Volume 23, Issue 2 (Summer 2017)                   IJPCP 2017, 23(2): 164-177 | Back to browse issues page


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Moin Al-Ghorabaiee F, Karamloo S, Noferesti A. Metacognitive Components in Patients With Generalized Anxiety Disorder, Obsessive-Compulsive Disorder and Depressed Mood Disorder. IJPCP. 2017; 23 (2) :164-177
URL: http://ijpcp.iums.ac.ir/article-1-2352-en.html
1- , Alborz Branch, Academic Center for Education, Culture and Research
2- Alborz Branch, Academic Center for Education, Culture and Research, Alborz Branch
3- Research Group of Cognitive Sciences, Alborz Branch, Karaj, Academic Center for Education, Culture and Research, , E-mail: noferest88@yahoo.com
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Extended Abstract
1. Introduction

Metacognitive models of depression and anxiety disorders put an emphasis on the predictive role of metacognitive beliefs in experiencing negative emotions ‌[1]. Also, the selection and implementation of coping strategies are considered to be the main determinant of continuation or termination of a psychological disorder ‌[2]. Thus, people experience emotional discomfort when their metacognitive beliefs produce a special pattern of response to inward experiences that perseveres and intensifies thoughts, emotions, and negative excitements ‌[3, 4, 5]. Generally, studies conducted on metacognition imply the significant role of metacognitive beliefs in the emergence and maintenance of emotional disturbances ‌[2, 3], and reviewing them from a theoretical and practical point of view is necessary. Conducting such studies can increase our knowledge regarding reviewing metacognitive mechanisms that are regulator and controller of cognitive processes and pave the path for other studies in this area. Such studies can also provide more evidence for practical use of metacognitive therapy for emotional disturbances at various clinical positions and in different populations. Therefore, the present study aims to compare metacognitive components in people with OCD, GAD,  depressed mood disorder, and ordinary people.
2. Method
Sample, sampling method and method of implementation

The present study is a descriptive study with a causal-comparative data collection method . According to the research method, the size of each desired group should be at least 30 [18]. Accordingly, 90 people (three groups of thirty) were selected through targeted sampling from among patients with OCD, generalized anxiety, and depressed mood in Tehran city.  These people had been referred to psychiatric clinics (5 clinics of counseling and psychology services in the center of North, South, East, West and downtown of Tehran) and private psychiatric clinics (5 psychiatric clinics in North, South, East, West and downtown of Tehran) for treatment for the first time. These participants who received a diagnosis of the disorder based on a Structured Clinical Interview for DSM Disorders (SCID) and psychiatrist's diagnosis were assigned to clinical groups. Participants were asked to fill Metacognitive Beliefs-Short Form ‌[19], Anxiety Thoughts ‌[20], and Thought Control ‌[21] questionnaires. 
A group of 30 people (14 men and 16 women) who did not have any mental disorders as found by the clinical and diagnostic interviews with a psychiatrist was assigned to a non-patient group. Fourteen questionnaires were answered incompletely; therefore, in the final analysis, only 106 questionnaires were examined. To control unwanted variables and prevent probable difficulties in explaining the results, the study also included subjects that: A) Had not received any psychological treatment before; B) Did not have diagnosis of mental disorders in the axis II (without personality disorder, according to psychiatrist); C) Did not take medication (three months before the questionnaires were administered); D) The minimum level of their literacy was third grade of secondary school; E) Their age range was between 18 and 55 years old; and F) Due to the low sample size, all OCD cases were included in the research.
3. Results
Investigating the demographic characteristics of the sample group showed that among the total sample of 120, 77 subjects were women (64.2%) and 43 men (35.8%). Their age range was between 18-37 years, and their average age was 24.71 years. A total of 67 subjects had a bachelor's degree (55.8%), 28 subjects were graduate students and higher (23.4%), and 25 had upper secondary school diploma (20.8%). 
In the sample group, the mean scores of patients with general anxiety in metacognitive components of MCQ-30 and AnTI questionnaires were higher than that of other groups. On the scale of cognitive trust, the difference between significant mean of groups suggests higher scores of group of depressed mood subjects than those of generalized anxiety disorder. Scores of this group are higher than that of normal group (P<0.01). About scales of cognitive self-awareness and positive beliefs about worries, there was a significant difference only between the mean scores of two groups of generalized anxiety and depressed mood at the level of 0.05 and 0.01. On the scale of negative beliefs about worries, the difference in mean scores for ordinary, obsessive, and depressed mood groups with generalized anxiety disorder group is significant with a level of 0.05. The scores of subjects in the normal group on this scale are lower than that of other groups.
