Metacognitive Belief Profiles Across OCD Symptom Dimensions: A Systematic Review and Clinical Implications for Personalised Treatment

Background/Objectives: Although obsessive–compulsive disorder (OCD) is clinically heterogeneous, it is unclear whether specific metacognitive belief domains are differentially associated with particular symptom dimensions in adults with confirmed OCD. This systematic review synthesised the available clinical evidence and explored its implications for dimension-informed case formulation and treatment planning. Methods: In March 2026, PubMed/MEDLINE, Scopus, Cochrane CENTRAL and Google Scholar were searched without date or language restrictions. Eligible studies enrolled adults with a confirmed diagnosis of OCD, administered at least one validated metacognitive instrument (MCQ-30/65, TFI, TAF, BARI, SSQ or OBQ-based subscales) and reported associations with validated dimensional OCD measures. The review was preregistered on PROSPERO (CRD420261338178). Due to methodological heterogeneity, the findings were synthesised narratively in accordance with SWiM guidance. Results: Ten studies, including 1320 adults with OCD, were included. These studies were conducted across five countries between 2010 and 2025. Negative beliefs about thought uncontrollability and danger (MCQ-30 NB) showed the broadest associations across the synthesis, particularly with the checking/harm avoidance and the unacceptable thought dimensions. Thought-fusion constructs (TAF/TFI) were most consistently associated with checking/harm avoidance and unacceptable thought presentations. Beliefs about rituals and stop-signal criteria (BARI/SSQ) were most relevant to symmetry/ordering. In contrast, contamination/washing and hoarding exhibited weaker and less consistent metacognitive profiles. Conclusions: The available evidence suggests that metacognitive belief profiles in OCD are not dimensionally uniform. Harm-relevant metacognitions appear to be the most salient factor in the checking and unacceptable thought dimensions, whereas ritual-regulation metacognitions appear to be more relevant to the symmetry/ordering dimension. While these findings may inform dimension-sensitive case formulation and generate testable hypotheses for future metacognitive and exposure-based treatment research, they do not yet justify prescriptive, dimension-specific treatment algorithms. The evidence base remains predominantly cross-sectional and methodologically diverse.