International Journal of Cognitive Therapy

, Volume 12, Issue 3, pp 157–178 | Cite as

Comparison Between Obsessive Compulsive Disorder and Panic Disorder on Metacognitive Beliefs, Emotional Schemas, and Cognitive Flexibility

  • Gulay Oguz
  • Zekiye Celikbas
  • Sedat BatmazEmail author
  • Saime Cagli
  • Mehmet Zihni Sungur


We aimed to investigate the similarities and differences between patients with OCD and PD, and healthy control subjects (NPC) on their metacognitive beliefs, emotional schemas, and cognitive flexibility. We hypothesized that the clinical groups would score higher than the NPC group on their dysfunctional metacognitive beliefs and negative beliefs about emotional schemas, and lower than the control subjects on their cognitive flexibility. Regarding the metacognitive beliefs, the clinical groups scored higher than the NPC group on the scores of the uncontrollability and danger, the need to control thoughts subscales, and on the total score of the MCQ-30. On the uncontrollability, comprehensibility, rumination, dissimilarity, dangerousness, and guilt dimensions, and on the total score of the LESS, the clinical groups scored significantly higher than the NPC group. The NPC group obtained higher scores than the clinical groups on the Cognitive Flexibility Inventory. Focusing on the psychological concepts that differentiate patients with OCD and PD from healthy controls might help identify potential targets for psychotherapy.


Cognitive flexibility Emotional schema Metacognition Obsessive-compulsive disorder Panic disorder 


Compliance with Ethical Standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee, and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants involved in the study.

Conflict of Interest

The authors declare that they have no conflicts of interest.