Results of multivariate analysis of variance indicated a significant difference at the level of 0.01 between the four groups studied in two approaches of thought control, punishment, and concern. Also, the results of multivariate analysis of variance indicated a significant difference (at the level of 0.01) between the four groups studied on the scales of concern areas.
4. Discussion
This study has been conducted with the aim to investigate the metacognitive components in patients with generalized anxiety disorder, obsession, depressed mood, and ordinary people. Our findings showed that there is a significant difference between all groups in all variables of metacognitive beliefs, anxious thoughts, and thought control strategies (except for social control strategy).
In this research, results of metacognitive beliefs indicate higher scores of depressed mood group in cognitive trust variable and in other metacognitive beliefs including the need for control, self-conscious, and positive and negative beliefs. The highest scores belonged to the generalized anxiety disorder group. This finding is consistent with the results of the research that showed that among metacognitive beliefs, belief in weak cognitive trust has more relationship with posterior signs of depression ‌[25]. The results of this study regarding the high scores of patients with generalized anxiety disorder in other metacognitive beliefs are consistent with the results of numerous studies, which showed that positive and negative metacognitive beliefs ‌[3, 13] and need for control ‌[26] have a relationship with general anxiety disorder.
In relation to data on anxiety thoughts, findings indicate higher scores for dimensions of anxiety thoughts in patients with generalized anxiety disorder compared to other groups. Given that, in the present study, patients with generalized anxiety disorder obtained higher scores in most metacognitive beliefs, this finding can be explained on this basis.  Findings of this study showed that patients with generalized anxiety disorder used thought control strategies of "worry" and "punishment" more than non-patient subjects. This finding is partly in line with the theoretical background of this research. Results of this study regarding comparison of thinking control strategies showed that anxious-depressed patients use the “distraction” strategy more than patients with obsessive disorder.
Acknowledgments 
Academic Center for Education, Culture and Research of Karaj has financially supported the present paper.
Conflict of Interest
The authors declared no conflicts of interest.
 
References
  1. Saed O, Purehsan S, Akbari S. Correlation among meta-cognitive beliefs and anxiety – depression symptoms. Procedia - Social and Behavioral Sciences. 2010; 5:1685–9. doi: 10.1016/j.sbspro.2010.07.346
  2. Papageorgiou C. Wells A. Meta cognitive beliefs about rumination in recurrent major depression. Cognitive & Behavior Practice. 2011, 8, 160-4.
  3. Wells A. Metacognitive therapy for Anxiety and depression. New York: Guilford press; 2009.
  4. Wells A. Emotional disorders and metacognition. New York: John Wiley & Sons Ltd; 2002. doi: 10.1002/9780470713662
  5. Wells A, Matthews G. Attention and emotion (Classic edition): A clinical perspective. Hove: Erlbaum; 2014.
  6. Papageorgiou C, Wells A. An empirical test of a clinical metacognitive model of rumination and depression. Cognitive Therapy and Research. 2003; 27(3):261-73. doi: 10.1023/A:1023962332399
  7. Wells A. Cognition about cognition: Metacognitive therapy and change in generalized anxiety disorder and social phobia. Cognitive and Behavioral Practice. 2007; 14(1):18–25. doi: 10.1016/j.cbpra.2006.01.005
  8. Papageorgiou C. Wells A. Meta cognitive beliefs about rumination in recurrent major depression. Cognitive & Behavior Practice. 2011, 8, 160-4.
  9. Wells A, King P. Metacognitive therapy for generalized anxiety disorder: An open trial. Journal of Behavior Therapy and Experimental Psychiatry. 2006; 37(3):206–12. doi: 10.1016/j.jbtep.2005.07.002
  10. Wells A, Carter K. Further tests of a cognitive model of generalized anxiety disorder: Metacognitions and worry in GAD, panic disorder, social phobia, depression, and nonpatients. Behavior Therapy. 2001; 32(1):85–102. doi: 10.1016/s0005-7894(01)80045-9
  11. Roussis P, Wells A. Post-traumatic stress symptoms: Tests of relationships with thought control strategies and beliefs as predicted by the metacognitive model. Personality and Individual Differences. 2006; 40(1):111–22. doi: 10.1016/j.paid.2005.06.019
  12. Yılmaz AE, Gençöz T, Wells A. The temporal precedence of metacognition in the development of anxiety and depression symptoms in the context of life-stress: A prospective study. Journal of Anxiety Disorders. 2011; 25(3):389–96. doi: 10.1016/j.janxdis.2010.11.001
  13. Bahrami F, Rezvan S. [Relationship between anxious thoughts and metacognitive beliefs in high school students with generalized anxiety disorder (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2007; 13(3):249-55.
