ABSTRACT
Metacognition and mindfulness are central to contemporary accounts of anxiety, yet their comparative profiles across social anxiety disorder (SAD) and panic disorder (PD) remain insufficiently defined. The objective of this study is to compare metacognition and mindfulness across SAD, PD and healthy controls (HC) and to examine how these processes predict disorder specific severity. Adults with SAD (n = 47), PD (n = 50) and HC (n = 50) participated, for a total of 147 individuals. Participants completed the Metacognitions Questionnaire 30 (MCQ‐30), the Five Facet Mindfulness Questionnaire Short Form (FFMQ‐SF) and disorder‐specific severity measures. Group differences were tested, followed by multiple linear regressions predicting severity within each clinical group from MCQ‐30 subscales and FFMQ‐SF facets. Metacognitive dysfunction was higher in SAD and PD than in HC, with the clearest separations in cognitive self‐consciousness and the need to control thoughts. Mindfulness was lowest in SAD, intermediate in PD and highest in HC. In regression analyses, only mindfulness variables predicted severity in SAD, with higher observing and higher nonjudging associated with lower symptom levels. In PD, the need to control thoughts was the sole metacognitive predictor positively associated with severity; other metacognitive and mindfulness facets were not significant. Metacognition and mindfulness index a shared liability across anxiety but show disorder‐specific signatures. In SAD, mindfulness facets related to observing and nonjudging are most relevant for severity, whereas in PD, control‐oriented metacognitive beliefs are most relevant. These patterns identify focused targets for future longitudinal and experimental studies and may inform disorder‐sensitive intervention strategies.
Keywords: metacognition, mindfulness, panic disorder, psychotherapy social anxiety disorder
Summary
Social anxiety disorder and panic disorder showed both shared and distinct patterns of metacognition and mindfulness compared with healthy controls.
In social anxiety disorder, lower observing and nonjudging were independently associated with greater symptom severity.
In panic disorder, a greater need to control thoughts was independently associated with greater symptom severity.
Assessment of mindfulness facets and metacognitive beliefs may provide useful additional information for disorder‐specific clinical formulation.
1. Introduction
Psychotherapies have an important place in the treatment of social anxiety disorder and panic disorder. Current clinical approaches recommend evidence‐based psychological interventions as one of the first‐line options for many patient groups (Yatham et al. 2018). Within this framework, metacognition and mindfulness have become increasingly important processes in the assessment of anxiety disorders and in the identification of treatment targets (Melbourne Academic Mindfulness Interest Group 2006).
Metacognition refers to a person's beliefs and evaluations about their own thoughts and mental processes. Core components of this domain include perceiving thoughts as uncontrollable or dangerous, the need to control thoughts, cognitive confidence and the tendency to monitor one's own thoughts closely. These beliefs may influence which thoughts a person attends to, how they evaluate threat, which coping strategies they use and the extent to which they rely on safety behaviours. Therefore, metacognitive beliefs may play a role in the development and maintenance of anxiety symptoms. Several studies indicate that metacognitive processes are important in social anxiety disorder. A systematic review examining clinical and nonclinical samples reported that social beliefs are strongly and positively associated with social anxiety (Gkika et al. 2018). This relationship was reported to be strengthened through processes such as anticipatory thinking, self‐focused attention, postevent processing and avoidance. The same review concluded that some metacognitive beliefs contribute to social anxiety symptoms both directly and through these intermediate processes. These findings suggest that metacognitive processes should be considered in case formulation and treatment planning for social anxiety disorder. Dysfunctional metacognitive beliefs also appear to be clinically important in panic disorder. Comparative studies have shown that individuals with panic disorder report higher levels of maladaptive metacognitive beliefs than healthy controls. In these individuals, negative beliefs about the uncontrollability and danger of thoughts and the need to control thoughts are especially prominent. These beliefs have been associated with anticipatory anxiety, more rigid emotional schemas and lower cognitive flexibility (Cucchi et al. 2012; Oguz et al. 2019). Studies in panic disorder have also shown that maladaptive metacognitive beliefs are higher than in healthy controls and may predict panic disorder diagnostic status. For this reason, metacognition can also be considered a clinically meaningful intervention target in panic disorder (Aydın et al. 2019).
Mindfulness is generally defined as directing purposeful, sustained, accepting and nonjudgemental attention to present‐moment experience. Observing, describing, acting with awareness, nonjudging and nonreactivity are among the main facets of this construct. These facets are important for emotion regulation, acceptance of experience and behavioural flexibility. In clinical practice, mindfulness‐based methods are often understood as approaches that help individuals gain some distance from their thoughts and emotions, reduce repetitive thinking and use attention more flexibly (Kocovski et al. 2013). Findings on mindfulness‐ and acceptance‐based interventions in social anxiety disorder are promising but should be interpreted with caution. A systematic review reported that these interventions may reduce social anxiety symptoms. However, the benefits were often similar to or smaller than those observed with cognitive behavioural therapy, and many available studies had limited sample sizes and a high risk of bias. Therefore, cognitive behavioural therapy remains the first‐line psychotherapy approach with the strongest evidence base for social anxiety disorder. The additional contribution of mindfulness and acceptance components should be clarified through stronger studies (Norton et al. 2015). In a randomized clinical trial in this field, a mindfulness‐ and acceptance‐based group intervention was compared with cognitive behavioural group therapy and a waitlist control condition. Both active treatments were more effective than the control condition in reducing social anxiety symptoms, but the two active treatments did not differ significantly from each other on most measures. This finding suggests that mindfulness‐ and acceptance‐based methods may be useful in social anxiety disorder, but it does not support their superiority over cognitive behavioural approaches (Kocovski et al. 2013). A later meta‐analysis also reported that mindfulness‐based interventions were more effective than no treatment, that treatment gains could last up to 12 months but that their average effects were smaller than those of cognitive behavioural therapies. The same study also suggested that longer interventions may be associated with stronger outcomes (Liu et al. 2021).