  1. Allen, L. B., McHugh, R. K., & Barlow, D. H. (2008). Emotional disorders: A unified protocol.Google Scholar
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.Google Scholar
  3. Andersen, P., Toner, P., Bland, M., & McMillan, D. (2016). Effectiveness of transdiagnostic cognitive behaviour therapy for anxiety and depression in adults: A systematic review and meta-analysis. Behavioural and Cognitive Psychotherapy, 44(6), 673–690.CrossRefPubMedGoogle Scholar
  4. Aydın, O., Balıkçı, K., Çökmüş, F. P., & Ünal Aydın, P. (2019). The evaluation of metacognitive beliefs and emotion recognition in panic disorder and generalized anxiety disorder: Effects on symptoms and comparison with healthy control. Nordic Journal of Psychiatry, 1-9.
  5. Barlow, D. H. (2001). Anxiety and its disorders, The Nature and Treatment of Anxiety and Panic (second ed.): Guilford Press.Google Scholar
  6. Batmaz, S., & Özdel, K. (2015). Psychometric properties of the Turkish version of the Leahy Emotional Schema Scale-II. Anatolian Journal of Psychiatry/Anadolu Psikiyatri Dergisi, 16(Supplement 1): 23–30.Google Scholar
  7. Batmaz, S., Kaymak, S. U., Kocbiyik, S., & Turkcapar, M. H. (2014). Metacognitions and emotional schemas: A new cognitive perspective for the distinction between unipolar and bipolar depression. Comprehensive Psychiatry, 55(7), 1546–1555.CrossRefPubMedGoogle Scholar
  8. Beck, A. T., & Clark, D. A. (1997). An information processing model of anxiety: Automatic and strategic processes. Behaviour Research and Therapy, 35(1), 49–58.CrossRefPubMedGoogle Scholar
  9. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988a). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56(6), 893–897.CrossRefPubMedGoogle Scholar
  10. Beck, A. T., Steer, R. A., & Carbin, M. G. (1988b). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8(1), 77–100.CrossRefGoogle Scholar
  11. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571.CrossRefPubMedGoogle Scholar
  12. Blakey, S. M., Jacoby, R. J., Reuman, L., & Abramowitz, J. S. (2016). The relative contributions of experiential avoidance and distress tolerance to OC symptoms. Behavioural and Cognitive Psychotherapy, 44(4), 460–471. Scholar
  13. Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. Scholar
  14. Boisseau, C. L., Farchione, T. J., Fairholme, C. P., Ellard, K. K., & Barlow, D. H. (2010). The development of the unified protocol for the transdiagnostic treatment of emotional disorders: A case study. Cognitive and Behavioral Practice, 17(1), 102–113.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and intrusions: The meta-cognitions questionnaire and its correlates. Journal of Anxiety Disorders, 11(3), 279–296.CrossRefPubMedGoogle Scholar
  16. Clark, D. A. (2004). Intrusive thoughts in clinical disorders: Theory, research and treatment. New York: The Guilford Press.Google Scholar
  17. Cucchi, M., Bottelli, V., Cavadini, D., Ricci, L., Conca, V., Ronchi, P., & Smeraldi, E. (2012). An explorative study on metacognition in obsessive-compulsive disorder and panic disorder. Comprehensive Psychiatry, 53(5), 546–553. Scholar
  18. de Jonge, P., Roest, A. M., Lim, C. C., Florescu, S. E., Bromet, E. J., Stein, D. J., et al. (2016). Cross-national epidemiology of panic disorder and panic attacks in the world mental health surveys. Depression and Anxiety, 33(12), 1155–1177. Scholar
  19. Dehlin, J. P., Morrison, K. L., & Twohig, M. P. (2013). Acceptance and commitment therapy as a treatment for scrupulosity in obsessive compulsive disorder. Behavior Modification, 37(3), 409–430.CrossRefPubMedGoogle Scholar
  20. Dennis, J. P., & Vander Wal, J. S. (2010). The cognitive flexibility inventory: Instrument development and estimates of reliability and validity. Cognitive Therapy and Research, 34(3), 241–253.CrossRefGoogle Scholar
  21. Edwards, E. R., & Wupperman, P. (2019). Research on emotional schemas: A review of findings and challenges. Clinical Psychologist, 23(1), 3–14.CrossRefGoogle Scholar
  22. Ellard, K. K., Fairholme, C. P., Boisseau, C. L., Farchione, T. J., & Barlow, D. H. (2010). Unified protocol for the transdiagnostic treatment of emotional disorders: Protocol development and initial outcome data. Cognitive and Behavioral Practice, 17(1), 88–101.CrossRefGoogle Scholar
  23. Exner, C., Kohl, A., Zaudig, M., Langs, G., Lincoln, T. M., & Rief, W. (2009). Metacognition and episodic memory in obsessive-compulsive disorder. Journal of Anxiety Disorders, 23(5), 624–631.CrossRefPubMedGoogle Scholar