  14. Akrami A, Kalantari M, Arizi HR, Abedi M, Maroofi M. [Comparison of the effectiveness of behavioral - cognitive and behavioral meta cognitive approaches in patient with obsessive-compulsive disorder (OCD) (Persian)]. Journal of Clinical Psychology. 2010; 2(2):59-71.
  15. Shafran R, Rachman S. Thought-action fusion: A review. Journal of Behavior Therapy and Experimental Psychiatry. 2004; 35(2):87–107. doi: 10.1016/j.jbtep.2004.04.002
  16. Fisher PL, Wells A. Experimental modification of beliefs in obsessive–compulsive disorder: A test of the metacognitive model. Behaviour Research and Therapy. 2005; 43(6):821–9. doi: 10.1016/j.brat.2004.09.002
  17. Tuna Ş, Tekcan Aİ, Topçuoğlu V. Memory and metamemory in obsessive–compulsive disorder. Behaviour Research and Therapy. 2005; 43(1):15–27. doi: 10.1016/j.brat.2003.11.001
  18. Delavar A. [Research Methods in Psychology and Educational Sciences (Persian)]. Tehran: Virayesh Publication Institute; 2006.
  19. Wells A, Cartwright-Hatton S. A short form of the metacognitions questionnaire: Properties of the MCQ-30. Behaviour Research and Therapy. 2004; 42(4):385–96. doi: 10.1016/s0005-7967(03)00147-5
  20. Wells A. A multi-dimensional measure of worry: Development and preliminary validation of the anxious thoughts inventory. Anxiety, Stress & Coping. 1994; 6(4):289–99. doi: 10.1080/10615809408248803
  21. Wells A, Davies MI. The thought control questionnaire: A measure of individual differences in the control of unwanted thoughts. Behaviour Research and Therapy. 1994; 32(8):871–8. doi: 10.1016/0005-7967(94)90168-6
  22. Cartwright-Hatton S, Wells A. Beliefs about worry and intrusions: The meta-cognitions questionnaire and its correlates. Journal of Anxiety Disorders. 1997; 11(3):279–96. doi: 10.1016/s0887-6185(97)00011-x
  23. Shirinzadeh Dastgiri S, Gudarzi MA, Ghanizadeh A, Taghavi SM. [Comparison of metacognitive and responsibility beliefs in patients with obsessive-compulsive disorder, generalized anxiety disorder and normal individuals (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2008; 14(1):46-55.
  24. Goodarzi MA, Esmaieli Torkanbori Y. [The relation between intrusive thoughts control strategies and severity of obsessive-compulsive symptoms (Persian)]. Hakim Research Journal. 2006; 8(4):44-51.
  25. Donnellan C, Al Banna M, Redha N, Al Sharoqi I, Al-Jishi A, Bakhiet M, et al. Association between metacognition and mood symptoms poststroke. Journal of Geriatric Psychiatry and Neurology. 2016; 29(4):212–20. doi: 10.1177/0891988716640374
  26. Pournamdarian S, Birshak B, Asgharnejad Farid AA. [Explanation of cognitive beliefs in predicting symptoms of depression, anxiety and stress among nurses (Persian)]. Knowledge and Research in Applied Psychology. 2012; 13(3):86-94.