Studies on panic disorder also suggest that mindfulness‐based approaches may have a supportive role. Mindfulness‐based cognitive therapy delivered as an adjunct to pharmacotherapy produced greater reductions in anxiety and depressive symptoms over an 8‐week period compared with an education control condition (Kim et al. 2009). Later studies suggested that intolerance of uncertainty may be an important clinical target in panic disorder. Baseline intolerance of uncertainty was associated with panic severity and depressive symptoms. In addition, reductions in intolerance of uncertainty during treatment were associated with reductions in panic severity, even after controlling for changes in depression (Kim et al. 2016). A recent case report described an integrated treatment approach for panic disorder. This protocol combined cognitive behavioural techniques targeting catastrophic interpretations of bodily sensations and threat schemas with mindfulness‐based cognitive therapy components aimed at increasing present‐moment awareness, reducing immediate reactivity and preventing relapse. This 16‐session approach was tailored to patient characteristics and presented as a clinically feasible option. However, the authors emphasized that controlled studies are needed to establish the effectiveness of this approach (Gawankar and Pandey 2025).
Social anxiety disorder and panic disorder share some fear‐based symptoms. However, these two disorders differ in their dominant cognitive and attentional processes. In social anxiety disorder, the main difficulties usually involve fear of negative evaluation, self‐focused attention in social situations, intense thinking before and after social situations and subtle safety behaviours used in interpersonal contexts. In panic disorder, sudden increases in fear, interpreting bodily sensations as signs of an approaching catastrophe, anticipatory anxiety and avoidance of situations that trigger internal sensations are more prominent. These clinical differences suggest that metacognitive profiles and mindfulness‐related processes may show both shared and distinct features in social anxiety disorder and panic disorder. Previous studies indicate that, in social anxiety disorder, social beliefs and metacognitive beliefs are associated with symptoms through specific cognitive pathways. In panic disorder, dysfunctional metacognitive beliefs appear to be more prominent and clinically meaningful. In addition, intolerance of uncertainty, cognitive strategies and mindfulness‐based approaches may become important for mechanism‐focused care in panic disorder. For these reasons, it is important to examine metacognition and mindfulness together in social anxiety disorder and panic disorder. Evaluating these two constructs within a comparative design may contribute to a better understanding of shared and disorder‐specific processes that explain symptom severity. The growing but mixed findings on mindfulness‐based approaches in social anxiety disorder, together with early evidence on mindfulness‐based or integrated interventions in panic disorder, provide a strong rationale for examining these two processes within the same model (Gkika et al. 2018; Cucchi et al. 2012; Oguz et al. 2019; Aydın et al. 2019; Norton et al. 2015; Kocovski et al. 2013; Kim et al. 2009; Liu et al. 2021; Kim et al. 2016; Gawankar and Pandey 2025).
From an intervention standpoint, metacognitive therapy conceptualizes psychopathology as maintained by perseverative processing styles that are governed by maladaptive metacognitive beliefs, whereas mindfulness‐based approaches may lessen the impact of such beliefs through decentring and a shift towards receptive awareness. Evidence specific to SAD includes a direct replication series applying a generic metacognitive therapy protocol across SAD presentations of increasing clinical complexity, with treatment response emerging during therapy and substantial symptom reductions largely maintained at 6‐month follow‐up, while acknowledging design constraints of small sample and single case methodology (Nordahl and Wells 2018). A secondary analysis from a randomized controlled trial in SAD further reported that both cognitive beliefs and metacognitive beliefs decreased during evidence‐based treatment, yet change in metacognition was the consistent independent predictor of improvement across outcomes, whereas change in cognitive beliefs did not predict outcomes when change in self‐consciousness was controlled (Nordahl et al. 2017). In parallel, the meta‐analytic, trial and practice‐oriented evidence summarized above suggests that mindfulness‐based strategies can be helpful for SAD, with superiority to no treatment and maintenance of gains up to 1 year, while remaining generally comparable to cognitive behavioural therapies and likely sensitive to treatment duration, and that in PD both adjunctive and integrated applications of mindfulness‐based methods may engage relevant processes such as intolerance of uncertainty and reactivity while complementing cognitive behavioural techniques, a signal that warrants confirmation in larger randomized studies (Kocovski et al. 2013; Kim et al. 2009; Liu et al. 2021; Kim et al. 2016; Gawankar and Pandey 2025).
Despite meaningful progress, previous studies have most often examined SAD and PD in separate cohorts. This limits direct inference about similarities and differences in metacognitive profiles and mindfulness related processes when the two disorders are evaluated side by side against the same comparison conditions. Comparative designs can clarify which processes are broadly shared across anxiety and which are stronger markers of SAD or of PD and can therefore inform case formulation and selection or emphasis of treatment strategies. The present study addresses this gap by directly comparing adults with SAD, adults with PD and healthy controls on metacognition and mindfulness and by testing whether these constructs relate to and independently predict disorder specific symptom severity within each clinical group. Guided by the clinical and theoretical background above, we anticipated that the patient groups would show greater metacognitive dysfunction and lower mindfulness than healthy controls, that within SAD higher metacognitive dysfunction would correspond to greater social anxiety severity whereas higher mindfulness would correspond to lower severity, that analogous associations would be observed within PD for panic severity and that metacognition and mindfulness would jointly yet differentially account for variance in symptom severity within each disorder after adjustment for competing dimensions.