  24. Fava, G. A., Rafanelli, C., Grandi, S., Conti, S., Ruini, C., Mangelli, L., & Belluardo, P. (2001). Long-term outcome of panic disorder with agoraphobia treated by exposure. Psychological Medicine, 31(5), 891–898.CrossRefPubMedGoogle Scholar
  25. Fisher, P. L., & Wells, A. (2008). Metacognitive therapy for obsessive–compulsive disorder: A case series. Journal of Behavior Therapy and Experimental Psychiatry, 39(2), 117–132.CrossRefPubMedGoogle Scholar
  26. Gloster, A. T., Klotsche, J., Chaker, S., Hummel, K. V., & Hoyer, J. (2011). Assessing psychological flexibility: What does it add above and beyond existing constructs? Psychological Assessment, 23(4), 970.CrossRefPubMedGoogle Scholar
  27. Gloster, A. T., Sonntag, R., Hoyer, J., Meyer, A. H., Heinze, S., Strohle, A., Eifert, G., & Wittchen, H. U. (2015). Treating treatment-resistant patients with panic disorder and agoraphobia using psychotherapy: A randomized controlled switching trial. Psychotherapy and Psychosomatics, 84(2), 100–109. Scholar
  28. Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Delgado, P., Heninger, G. R., & Charney, D. S. (1989b). The Yale-Brown obsessive compulsive scale. II Validity Archives of General Psychiatry, 46(11), 1012–1016.CrossRefPubMedGoogle Scholar
  29. Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., et al. (1989a). The Yale-Brown obsessive compulsive scale: I. development, use, and reliability. Archives of General Psychiatry, 46(11), 1006–1011.CrossRefPubMedGoogle Scholar
  30. Gwilliam, P., Wells, A., & Cartwright-Hatton, S. (2004). Dose meta-cognition or responsibility predict obsessive–compulsive symptoms: A test of the metacognitive model. Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 11(2), 137–144.CrossRefGoogle Scholar
  31. Harvey, A. G., & Watkins, E. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. USA: Oxford University Press.CrossRefGoogle Scholar
  32. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: The process and practice of mindful change. New York: Guilford Press.Google Scholar
  33. Hayes, S. C., Strosahl, K. D., & Wilson. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press.Google Scholar
  34. Hermans, D., Engelen, U., Grouwels, L., Joos, E., Lemmens, J., & Pieters, G. (2008). Cognitive confidence in obsessive-compulsive disorder: Distrusting perception, attention and memory. Behaviour Research and Therapy, 46(1), 98–113.CrossRefPubMedGoogle Scholar
  35. Hermans, D., Martens, K., De Cort, K., Pieters, G., & Eelen, P. (2003). Reality monitoring and metacognitive beliefs related to cognitive confidence in obsessive-compulsive disorder. Behaviour Research and Therapy, 41(4), 383–401.CrossRefPubMedGoogle Scholar
  36. Hezel, D. M., & McNally, R. J. (2016). A theoretical review of cognitive biases and deficits in obsessive-compulsive disorder. Biological Psychology, 121(Pt B), 221–232. Scholar
  37. Hisli, N. (1989). Beck Depresyon Envanterinin üniversite öğrencileri için geçerliği, güvenirliği. Psikoloji dergisi, 7(23), 3–13.Google Scholar
  38. Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. The Journal of Clinical Psychiatry, 69(4), 621–632.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Janeck, A. S., Calamari, J. E., Riemann, B. C., & Heffelfinger, S. K. (2003). Too much thinking about thinking?: Metacognitive differences in obsessive–compulsive disorder. Journal of Anxiety Disorders, 17(2), 181–195.CrossRefPubMedGoogle Scholar
  40. Jones, S. H., Thornicroft, G., Coffey, M., & Dunn, G. (1995). A brief mental health outcome scale-reliability and validity of the global assessment of functioning (GAF). The British Journal of Psychiatry, 166(5), 654–659.CrossRefPubMedGoogle Scholar
  41. Kwak, K. H., & Lee, S. J. (2015). A comparative study of early maladaptive schemas in obsessive-compulsive disorder and panic disorder. Psychiatry Research, 230(3), 757–762. Scholar
  42. Leahy, R. L. (2002). A model of emotional schemas. Cognitive and Behavioral Practice, 9, 177–190.CrossRefGoogle Scholar
  43. Leahy, R. L. (2007a). Emotional schemas and resistance to change in anxiety disorders. Cognitive and Behavioral Practice, 14, 36–45.CrossRefGoogle Scholar
  44. Leahy, R. L. (2007b). Emotional schemas and self-help: Homework compliance and obsessive-compulsive disorder. Cognitive and Behavioral Practice, 14(3), 297–302.CrossRefGoogle Scholar
  45. Leahy, R. L. (2018). Emotional schema therapy: Distinctive features. Routledge.Google Scholar
  46. Leahy, R. L., Wupperman, P., Edwards, E., Shivaji, S., & Molina, N. (2019). Metacognition and emotional schemas: Effects on depression and anxiety. International Journal of Cognitive Therapy, 12(1), 25–37.CrossRefGoogle Scholar