  27. Behar E, DiMarco ID, Hekler EB, Mohlman J, Staples AM. Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders. 2009; 23(8):1011–23. doi: 10.1016/j.janxdis.2009.07.006
  28. Miguel Ángel PN, Marta Mª RD, Leticia LM, Nereida B. Metacognitive beliefs and strategies of control thought in GAD and OCD. Clínica y Salud. 2010; 21(2):159–66. doi: 10.5093/cl2010v21n2a5
  29. Prados JM. Do beliefs about the utility of worry facilitate worry. Journal of Anxiety Disorders. 2011; 25(2):217–23. doi: 10.1016/j.janxdis.2010.09.005
  30. Wells A. The metacognitive model of GAD: Assessment of meta-worry and relationship with DSM-IV generalized anxiety disorder. Cognitive Therapy and Research. 2005; 29(1):107–21. doi: 10.1007/s10608-005-1652-0
  31. Borkovec TD, Hazlett-Stevens H, Diaz ML. The role of positive beliefs about worry in generalized anxiety disorder and its treatment. Clinical Psychology & Psychotherapy. 1999; 6(2):126-38. doi: 10.1002/(sici)1099-0879(199905)6:2<126::aid-cpp193>3.0.co; 2-m
  32. Dugas MJ, Ladouceur R. Analysis and treatment of generalized anxiety disorder. In: Caballo VE, editors. International Handbook of Cognitive and Behavioural Treatments for Psychological Disorders. New York: Pergamon; 1998. doi: 10.1016/b978-008043433-9/50009-2
  33. Clark D, Ferborn CG. Science and CBT methods [Kavyani H, Persian trans]. Tehran: Fars Publication; 2001. 
  34. Teasdale JD, Segal ZV, Williams JMG, Ridgeway VA, Soulsby JM, Lau MA. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology. 2000; 68(4):615–23. doi: 10.1037/0022-006x.68.4.615
  35. Amir N, Cashman L, Foa EB. Strategies of thought control in obsessive-compulsive disorder. Behaviour Research and Therapy. 1997; 35(8):775. doi: 10.1016/s0005-7967(97)00030-2
  36. Freeston MH, Ladouceur R. The cognitive-behavioral treatment of obsessions. In: VE. Caballo (Ed), International handbook of cognitive and behavioural treatments for psychological disorders. Oxford: Pergamon Press; 1998. doi: 10.1016/b978-008043433-9/50007-9
  37. Salkovskis PM, Forrester E, Richards HC, Morrison N. The devil is in the detail: Conceptualising and treating obsessional problems. In: Tarrier N, Wells A, editors. Treating Complex Cases: A Cognitive Behavioural Therapy Approach. Chichester: John Wiley & Sons; 1998.
  38. Emmelkamp PM, Aardema A. Metacognition, specific obsessiveą compulsive beliefs and obsessiveą compulsive behaviour. Clinical Psychology & Psychotherapy. 1999; 6:139-45. doi: 10.1002/(sici)1099-0879(199905)6:2<139::aid-cpp194>3.3.co; 2-0
Type of Study: Original Research | Subject: Psychiatry and Psychology
Received: 2015/09/27 | Accepted: 2017/01/4 | Published: 2017/07/1

References
1. Saed O, Purehsan S, Akbari S. Correlation among meta-cognitive beliefs and anxiety – depression symptoms. Procedia - Social and Behavioral Sciences. 2010; 5:1685–9. doi: 10.1016/j.sbspro.2010.07.346 [DOI:10.1016/j.sbspro.2010.07.346]
2. Papageorgiou C. Wells A. Meta cognitive beliefs about rumination in recurrent major depression. Cognitive & Behavior Practice. 2011, 8, 160-4. [DOI:10.1016/S1077-7229(01)80021-3]
3. Wells A. Metacognitive therapy for Anxiety and depression. New York: Guilford press; 2009.
4. Wells A. Emotional disorders and metacognition. New York: John Wiley & Sons Ltd; 2002. doi: 10.1002/9780470713662 [DOI:10.1002/9780470713662]