2. Methods
2.1. Participants
This study included 47 patients who met the DSM‐5 SAD diagnostic criteria and 50 patients who met the DSM‐5 PD diagnostic criteria who applied to the psychiatry outpatient clinic of Izmir Tınaztepe University Private Galen Hospital and Izmir Tınaztepe Buca Medical Center. The healthy control group consisted of 50 individuals acquired from the nonclinical sample group. Inclusion criteria for the study were as follows: (1) to be diagnosed with SAD or PD according to the DSM‐5 diagnostic criteria, (2) to be between the ages of 18–65 and (3) to provide the informed consent form. Exclusion criteria for the study were as follows: (1) to have any comorbid mental disorder and (2) to have mental retardation or any neurological disease. For the healthy control group, the inclusion criteria were (1) being between the ages of 18–65, (2) not having mental retardation or any neurological disease and (3) not having any psychiatric disorder diagnosis.
2.2. Instruments
2.2.1. Sociodemographic Information Form
The form was prepared by the researcher that includes questions about sociodemographic information about the participant, such as the participant's gender, age, education level, marital status, type and duration of psychiatric treatment.
2.2.2. DSM‐5 Social Anxiety Disorder Severity Scale–Adult (SADSS)
This scale assesses the level of SAD in adults (18 years and older). The scale was developed by Craske et al. (2013b). Individuals diagnosed with SAD or those exhibiting clinically significant social anxiety symptoms are intended to complete this scale before follow‐up interviews. The questions on the scale require participants to assess the level of social anxiety disorder symptoms they have experienced in the last 7 days.
The scale is a 10‐item scale in which the items are rated on a 5‐point Likert‐type scale: (0) never, (1) sometimes, (2) half of the week, (3) most of the week and (4) all of the week. ‘An example item is: “I have felt moments of sudden terror, fear, or fright in social situations.”’ Total scores range from 0 to 40, with higher scores indicating greater SAD symptom severity. The total score is calculated by summing the scores of the 10 items. The Turkish validity and reliability study was performed by Cokmus et al. (2026).
2.2.3. DSM‐5 Panic Disorder Severity Scale–Adult (PDSS)
This scale evaluates the level of PD in adults (18 years of age and older). It was developed by Craske et al. (2013a). Individuals diagnosed with PD or those showing clinically significant PD symptoms were intended to complete this scale before follow‐up interviews. The questions on the scale require participants to answer by evaluating the level of panic disorder symptoms in the last 7 days.
The scale is a 10‐item scale in which the items are rated on a 5‐point Likert‐type scale: (0) never, (1) sometimes, (2) half the week, (3) most of the week and (4) all of the week. ‘An example item is: “I have felt moments of sudden terror, fear, or fright, sometimes out of the blue (i.e., a panic attack).”’ The values specified for the 10 items should be added to obtain a total raw score. For clinical evaluation, the mean value of the total score of the values specified for each item is calculated. The Turkish version of the scale has been evaluated as reliable, easy to apply and useful for clinicians in field studies. Balıkçı et al. (2017) reported an internal consistency coefficient of 0.96, with item‐total correlations ranging from 0.68 to 0.88.
2.2.4. Metacognition Questionnaire‐30
The Metacognition Questionnaire‐30 (MCQ‐30) was developed to assess metacognitive beliefs and consists of a total of 30 items (Wells and Cartwright‐Hatton 2004). The MCQ‐30 is a self‐report instrument with items rated on a 4‐point Likert‐type questionnaire: 1 (strongly disagree), 2 (somewhat disagree), 3 (somewhat agree) and 4 (strongly agree). The questionnaire has five subscales, each with six items.
Positive beliefs about worry: (1) ‘Worrying helps me to avoid problems in the future’. Negative beliefs about the uncontrollability and danger of worry: (2) ‘My worrying thoughts persist, no matter how I try to stop them’. Cognitive confidence: (3) ‘I have little confidence in my memory for words and names’ Beliefs about the need to control thoughts: (4) ‘If I did not control a worrying thought, and then it happened, it would be my fault’. Cognitive self‐consciousness: (5) ‘I am aware of the way my mind works when I am thinking through a problem’.
Total MCQ‐30 scores range from 30 to 120, with higher scores indicating greater maladaptive metacognitive beliefs and tendencies (Tosun and Irak 2008). The Turkish adaptation, validity and reliability study of the MCQ‐30 was conducted by Tosun and Irak (2008). The Turkish version demonstrated good internal consistency, with a Cronbach's alpha coefficient of 0.86 for the total scale. Cronbach's alpha coefficients for the subscales were 0.85 for positive beliefs, 0.87 for cognitive confidence, 0.81 for uncontrollability and danger, 0.70 for cognitive self‐consciousness and 0.65 for need to control thoughts.
