
      • Tolin D.F.
      Changes in quality of life following cognitive-behavioral therapy for obsessive-compulsive disorder.
      ). In another study
      • Vorstenbosch V.
      • Hood H.K.
      • Rogojanski J.
      • Antony M.M.
      • Summerfeldt L.J.
      • McCabe R.E.
      Exploring the relationship between OCD symptom subtypes and domains of functional impairment.
      found that Y-BOCS total severity predicted overall functional impairment which was measured by Illness Intrusiveness Ratings Scale. Among the obsessive beliefs only beliefs about perfection and certainty were found to explain the variance in Qol. This is inconsistent with the results of the only one previous study (
      • Kumar A.
      • Sharma M.P.
      • Kandavel T.
      • Janardhan R.Y.C.
      Cognitive appraisals and quality of life in patients with obsessive compulsive disorder.
      ) that examined the association of cognitive appraisals to Qol in OCD. In that study,
      • Kumar A.
      • Sharma M.P.
      • Kandavel T.
      • Janardhan R.Y.C.
      Cognitive appraisals and quality of life in patients with obsessive compulsive disorder.
      found the appraisals regarding the importance of thoughts, control of thoughts and inflated personal responsibility to be associated with impaired QoL. In the present study, although these cognitive appraisals were associated with decreased QoL in OCD patients, only beliefs regarding perfectionism and intolerance of uncertainty contributed to the prediction of QoL in this OCD sample. Although this finding indicates the importance of targeting specific obsessive beliefs to improve the QoL of OCD patients, it also implies that further research with larger and more heterogeneous samples of OCD patients, with different clinical characteristics may lead to different conclusions regarding the importance of specific cognitive appraisals to the QoL of OCD patients.
      Further analyses indicated that different domains of quality of life were associated with different variables. While total OCD severity served to predict QoL in each of the domains examined, obsessive beliefs about perfection and intolerance of uncertainty and metacognitive self-consciousness together contributed to the prediction of quality of psychological health and social relationships. In addition, beliefs about perfection and intolerance of uncertainty also contributed to the quality of physical health, and metacognitive self-consciousness was found to likely impact perceived quality of the environment. Findings imply that apart from severity of compulsions, cognitions about perfection and certainty and metacognitive tendency of OCD patients to be aware of their own mental processes need to be addressed in interventions designed to improve the quality of life of these patients.
      It is of interest to note that while metacognitive beliefs about uncontrollability and danger and beliefs about cognitive confidence were associated with OCD symptom severity, neither of these beliefs contributed to the prediction of QoL in these patients. Instead, the metacognition, cognitive self-consciousness seems to play a role in the QoL of OCD patients. Cognitive self-consciousness has been found to characterize OCD patients (
      • Barahmand U.
      Meta-cognitive profiles in anxiety disorders.
      • Exner C.
      • Kohl A.
      • Zaudig M.
      • Langs G.
      • Lincoln T.M.
      • Rief W.
      Metacognition and episodic memory in obsessive–compulsive disorder.
      ) setting them apart from individuals with other psychiatric conditions. This might imply that cognitive self-consciousness is not necessarily related to OCD severity and is more or less a trait-like characteristic in individuals with OCD, making them vulnerable to impaired QoL. Further research into the specific contributions of metacognitions to specific symptom dimensions in OCD as well as to OCD dimension specific QoL is needed. In several studies (
      • Koran L.M.
      • Thienemann M.L.
      • Davenport R.
      Quality of life for patients with obsessive-compulsive disorder.
      • Bystritsky A.
      • Saxena S.
      • Maidment K.
      • Vapnik T.
      • Tarlow G.
      • Rosen R.
      Quality-of-life changes among patients with obsessive–compulsive disorder in a partial hospitalization program.
      ) absent or a minimal association between changes in OCD symptoms and changes in QoL have been reported, implying that symptom reduction through addressing correlates of symptom severity alone will not guarantee improved QoL.
      To date, no study has explored the association between metacognitive beliefs and QoL. Although OCD symptom severity has been related to metacognitions about uncontrollability and danger and the need to control thoughts (
      • Moritz S.
      • Hottenrott B.
      • Jelinek L.
      • Brooks A.M.
      • Scheurich A.
      Effects of obsessive-compulsive symptoms on neuropsychological test performance: complicating an already complicated story.
      ) and metacognitive beliefs about reduced cognitive confidence (
      • Cucchi M.
      • Bottelli V.
      • Cavadini D.
      • Ricci L.
      • Conca V.
      • Ronchi P.
      • et al.
      An explorative study on metacognition in obsessive-compulsive disorder and panic disorder.
      ), implying that metacognitive dysfunctions play a role in maintaining the disorders and are important for treatment, the findings of the current study coupled with previous ones (
      • Barahmand U.
      Meta-cognitive profiles in anxiety disorders.
      ) demonstrate that symptom reduction alone may not improve the QoL of OCD patients.
      This is the first study to investigate the role of metacognitions and the second to examine the role of cognitive appraisals in the QoL of OCD patients. However, the results of the study need to be understood within certain limitations. The relatively small sample size and lack of control over confounding comorbid psychiatric conditions limit generalization of findings. Future studies with rigorous control over sociodemographic characteristics, comorbid clinical conditions, and symptom dimensions analyzing the contribution of mediating factors will help clarify the role of metacognitions specific to symptom severity and QoL impairment in OCD.

      Conclusions

      To conclude, this study underscores the contribution of cognitive appraisals and metacognitive beliefs to QOL in patients with OCD. The study found that the metacognitive beliefs associated with obsession and compulsion severity are different from the metacognitive belief associated with QoL in OCD. Therefore, metacognitive therapy targeting metacognitive beliefs to reduce symptom severity may not necessarily lead to improved QoL in OCD patients.

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