5. Wells A, Matthews G. Attention and emotion (Classic edition): A clinical perspective. Hove: Erlbaum; 2014.
6. Papageorgiou C, Wells A. An empirical test of a clinical metacognitive model of rumination and depression. Cognitive Therapy and Research. 2003; 27(3):261-73. doi: 10.1023/A:1023962332399 [DOI:10.1023/A:1023962332399]
7. Wells A. Cognition about cognition: Metacognitive therapy and change in generalized anxiety disorder and social phobia. Cognitive and Behavioral Practice. 2007; 14(1):18–25. doi: 10.1016/j.cbpra.2006.01.005 [DOI:10.1016/j.cbpra.2006.01.005]
8. Papageorgiou C. Wells A. Meta cognitive beliefs about rumination in recurrent major depression. Cognitive & Behavior Practice. 2011, 8, 160-4. [DOI:10.1016/S1077-7229(01)80021-3]
9. Wells A, King P. Metacognitive therapy for generalized anxiety disorder: An open trial. Journal of Behavior Therapy and Experimental Psychiatry. 2006; 37(3):206–12. doi: 10.1016/j.jbtep.2005.07.002 [DOI:10.1016/j.jbtep.2005.07.002]
10. Wells A, Carter K. Further tests of a cognitive model of generalized anxiety disorder: Metacognitions and worry in GAD, panic disorder, social phobia, depression, and nonpatients. Behavior Therapy. 2001; 32(1):85–102. doi: 10.1016/s0005-7894(01)80045-9 [DOI:10.1016/S0005-7894(01)80045-9]
11. Roussis P, Wells A. Post-traumatic stress symptoms: Tests of relationships with thought control strategies and beliefs as predicted by the metacognitive model. Personality and Individual Differences. 2006; 40(1):111–22. doi: 10.1016/j.paid.2005.06.019 [DOI:10.1016/j.paid.2005.06.019]
12. Yılmaz AE, Gençöz T, Wells A. The temporal precedence of metacognition in the development of anxiety and depression symptoms in the context of life-stress: A prospective study. Journal of Anxiety Disorders. 2011; 25(3):389–96. doi: 10.1016/j.janxdis.2010.11.001 [DOI:10.1016/j.janxdis.2010.11.001]
13. Bahrami F, Rezvan S. [Relationship between anxious thoughts and metacognitive beliefs in high school students with generalized anxiety disorder (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2007; 13(3):249-55.
14. Akrami A, Kalantari M, Arizi HR, Abedi M, Maroofi M. [Comparison of the effectiveness of behavioral - cognitive and behavioral meta cognitive approaches in patient with obsessive-compulsive disorder (OCD) (Persian)]. Journal of Clinical Psychology. 2010; 2(2):59-71.
15. Shafran R, Rachman S. Thought-action fusion: A review. Journal of Behavior Therapy and Experimental Psychiatry. 2004; 35(2):87–107. doi: 10.1016/j.jbtep.2004.04.002 [DOI:10.1016/j.jbtep.2004.04.002]
16. Fisher PL, Wells A. Experimental modification of beliefs in obsessive–compulsive disorder: A test of the metacognitive model. Behaviour Research and Therapy. 2005; 43(6):821–9. doi: 10.1016/j.brat.2004.09.002 [DOI:10.1016/j.brat.2004.09.002]
17. Tuna Ş, Tekcan Aİ, Topçuoğlu V. Memory and metamemory in obsessive–compulsive disorder. Behaviour Research and Therapy. 2005; 43(1):15–27. doi: 10.1016/j.brat.2003.11.001 [DOI:10.1016/j.brat.2003.11.001]
18. Delavar A. [Research Methods in Psychology and Educational Sciences (Persian)]. Tehran: Virayesh Publication Institute; 2006.
19. Wells A, Cartwright-Hatton S. A short form of the metacognitions questionnaire: Properties of the MCQ-30. Behaviour Research and Therapy. 2004; 42(4):385–96. doi: 10.1016/s0005-7967(03)00147-5 [DOI:10.1016/S0005-7967(03)00147-5]
20. Wells A. A multi-dimensional measure of worry: Development and preliminary validation of the anxious thoughts inventory. Anxiety, Stress & Coping. 1994; 6(4):289–99. doi: 10.1080/10615809408248803 [DOI:10.1080/10615809408248803]
21. Wells A, Davies MI. The thought control questionnaire: A measure of individual differences in the control of unwanted thoughts. Behaviour Research and Therapy. 1994; 32(8):871–8. doi: 10.1016/0005-7967(94)90168-6 [DOI:10.1016/0005-7967(94)90168-6]
22. Cartwright-Hatton S, Wells A. Beliefs about worry and intrusions: The meta-cognitions questionnaire and its correlates. Journal of Anxiety Disorders. 1997; 11(3):279–96. doi: 10.1016/s0887-6185(97)00011-x [DOI:10.1016/S0887-6185(97)00011-X]
23. Shirinzadeh Dastgiri S, Gudarzi MA, Ghanizadeh A, Taghavi SM. [Comparison of metacognitive and responsibility beliefs in patients with obsessive-compulsive disorder, generalized anxiety disorder and normal individuals (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2008; 14(1):46-55.