2.2.5. Five‐Facet Mindfulness Questionnaire–Short Form
The Five‐Facet Mindfulness Questionnaire‐Short Form (FFMQ‐SF) was developed by Tran and colleagues in 2013. The questionnaire was designed to assess the participants' mindfulness levels. The Turkish adaptation study of the FFMQ‐SF was conducted by Ayalp and Hisli Şahin (2018). The questionnaire consists of 20 items, and 10 of the items (Items 5, 7 and 9–16 of the FFMQ‐SF) consist of reversed statements. It is applied with a 5‐point Likert‐type assessment: (1) never, (2) rarely, (3) sometimes, (4) often and (5) almost always.
The Cronbach's alpha values obtained for the five subfactors (‘observing’, ‘describing’, ‘acting with awareness’, ‘nonjudging’ and ‘nonreacting’), which are the same as the original form, are 0.78, 0.89, 0.80, 0.85 and 0.69, respectively (Tran et al. 2013). The Cronbach's alpha reliability coefficient for the Turkish version is 0.71.
2.3. Procedure
After obtaining the necessary permissions, work began on data collection on 28.04.2024. Data collection continued until 30 November 2024. Participants who applied to Izmir Tınaztepe University Private Galen Hospital and Izmir Tınaztepe Buca Medical Center Psychiatry Outpatient Clinic and met the diagnostic criteria for SAD and PD after being given SCID‐5 (Elbir et al. 2019) during the psychiatric interview were included in the study. Afterward, they were taken to the interview room designated in the hospital, and first, the Voluntary Informed Consent Form was given to inform the participant about the study and obtain their consent. A sociodemographic information form and relevant questionnaires were given to both healthy control and patient groups to be answered. Healthy controls were recruited from community volunteers using convenience sampling.
2.4. Statistical Analysis
Data analysis was conducted using IBM SPSS Statistics 25 (Statistical Package for the Social Sciences). A frequency table was generated to summarize the variables obtained from the Sociodemographic Information Form completed by the volunteer participants. Prior to the main analyses, multiple normality tests were conducted to assess whether the data met the assumptions required for the planned statistical procedures. The study aimed to compare one independent variable with three subgroups including patients diagnosed with SAD, PD and a healthy control group, across two dependent variables: metacognition and mindfulness levels. A one‐way analysis of variance (ANOVA) was conducted to assess whether there were statistically significant differences among the three groups on these variables. When ANOVA results indicated significant differences, post hoc comparisons using the Bonferroni correction were applied to identify which groups differed from each other.
Additionally, correlation analyses were performed to examine the relationships between disease severity in the clinical groups and their levels of metacognition and mindfulness. Based on these results, multiple linear regression analyses were conducted to test the study's hypotheses. Specifically, the analyses aimed to determine whether the subdimensions of the MCQ‐30 and the FFMQ‐SF predicted the severity of SAD and PD, respectively.
3. Results
3.1. Participants' Characteristics and Scale Comparisons
The sociodemographic and clinical characteristics of the SAD, PD and healthy control groups are presented in Table 1. Overall, the groups were comparable in terms of gender distribution and age range. The PD group tended to be older and had fewer years of education, longer treatment duration and later disease onset compared with the SAD group.
TABLE 1.
Sociodemographic features of the groups.
| SAD (n = 47) | PD (n = 50) | Healthy control (n = 50) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Variables | n (%) | M | SD | n (%) | M | SD | n (%) | M | SD | |
| Gender | Female | 24 (51.1) | — | — | 28 (56.0) | — | — | 25 (50.0) | — | — |
| Male | 23 (48.9) | — | — | 22 (44.0) | — | — | 25 (50.0) | — | — | |
| Age | — | 28.77 | 10.48 | — | 34.48 | 10.33 | — | 30.56 | 10.47 | |
| education level | Year | — | 15.50 | 3.02 | — | 13.50 | 3.10 | — | 15.20 | 2.47 |
| Treatment duration | Month | — | 14.49 | 16.41 | — | 35.16 | 63.02 | — | — | — |
| Age of onset of disease | — | 23.66 | 8.79 | — | 28.62 | 8.78 | — | — | — | |
Abbreviations: M, mean; n, number; PD, panic disorder; SAD, social anxiety disorder; SD, standard deviation.
Group comparisons of metacognitive beliefs and mindfulness dimensions are presented in Table 2. Overall, the clinical groups showed higher dysfunctional metacognitive beliefs than healthy controls, particularly in cognitive self‐consciousness, need to control thoughts and total MCQ‐30 scores. In contrast, mindfulness‐related scores were generally lower in the SAD group, with the most pronounced differences observed in observing, describing, acting with awareness, nonjudging and total FFMQ‐SF scores. The SAD group demonstrated the lowest overall mindfulness profile, whereas healthy controls generally showed the highest mindfulness scores. No significant group differences were found for positive beliefs about worry, cognitive confidence, negative beliefs about uncontrollability and danger, or nonreactivity to inner experiences.
TABLE 2.