  47. Lee, E. B., Ong, C. W., An, W., & Twohig, M. P. (2018). Acceptance and commitment therapy for a case of scrupulosity-related obsessive-compulsive disorder. Bulletin of the Menninger Clinic, 82(4), 407–423.CrossRefPubMedGoogle Scholar
  48. Levin, M. E., MacLane, C., Daflos, S., Seeley, J. R., Hayes, S. C., Biglan, A., & Pistorello, J. (2014). Examining psychological inflexibility as a transdiagnostic process across psychological disorders. Journal of Contextual Behavioral Science, 3(3), 155–163.CrossRefPubMedPubMedCentralGoogle Scholar
  49. Lieberman, L., Gorka, S. M., Sarapas, C., & Shankman, S. A. (2017). Cognitive flexibility mediates the relation between intolerance of uncertainty and safety signal responding in those with panic disorder. Cognition & Emotion, 1–9.
  50. Meuret, A. E., Twohig, M. P., Rosenfield, D., Hayes, S. C., & Craske, M. G. (2012). Brief acceptance and commitment therapy and exposure for panic disorder: A pilot study. Cognitive and Behavioral Practice, 19(4), 606–618.Google Scholar
  51. Monkul, E. S., Tural, U., Onur, E., Fidaner, H., Alkin, T., & Shear, M. K. (2004). Panic disorder severity scale: Reliability and validity of the Turkish version. Depression and Anxiety, 20(1), 8–16. Scholar
  52. Moritz, S., Peters, M. J., Laroi, F., & Lincoln, T. M. (2010). Metacognitive beliefs in obsessive-compulsive patients: A comparison with healthy and schizophrenia participants. Cognitive Neuropsychiatry, 15(6), 531–548. Scholar
  53. Morris, L., & Mansell, W. (2018). A systematic review of the relationship between rigidity/flexibility and transdiagnostic cognitive and behavioral processes that maintain psychopathology. Journal of Experimental Psychopathology, 9(3), 2043808718779431.CrossRefGoogle Scholar
  54. Morrison, A. P., & Wells, A. (2003). A comparison of metacognitions in patients with hallucinations, delusions, panic disorder, and non-patient controls. Behaviour Research and Therapy, 41(2), 251–256.CrossRefPubMedGoogle Scholar
  55. Myers, S. G., & Wells, A. (2005). Obsessive-compulsive symptoms: The contribution of metacognitions and responsibility. Journal of Anxiety Disorders, 19(7), 806–817. Scholar
  56. Myers, S. G., Fisher, P. L., & Wells, A. (2009). An empirical test of the metacognitive model of obsessive-compulsive symptoms: Fusion beliefs, beliefs about rituals, and stop signals. Journal of Anxiety Disorders, 23(4), 436–442. Scholar
  57. Newby, J. M., McKinnon, A., Kuyken, W., Gilbody, S., & Dalgleish, T. (2015). Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clinical Psychology Review, 40, 91–110.CrossRefPubMedGoogle Scholar
  58. Pearl, S. B., & Norton, P. J. (2017). Transdiagnostic versus diagnosis specific cognitive behavioural therapies for anxiety: A meta-analysis. Journal of Anxiety Disorders, 46, 11–24.CrossRefPubMedGoogle Scholar
  59. Rector, N. A., Man, V., & Lerman, B. (2014). The expanding cognitive-behavioural therapy treatment umbrella for the anxiety disorders: Disorder-specific and transdiagnostic approaches. Canadian Journal of Psychiatry, 59(6), 301–309.CrossRefPubMedGoogle Scholar
  60. Reinholt, N., & Krogh, J. (2014). Efficacy of transdiagnostic cognitive behaviour therapy for anxiety disorders: A systematic review and meta-analysis of published outcome studies. Cognitive Behaviour Therapy, 43(3), 171–184.CrossRefPubMedGoogle Scholar
  61. Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular Psychiatry, 15(1), 53–63. Scholar
  62. Sapmaz, F., & Doğan, T. (2013). Bilişsel esnekliğin değerlendirilmesi: Bilişsel Esneklik Envanteri Türkçe versiyonunun geçerlik ve güvenirlik çalışmaları. Ankara Üniversitesi Eğitim Bilimleri Fakültesi Dergisi, 46(1), 143–161.CrossRefGoogle Scholar
  63. Sharp, K. (2012). A review of acceptance and commitment therapy with anxiety disorders. International Journal of Psychology and Psychological Therapy, 12(3), 359–372.Google Scholar
  64. Shear, M. K., Rucci, P., Williams, J., Frank, E., Grochocinski, V., Vander Bilt, J., & Wang, T. (2001). Reliability and validity of the panic disorder severity scale: Replication and extension. Journal of Psychiatric Research, 35(5), 293–296.CrossRefPubMedGoogle Scholar
  65. Sighvatsson, M. B., Salkovskis, P. M., Sigurdsson, E., Valdimarsdottir, H. B., Thorsdottir, F., & Sigurdsson, J. F. (2019). ‘You should always look at the washing machine without actually being in it!’ Thematic framework analysis of patients’ understanding of transdiagnostic cognitive behaviour therapy and its mechanisms. Psychology and Psychotherapy: Theory, Research and Practice.
  66. Silberstein, L. R., Tirch, D., & Leahy, R. L. (2012). Mindfulness, psychological flexibility and emotional schemas. International Journal of Cognitive Therapy, 5(4), 406–419.CrossRefGoogle Scholar