24. Goodarzi MA, Esmaieli Torkanbori Y. [The relation between intrusive thoughts control strategies and severity of obsessive-compulsive symptoms (Persian)]. Hakim Research Journal. 2006; 8(4):44-51.
25. Donnellan C, Al Banna M, Redha N, Al Sharoqi I, Al-Jishi A, Bakhiet M, et al. Association between metacognition and mood symptoms poststroke. Journal of Geriatric Psychiatry and Neurology. 2016; 29(4):212–20. doi: 10.1177/0891988716640374 [DOI:10.1177/0891988716640374]
26. Pournamdarian S, Birshak B, Asgharnejad Farid AA. [Explanation of cognitive beliefs in predicting symptoms of depression, anxiety and stress among nurses (Persian)]. Knowledge and Research in Applied Psychology. 2012; 13(3):86-94.
27. Behar E, DiMarco ID, Hekler EB, Mohlman J, Staples AM. Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders. 2009; 23(8):1011–23. doi: 10.1016/j.janxdis.2009.07.006 [DOI:10.1016/j.janxdis.2009.07.006]
28. Miguel Ángel PN, Marta Mª RD, Leticia LM, Nereida B. Metacognitive beliefs and strategies of control thought in GAD and OCD. Clínica y Salud. 2010; 21(2):159–66. doi: 10.5093/cl2010v21n2a5 [DOI:10.5093/cl2010v21n2a5]
29. Prados JM. Do beliefs about the utility of worry facilitate worry. Journal of Anxiety Disorders. 2011; 25(2):217–23. doi: 10.1016/j.janxdis.2010.09.005 [DOI:10.1016/j.janxdis.2010.09.005]
30. Wells A. The metacognitive model of GAD: Assessment of meta-worry and relationship with DSM-IV generalized anxiety disorder. Cognitive Therapy and Research. 2005; 29(1):107–21. doi: 10.1007/s10608-005-1652-0 [DOI:10.1007/s10608-005-1652-0]
31. Borkovec TD, Hazlett-Stevens H, Diaz ML. The role of positive beliefs about worry in generalized anxiety disorder and its treatment. Clinical Psychology & Psychotherapy. 1999; 6(2):126-38. doi: 10.1002/(sici)1099-0879(199905)6:2<126::aid-cpp193>3.0.co; 2-m
32. Dugas MJ, Ladouceur R. Analysis and treatment of generalized anxiety disorder. In: Caballo VE, editors. International Handbook of Cognitive and Behavioural Treatments for Psychological Disorders. New York: Pergamon; 1998. doi: 10.1016/b978-008043433-9/50009-2 [DOI:10.1016/B978-008043433-9/50009-2]
33. Clark D, Ferborn CG. Science and CBT methods [Kavyani H, Persian trans]. Tehran: Fars Publication; 2001.
34. Teasdale JD, Segal ZV, Williams JMG, Ridgeway VA, Soulsby JM, Lau MA. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology. 2000; 68(4):615–23. doi: 10.1037/0022-006x.68.4.615 [DOI:10.1037/0022-006X.68.4.615]
35. Amir N, Cashman L, Foa EB. Strategies of thought control in obsessive-compulsive disorder. Behaviour Research and Therapy. 1997; 35(8):775. doi: 10.1016/s0005-7967(97)00030-2 [DOI:10.1016/S0005-7967(97)00030-2]
36. Freeston MH, Ladouceur R. The cognitive-behavioral treatment of obsessions. In: VE. Caballo (Ed), International handbook of cognitive and behavioural treatments for psychological disorders. Oxford: Pergamon Press; 1998. doi: 10.1016/b978-008043433-9/50007-9 [DOI:10.1016/B978-008043433-9/50007-9]
37. Salkovskis PM, Forrester E, Richards HC, Morrison N. The devil is in the detail: Conceptualising and treating obsessional problems. In: Tarrier N, Wells A, editors. Treating Complex Cases: A Cognitive Behavioural Therapy Approach. Chichester: John Wiley & Sons; 1998.
38. Emmelkamp PM, Aardema A. Metacognition, specific obsessiveą compulsive beliefs and obsessiveą compulsive behaviour. Clinical Psychology & Psychotherapy. 1999; 6:139-45. doi: 10.1002/(sici)1099-0879(199905)6:2<139::aid-cpp194>3.3.co; 2-0

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