Comparison of the subscales and overall scores of the assessed variables.
| Measure | SAD (n = 47) | PD (n = 50) | HC (n = 50) | Statistics | |||||
|---|---|---|---|---|---|---|---|---|---|
| M | SD | M | SD | M | SD | F | p | Pairwise comparison | |
| MCQ‐POS | 11.74 | 4.24 | 10.68 | 3.82 | 11.90 | 3.69 | 1.427 | 0.243 | — |
| MCQ‐CC | 13.09 | 5.13 | 10.96 | 4.48 | 11.22 | 4.69 | 2.836 | 0.062 | — |
| MCQ‐NEG | 15.55 | 4.84 | 15.58 | 4.11 | 15.48 | 4.59 | 0.007 | 0.993 | — |
| MCQ‐ CSC | 16.91 | 3.78 | 17.80 | 3.81 | 13.52 | 3.05 | 20.041 | < 0.001 | PD > SAD > HC |
| MCQ‐NC | 16.70 | 4.75 | 16.28 | 5.03 | 13.32 | 4.20 | 7.654 | 0.001 | SAD > PD > HC |
| MCQ‐30 total | 74.02 | 14.45 | 70.56 | 15.36 | 65.44 | 13.05 | 4.427 | 0.014 | SAD > PD > HC |
| FFMQ‐observe | 10.26 | 4.69 | 12.72 | 4.38 | 13.78 | 4.06 | 8.202 | < 0.001 | HC > PD > SAD |
| FFMQ‐nonjudge | 11.36 | 3.93 | 11.02 | 4.51 | 13.94 | 4.15 | 7.135 | < 0.001 | HC > SAD > PD |
| FFMQ‐nonreact | 12.40 | 3.31 | 12.06 | 3.93 | 13.04 | 3.69 | 0.920 | 0.401 | — |
| FFMQ–act with awareness | 12.83 | 3.70 | 14.84 | 3.46 | 14.04 | 2.88 | 4.387 | 0.014 | PD > HC > SAD |
| FFMQ‐describe | 10.74 | 3.99 | 15.30 | 3.22 | 14.22 | 3.51 | 21.243 | < 0.001 | PD > HC > SAD |
| FFMQ‐SF total | 57.60 | 13.34 | 65.94 | 11.67 | 69.02 | 10.99 | 11.641 | < 0.001 | HC > PD > SAD |
| SADSS total | 37.00 | 17.45 | — | — | — | — | — | — | — |
| PDSS total | — | — | 35 | 16.26 | — | — | — | — | — |
Note: Bold text indicates statistically significant results.
Abbreviations: FFMQ–act with awareness, acting with awareness; FFMQ‐describe, describing with words; FFMQ‐nonjudge, nonjudging of experience; FFMQ‐nonreact, nonreactivity to inner experiences; FFMQ‐observe, observing thoughts/feelings; FFMQ‐SF, Five Factor Mindfulness Questionnaire‐Short Form; HC, healthy control; M, mean; MCQ‐30, Meta‐Cognitions Questionnaire‐30; MCQ‐CC, cognitive confidence; MCQ‐CSC, cognitive self‐consciousness; MCQ‐NC, need to control thoughts; MCQ‐NEG, negative beliefs about uncontrollability and danger of worry; MCQ‐POS, positive beliefs about worry; n, number; PD, panic disorder; PDSS, Panic Disorder Severity Scale; SAD, social anxiety disorder; SADSS, Social Anxiety Disorder Severity Scale; SD, standard deviation; Sig, significance level.
3.2. The Relationship Between the Metacognition, Mindfulness and Symptom Severity
Correlation analysis was conducted to examine the statistical significance and direction of the relationships between the measures. The bivariate correlations among the MCQ‐30, FFMQ and SADSS are presented in Table 3. Higher SADSS scores were significantly associated with greater dysfunctional metacognitive beliefs, particularly negative beliefs about uncontrollability and danger, cognitive self‐consciousness, need to control thoughts and total MCQ‐30 scores. In contrast, social anxiety severity was negatively associated with several mindfulness dimensions, including observing, nonjudging, nonreactivity, describing and total FFMQ‐SF scores. Among these associations, the strongest relationships with SADSS were observed for lower nonjudging of experience and lower total mindfulness. Overall, the findings indicate that greater social anxiety severity is related to stronger maladaptive metacognitive beliefs and reduced mindfulness‐related capacities.
TABLE 3.
The bivariate correlations between MCQ‐30, FFMQ and SADSS.
| Measure | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 MCQ‐POS | 1 | ||||||||||||
| 2 MCQ‐CC | 0.275 | 1 | |||||||||||
| 3 MCQ‐NEG | 0.134 | 0.257 | 1 | ||||||||||
| 4 MCQ‐CSC | 0.254 | 0.061 | 0.102 | 1 | |||||||||
| 5 MCQ‐NC | 0.160 | 0.216 | 0.581** | 0.446** | 1 | ||||||||
| 6 MCQ‐30 total | 0.555** | 0.609** | 0.682** | 0.539** | 0.764** | 1 | |||||||
| 7 FFMQ‐observe | 0.079 | −0.270 | −0.133 | −0.028 | −0.298* | −0.223 | 1 | ||||||
| 8 FFMQ‐nonjudge | −0.237 | −0.361* | −0.664** | −0.316* | −0.634** | −0.711** | 0.362* | 1 | |||||
| 9 FFMQ‐nonreact | 0.137 | −0.100 | −0.236 | 0.064 | −0.340* | −0.168 | 0.344* | 0.410** | 1 | ||||
| 10 FFMQ–act with awareness | 0.149 | −0.157 | −0.214 | 0.137 | −0.131 | −0.089 | 0.046 | 0.252 | 0.521** | 1 | |||
| 11 FFMQ‐Describe | −0.185 | −0.440** | −0.453** | −0.099 | −0.323* | −0.493** | 0.196 | 0.393** | 0.315* | 0.521** | 1 | ||
| 12 FFMQ‐SF total | −0.022 | −0.402** | −0.496** | −0.079 | −0.509** | −0.502** | 0.615** | 0.712** | 0.729** | 0.653** | 0.707** | 1 | |
| 13 SADSS | 0.136 | 0.258 | 0.364 * | 0.330 * | 0.362 * | 0.458 ** | −0.463 ** | −0.624 ** | −0.305 * | −0.125 | −0.430 ** | −0.586 ** | 1 |
Note: Bold text indicates statistically significant results.