  67. Solem, S., Håland, Å. T., Vogel, P. A., Hansen, B., & Wells, A. (2009). Change in metacognitions predicts outcome in obsessive–compulsive disorder patients undergoing treatment with exposure and response prevention. Behaviour Research and Therapy, 47(4), 301–307.CrossRefPubMedGoogle Scholar
  68. Sun, X., Zhu, C., & So, S. H. W. (2017). Dysfunctional metacognition across psychopathologies: A meta-analytic review. European Psychiatry, 45, 139–153.CrossRefPubMedGoogle Scholar
  69. Tek, C., Uluǧ, B., Rezaki, B. G., Tanriverdi, N., Mercan, S., Demir, B., & Vargel, S. (1995). Yale-Brown obsessive compulsive scale and US National Institute of Mental Health global obsessive compulsive scale in Turkish: Reliability and validity. Acta Psychiatrica Scandinavica, 91(6), 410–413.CrossRefPubMedGoogle Scholar
  70. Tirch, D. D., Leahy, R. L., Silberstein, L. R., & Melwani, P. S. (2012). Emotional schemas, psychological flexibility, and anxiety: The role of flexible response patterns to anxious arousal. International Journal of Cognitive Therapy, 5(4), 380–391.CrossRefGoogle Scholar
  71. Tosun, A., & Irak, M. (2008). Adaptation, validity, and reliability of the metacognition Questionnaire-30 for the Turkish population, and its relationship to anxiety and obsessive-compulsive symptoms. Türk Psikiyatri Dergisi, 19(1), 67–80.PubMedGoogle Scholar
  72. Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9. Scholar
  73. Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). Increasing willingness to experience obsessions: Acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behavior Therapy, 37(1), 3–13.CrossRefPubMedGoogle Scholar
  74. Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H., & Woidneck, M. R. (2010). A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705–716. Scholar
  75. Twohig, M. P., Jennifer, C. P. V., Levina, M. E., & Hayes, S. C. (2015). Changes in psychological flexibility during acceptance and commitment therapy for obsessive compulsive disorder. Journal of Contextual Behavioral Science, 4(3), 196–202.CrossRefGoogle Scholar
  76. Twohig, M. P., Lewin, M. P. (2017). Acceptance and commitment therapy as a treatment for anxiety and depression: A review. Retrieved Utah State University, DigitalCommons@USU, from psychology faculty publications.Google Scholar
  77. Ulusoy, M., Şahin, N., & Erkman, H. T. (1998). Turkish version of the beck anxiety inventory: Psychometric properties. Journal of Cognitive Psychoterapy, 12, 28–35.Google Scholar
  78. Ulusoy, S., Yavuz, K. F., Kara, T., Karadere, M. E. (2015). The role of metacognitive processes and emotional schemas in obsessive compulsive disorder. Journal of Cognitive-Behavioral Psychotherapy and Research, 4 (3), 173-183. Turkish.
  79. Vakili, Y., Gharaee, B., & Habibi, M. (2015). Acceptance and commitment therapy, selective serotonin reuptake inhibitors and their combination in the improvement of obsessive-compulsive symptoms and experiential avoidance in patients with obsessive-compulsive disorder. Iranian journal of psychiatry and behavioral sciences, 9(2).Google Scholar
  80. Wells, A. (2009). Metacognitive therapy for anxiety and depression. New York: The Guildford Press.Google Scholar
  81. Wells, A., & Carter, K. (2001). Further tests of a cognitive model of generalized anxiety disorder: Metacognitions and worry in GAD, panic disorder, social phobia, depression, and nonpatients. Behavior Therapy, 32(1), 85–102.CrossRefGoogle Scholar
  82. Wells, A., & Cartwright-Hatton, S. (2004). A short form of the metacognitions questionnaire: properties of the MCQ-30. Behaviour research and therapy, 42(4), 385–396Google Scholar
  83. Wells, A., & Papageorgiou, C. (1998). Relationships between worry, obsessive–compulsive symptoms and meta-cognitive beliefs. Behaviour Research and Therapy, 36(9), 899–913.CrossRefPubMedGoogle Scholar
  84. Yavuz, K. F., Türkçapar, M. H., Demirel, B., & Karadere, E. (2011). Üniversite Öğrencileri ve Çalışanları Örnekleminde Leahy Duygusal Şema Ölçeği'nin Türkçe Uyarlaması, Geçerlilik ve Güvenilirliği. Düşünen Adam Psikiyatri ve Nörolojik Bilimler Dergisi, 24, 273–282.Google Scholar

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Authors and Affiliations

  1. 1.Ogrenme AkademisiSamsunTurkey
  2. 2.Psychiatry ClinicTokat Mental Health and Disorders HospitalTokatTurkey
  3. 3.Department of Psychiatry, School of MedicineTokat Gaziosmanpasa UniversityTokatTurkey
  4. 4.Department of PsychologyIstanbul Kent UniversityIstanbulTurkey

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