Drops in confidence precede symptoms of obsessive-compulsive disorder

Nat Commun. 2026 Aug 13;17(1):8333. doi: 10.1038/s41467-026-76671-5.

ABSTRACT

Mental health symptoms, like those in obsessive-compulsive disorder, show pronounced fluctuations over time. However, little is known about the underlying factors driving these fluctuations. Whilst theoretical accounts propose that cognitive processes drive symptom variability, cross-sectional work is unable to effectively probe these mechanisms. Based on prevailing notions of doubt and underconfidence being cognitive hallmarks of the disorder, we investigate whether metacognitive processes correspond to obsessive-compulsive disorder symptoms. We employ a smartphone-based momentary assessment design wherein participants with obsessive-compulsive disorder (N = 137) log instances of experiencing symptoms across 2-weeks. Participants also complete daily scheduled assessments and play a perceptual metacognitive task every two days. Our results reveal that metacognition is associated with obsessive-compulsive symptoms. Concretely, we find directional effects whereby reductions in both self-confidence and task-based metacognition precede occurrences of obsessive-compulsive symptom logs, but not vice versa. Moreover, confidence during perceptual decision-making is significantly related to self-reported confidence on a moment-to-moment basis, indicating that distinct metacognitive modalities may be interrelated. Results remain robust in the face of several sensitivity analyses targeting possible imbalances and missingness in the data. Thus, our micro-longitudinal study design provides evidence for cognitive distortions (both self-reported and task-based) preceding symptom escalations, signifying the potential for designing just-in-time interventions.

PMID:42595758 | DOI:10.1038/s41467-026-76671-5