Abbreviations: FFMQ‐act with awareness, acting with awareness; FFMQ‐describe, describing with words; FFMQ‐nonjudge, nonjudging of experience; FFMQ‐nonreact, nonreactivity to inner experiences; FFMQ‐observe, observing thoughts/feelings; FFMQ‐SF, Five Factor Mindfulness Questionnaire‐Short Form; MCQ‐30, Meta‐Cognitions Questionnaire‐30; MCQ‐CC, cognitive confidence; MCQ‐CSC, cognitive self‐consciousness; MCQ‐NC, need to control thoughts; MCQ‐NEG, negative beliefs about uncontrollability and danger of worry; MCQ‐POS, positive beliefs about worry; SADSS, Social Anxiety Disorder Severity Scale.
p < 0.05.
p < 0.001.
The bivariate correlations between MCQ‐30, FFMQ, and PDSS are presented in Table 4. Higher PDSS scores were significantly associated with greater dysfunctional metacognitive beliefs, including cognitive confidence, negative beliefs about uncontrollability and danger, cognitive self‐consciousness, need to control thoughts and total MCQ‐30 scores. Among these, need to control thoughts and total MCQ‐30 showed the strongest positive associations with panic disorder severity. In contrast, PDSS scores were negatively correlated with several mindfulness dimensions, including observing, nonjudging, nonreactivity and total FFMQ‐SF scores. Overall, greater panic disorder severity was related to more maladaptive metacognitive beliefs and lower mindfulness‐related capacity.
TABLE 4.
The bivariate correlations between MCQ‐30, FFMQ, and PDSS.
| Measure | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. MCQ‐POS | 1 | ||||||||||||
| 2. MCQ‐CC | −0.015 | 1 | |||||||||||
| 3. MCQ‐NEG | 0.271 | 0.460** | 1 | ||||||||||
| 4. MCQ‐ CSC | 0.235 | 0.262 | 0.795** | 1 | |||||||||
| 5. MCQ‐NC | 0.106 | 0.367** | 0.698** | 0.640** | 1 | ||||||||
| 6. MCQ‐30 total | 0.415** | 0.610** | 0.885** | 0.782** | 0.817** | 1 | |||||||
| 7. FFMQ‐observe | −0.100 | −0.314* | −0.391** | −0.262 | −0.472** | −0.444** | 1 | ||||||
| 8. FFMQ‐nonjudge | −0.127 | −0.176 | −0.359* | −0.311* | −0.485** | −0.456** | 0.586** | 1 | |||||
| 9. FFMQ‐nonreact | 0.046 | −0.337* | −0.040 | 0.191 | −0.240 | −0.172 | 0.303* | 0.218 | 1 | ||||
| 10. FFMQ–act with awareness | −0.049 | 0.075 | 0.310* | 0.435** | 0.296* | 0.290* | −0.155 | −0.335* | 0.187 | 1 | |||
| 11. FFMQ‐describe | 0.102 | −0.331* | −0.080 | 0.211 | −0.123 | −0.085 | 0.386** | 0.177 | 0.512** | −0.072 | 1 | ||
| 12. FFMQ‐SF total | −0.058 | −0.369** | −0.229 | 0.033 | −0.392** | −0.339* | 0.765** | 0.630** | 0.732** | 0.152 | 0.640** | 1 | |
| 13. PDSS | 0.117 | 0.397 ** | 0.469 ** | 0.370 ** | 0.660 ** | 0.593 ** | −0.350 * | −0.282 * | −0.291 * | 0.188 | −0.083 | −0.306 * | 1 |
Abbreviations: FFMQ‐act with awareness, acting with awareness; FFMQ‐describe, describing with words; FFMQ‐nonjudge, nonjudging of experience; FFMQ‐nonreact, nonreactivity to inner experiences; FFMQ‐observe, observing thoughts/feelings; FFMQ‐SF, Five Factor Mindfulness Questionnaire‐Short Form; MCQ‐30, Meta‐Cognitions Questionnaire‐30; MCQ‐CC, cognitive confidence; MCQ‐CSC, cognitive self‐consciousness; MCQ‐NC, need to control thoughts; MCQ‐NEG, negative beliefs about uncontrollability and danger of worry; MCQ‐POS, positive beliefs about worry; PDSS, Panic Disorder Severity Scale.
p < 0.05.
p < 0.001.
3.3. The Regression Models Developed to Assess the Predictive Relationships Between the Measures
The multiple regression model was used to assess whether the subscales of the MCQ‐30 and FFMQ‐SF could predict the severity of the disorder for SADSS and PDSS, respectively. The regression model examining predictors of symptom severity in the SAD group is presented in Table 5. Among the metacognitive and mindfulness‐related variables entered into the model, lower observing and lower nonjudging of experience emerged as significant predictors of greater social anxiety symptom severity. Other metacognitive dimensions and mindfulness facets did not independently predict SADSS scores in the multivariable model. These findings suggest that reduced mindfulness‐related capacities, particularly limited awareness of internal experiences and a more judgemental stance towards experience, may be more closely associated with social anxiety severity than metacognitive beliefs when considered simultaneously.
TABLE 5.
The predictor variables of symptom severity in SAD group.
| Measure | B | Std. error of B | β | t | R 2 |
|---|---|---|---|---|---|
| MCQ‐POS | −0.05 | 0.26 | −0.02 | −0.20 | 0.49 |
| MCQ‐CSC | 0.63 | 0.32 | 0.25 | 1.98 | |
| MCQ‐NC | −0.44 | 0.30 | −0.22 | −1.47 | |
| FFMQ‐observe | −0.59 | 0.24 | −0.29 | −2.41** | |
| FFMQ‐nonjudge | −1.17 | 0.37 | −0.49 | −3.14** | |
| FFMQ‐nonreact | −0.06 | 0.37 | −0.02 | −0.17 | |
| FFMQ‐describe | −0.53 | 0.29 | −0.23 | −1.85 |
Abbreviations: MCQ‐CSC, cognitive self‐consciousness; MCQ‐NC, need to control thoughts; MCQ‐POS, positive beliefs about worry; FFMQ‐describe, describing with words; FFMQ‐nonjudge, nonjudging of experience; FFMQ‐nonreact, nonreactivity to inner experiences; FFMQ‐observe, observing thoughts/feelings.
p < 0.001.
p < 0.05.
The regression model examining predictors of symptom severity in the PD group is presented in Table 6. Among the metacognitive and mindfulness‐related variables entered into the model, need to control thoughts emerged as the only significant independent predictor of PD symptom severity. Higher need to control thoughts was associated with greater PDSS scores, whereas cognitive confidence, negative beliefs about uncontrollability and danger, cognitive self‐consciousness and mindfulness facets did not independently predict symptom severity.
TABLE 6.
The predictor variables of symptom severity in panic disorder group.
| Measure | B | Std. error of B | β | t | R 2 |
|---|---|---|---|---|---|
| MCQ‐CC | 0.31 | 0.29 | 0.15 | 1.08 | 0.46 |
| MCQ‐NEG | 0.03 | 0.51 | 0.01 | 0.05 | |
| MCQ‐CSC | −0.12 | 0.53 | −0.05 | −0.22 | |
| MCQ‐NC | 1.20 | 0.35 | 0.63 | 3.45* | |
| FFMQ‐observe | −0.08 | 0.32 | −0.04 | −0.24 | |
| FFMQ‐nonjudge | −017 | 0.31 | 0.08 | 0.54 | |
| FFMQ‐nonreact | −0.22 | 0.34 | −0.09 | −0.63 |
Abbreviations: FFMQ‐nonjudge, nonjudging of experience; FFMQ‐nonreact, nonreactivity to inner experiences; FFMQ‐observe, observing thoughts/feelings; MCQ‐CC, cognitive confidence; MCQ‐CSC, cognitive self‐consciousness; MCQ‐NC, need to control thoughts; MCQ‐NEG, negative beliefs about uncontrollability and danger of worry.
p < 0.001.
p < 0.05.
4. Discussion
In this study, we aimed to compare metacognition and mindfulness among patients with social anxiety disorder, patients with panic disorder and healthy controls and to examine how these processes are associated with disorder‐specific symptom severity. We also sought to determine which aspects of metacognition and mindfulness may reflect shared processes in social anxiety disorder and panic disorder and which aspects may help differentiate these two conditions. Within this framework, we aimed to identify process‐based indicators that may contribute to clinical formulation and the prioritization of intervention targets.
The findings suggest that metacognition and mindfulness show both shared and distinct patterns across social anxiety disorder, panic disorder and healthy controls. Compared with healthy controls, the clinical groups showed higher overall metacognitive dysfunction. However, this difference was not observed uniformly across all metacognitive domains. Group differences were particularly evident in cognitive self‐consciousness, need to control thoughts and total Metacognitions Questionnaire scores. In contrast, positive beliefs about worry, cognitive confidence and negative beliefs about the uncontrollability and danger of thoughts did not differ significantly between groups. This finding indicates that, in the present sample, the most discriminating metacognitive characteristics were self‐monitoring and control‐oriented beliefs rather than all dimensions of metacognitive dysfunction.
Overall metacognitive dysfunction was highest in the social anxiety disorder group, lower in the panic disorder group and lowest among healthy controls. This pattern is consistent with previous studies suggesting that self‐focused monitoring and control‐oriented beliefs are important in anxiety disorders (Gkika et al. 2018; Cucchi et al. 2012; Oguz et al. 2019; Aydın et al. 2019). The association between need to control thoughts and panic disorder severity, in particular, suggests that control‐oriented metacognitive beliefs may be particularly relevant to panic disorder (Cucchi et al. 2012; Oguz et al. 2019; Aydın et al. 2019). By contrast, social anxiety disorder appears to be characterized by a broader profile of metacognitive disturbance. The absence of significant group differences in negative beliefs and cognitive confidence does not fully correspond with some previous findings. This discrepancy may be related to sample characteristics, the exclusion of comorbidities, cultural context or the possibility that self‐consciousness, and control beliefs were more prominent metacognitive features in the present sample.
With regard to mindfulness, total mindfulness scores were highest among healthy controls, intermediate in the panic disorder group and lowest in the social anxiety disorder group. At the facet level, observing and nonjudging were particularly lower in the social anxiety disorder group. This finding is consistent with accounts suggesting that social anxiety is associated with reduced receptive awareness and a more evaluative stance towards internal experience. It is also in line with studies reporting that stronger nonjudging skills may be associated with lower social anxiety symptom severity (Norton et al. 2015; Kocovski et al. 2013; Liu et al. 2021; Solem et al. 2015).
A different pattern was observed for acting with awareness and describing. Scores on these facets were highest in the panic disorder group, intermediate among healthy controls and lowest in the social anxiety disorder group. One possible explanation is that the higher scores observed in the panic disorder group may not necessarily reflect an entirely adaptive form of mindfulness but rather a greater tendency to attend to internal states and label them verbally. This interpretation is also compatible with the higher cognitive self‐consciousness scores observed in the panic disorder group (Solem et al. 2015). Nevertheless, this explanation is not directly demonstrated by the present data and should be examined in future studies using behavioural measures, ecological assessment or longitudinal designs. The absence of group differences in nonreactivity suggests that automatic responses to inner experience may be less useful in distinguishing between these two diagnostic groups than acceptance, observation or describing.
Correlation analyses showed that higher metacognitive dysfunction was associated with greater symptom severity. In contrast, higher mindfulness was generally associated with lower symptom severity. Although this broad pattern was observed in both clinical groups, the variables that remained associated with symptom severity in the multivariable models differed between social anxiety disorder and panic disorder.
In the social anxiety disorder group, lower observing and lower nonjudging independently predicted greater symptom severity. This finding suggests that the ability to notice internal experiences and to relate to them in a less judgemental way may be closely associated with social anxiety symptoms. The result is consistent with theoretical approaches proposing that meta‐awareness and an accepting attitude may help reduce prolonged cognitive processing and self‐focused monitoring (Solem et al. 2015). It is also consistent with review findings, indicating that mindfulness‐based interventions may provide symptomatic benefit in social anxiety disorder, although they are generally not superior to cognitive behavioural therapy (Norton et al. 2015; Kocovski et al. 2013; Liu et al. 2021).
In the panic disorder group, need to control thoughts was the only significant positive predictor of symptom severity. This finding indicates that the perceived need to control internal experiences may be especially relevant to panic disorder severity. Considering that panic symptoms are often maintained by threatening interpretations of bodily sensations, anticipatory anxiety and attempts to control internal experiences, the prominence of need to control thoughts is clinically meaningful. This result is also consistent with previous studies showing that control‐oriented metacognitive beliefs are more pronounced in panic disorder than in healthy controls and are associated with panic symptoms (Cucchi et al. 2012; Oguz et al. 2019; Aydın et al. 2019).
Taken together, these findings suggest that metacognition and mindfulness may have different clinical meanings in social anxiety disorder and panic disorder. Although metacognitive disturbance was higher in social anxiety disorder than in healthy controls, mindfulness facets remained the variables independently associated with symptom severity. In particular, observing and nonjudging appear to be closely related to social anxiety symptoms. In panic disorder, however, need to control thoughts emerged as a more prominent process. Therefore, clinical work with social anxiety disorder may particularly benefit from skills aimed at noticing internal experience without judgement, whereas work with panic disorder may place greater emphasis on metacognitive beliefs related to the need to control thoughts and internal experiences.
This study has several limitations. First, the cross‐sectional design does not allow causal conclusions about the relationships among metacognition, mindfulness and symptom severity. Therefore, it cannot be concluded that lower observing and nonjudging increase social anxiety symptoms, or that need to control thoughts increases panic symptoms. These variables should be interpreted only as processes associated with symptom severity. Second, the sample size was relatively limited, and participants were recruited from two outpatient treatment centres, whereas controls were recruited from community volunteers. This may limit generalizability and introduce selection bias. Third, all variables were assessed at a single time point using self‐report measures, which increases the risk of shared method variance. In addition, because metacognition and mindfulness may partially overlap conceptually, the associations between these constructs should be interpreted with caution. Fourth, variables that may differ between groups, such as age, education level and treatment duration, were not included as covariates in the models. These factors may have influenced scale scores or the observed associations. Although excluding comorbidities strengthened the internal validity of the study, it may reduce generalizability to routine clinical practice. Finally, the findings were obtained in a Turkish clinical context and should therefore be re‐examined in different cultural and healthcare settings.
Despite these limitations, the study has several strengths. The inclusion of social anxiety disorder, panic disorder and healthy control groups within the same research design allowed shared and distinct processes to be compared directly. In addition, examining metacognition and mindfulness together made it possible to evaluate the relationship of these two processes with each other and with disorder‐specific symptom severity in a more integrated manner. Future studies should use longitudinal or experimental designs to examine whether changes in observing and nonjudging precede reductions in social anxiety symptoms and whether reductions in need to control thoughts predict decreases in panic disorder symptoms. Studies using multimethod assessment, including clinician‐rated measures, behavioural tasks and ecological sampling, and conducted in larger, more diverse samples that include common comorbidities, would further strengthen the validity and generalizability of these findings.
Funding
The authors have nothing to report.
Ethics Statement
The study protocol was approved by the Non‐Interventional Clinical Research Ethics Committee of İzmir Tınaztepe University (Approval No. MUKCE 2024/32; 25 April 2024). The study was conducted in accordance with the principles of the Declaration of Helsinki.
Consent
Written informed consent was obtained from all participants prior to their participation in the study.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.