Psychiatry Research 316 (2022) 114752

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Review article

Social cognition and empathy in adults with obsessive compulsive disorder:

A meta-analysis
Emre Bora a, b, c, *
a
Department of Psychiatry, Dokuz Eylul University Medical School, Izmir 35340, Turkey
b
Department of Neurosciences, Institute of Health Sciences, Dokuz Eylul University, Izmir, Turkey
c
Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne and, Melbourne Health, Carlton South, Victoria 3053, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Obsessive-compulsive disorder (OCD) is characterized by intrusive thoughts (obsessions) and compulsions and
Obsessive-compulsive disorder has been associated with psychosocial impairment. Indeed, a number of studies have highlighted impairments in
Social cognition both social cognitive functions and empathic skills in OCD, despite several inconsistencies. This study aimed to
Theory of mind
investigate social cognitive dysfunction and empathy deficits in patients with OCD using a meta-analytic
Empathy
approach. A literature search was conducted using the databases Pubmed, PsycINFO, ProQuest and Scopus to
Emotion recognition
identify the relevant studies (January 1980 to March 2020). Following the systematic review of relevant OCD
studies, a random-effects meta-analysis was conducted. The current meta-analysis included 25 studies consisting
of 1161 patients with OCD and 1329 healthy controls. OCD was associated with decreased performance in theory
of mind (ToM). In the facial emotion recognition domain, patients with OCD significantly underperformed
healthy controls only in their recognition of disgust. OCD was significantly related to reduced cognitive empathy.
OCD was associated with medium-sized impairments in ToM and cognitive empathy, which can likely contribute
to psychosocial impairment in this disorder. Further studies are needed to investigate state and trait-related
factors using experimental measures of empathy.

1. Introduction
Obsessive-compulsive disorder (OCD) is a chronic neuropsychiatric
disorder characterized by recurrent obsessions and compulsions. OCD is
commonly associated with impairments in social functioning and dete­
rioration in the quality of life (Bobes et al., 2001; Bystritsky et al., 2001;
Huppert et al., 2009; Ruscio et al., 2010). In OCD, multiple factors,
including symptoms, co-morbidities and neurocognitive functioning
contribute to social dysfunction (Markarian et al., 2010). Potential ab­
normalities in social cognition and empathy in OCD might be clinically
relevant as such deficits contribute to functional impairment and poor
insight in other psychiatric disorders including schizophrenia, autism
spectrum disorder, and major depressive disorder (Baron-Cohen et al.,
2001; Bora, 2017; Bora et al., 2006; Lee et al., 2005).
The current dominant neuroanatomical model of OCD, which fo­
cuses on abnormalities in the frontal lobes, basal ganglia, and
orbitofronto-striato-thalamic circuits is compatible with potential diffi­
culties in social cognition and empathy in this disorder (Menzies et al.,
2008). These brain networks are not only critical for executive functions
but also for social cognition and empathy (Abu-Akel and Sha­
may-Tsoory, 2011; Cox et al., 2012). Recent studies have showed that
patients with diseases affecting the basal ganglia and its connections
within fronto-striato-thalamic circuits, including Parkinson’s disease
and Huntington’s disease, have significant deficits in social cognition
and empathy (Bora et al., 2015; Bora et al., 2016; Maurage et al., 2016).
Therefore, it is important to investigate empathy and social cognitive
impairments in OCD.
Traditional neuropsychological domains, such as executive functions
and memory, have been extensively studied in OCD. However, social
cognition is relatively an understudied subject in OCD. The recognition
of emotions from facial perceptual cues, and theory of mind (ToM), the
ability to attribute mental states (feelings, beliefs, intentions, and de­
sires) to others and understand and predict others’ behavior based on
their mental states, are the most commonly studied domains of social
cognition in OCD. An earlier study reported impaired recognition of
disgust from facial stimuli in OCD (Sprengelmeyer et al., 1997). How­
ever, the subsequent studies have not supported a specific impairment in
recognition of disgust in OCD (Aigner et al., 2007; Corcoran et al., 2008;

* Corresponding author at: Dokuz Eylul Universitesi Tip Fakultesi, Psikiyatri Anabilim Dali, Mithatpaşa Cad. No:1606 Inciraltı Yerleskesi 35340 Balcova Izmir.
E-mail addresses: emre.bora@deu.edu.tr, ibora@unimelb.edu.au.

https://doi.org/10.1016/j.psychres.2022.114752
Received 8 April 2020; Received in revised form 18 July 2022; Accepted 27 July 2022
Available online 28 July 2022
0165-1781/© 2022 Elsevier B.V. All rights reserved.
E. Bora
Daros et al., 2014; Parker et al., 2004). Relatively few studies have
examined ToM skills in OCD (Jansen et al., 2020). Several studies have
found no evidence of ToM impairment in OCD (Buhlmann et al., 2015;
Mavrogiorgou et al., 2016). On the other hand, other studies have
suggested that patients with OCD might have difficulties in ToM tasks
(Pino et al., 2016; Sayin et al., 2010).
Empathy is a construct that is partly related to social cognition.
Abnormalities in empathic skills can contribute to problems in social
functioning in OCD. In studies concerning OCD, empathy is most
commonly measured with self-report measures such as the interpersonal
reactivity index (IRI) and the Empathy Quotient (EQ) (Baron-Cohen and
Wheelright, 2004; Davis, 1980). Empathy has several dimensions
including cognitive (i.e., the perspective-taking subscale in IRI) and af­
fective components (i.e. the empathic concern and personal distress
subscales in IRI). Cognitive empathy measures the ability to understand
the psychological viewpoints of others and is conceptually similar to
ToM and emotion recognition. On the other hand, affective components
of empathy are constructs that are relatively independent of traditional
social cognitive abilities (ToM and emotion recognition). Empathic
concern measures the individual’s tendency to experience "other-or­
iented" feelings of sympathy and concern for others. Unlike empathic
concern, “personal distress” is a self-focused emotional reaction and is
often related to emotional contagion. It reflects one’s anxiety and
emotional reactivity in response to the comprehension of another’s
emotional state or condition. Developmentally, personal distress and
emotional contagion emerge earlier than empathic concern. Investi­
gating multiple aspects of empathy can help us to understand the source
of functional impairment in OCD. Relatively few studies have examined
empathy skills in OCD. These studies reported increased personal
distress but found inconsistent findings regarding the other aspects of
empathy (Cain et al., 2015; Fontenelle et al., 2009; Pino et al., 2016).
Some of the inconsistent findings of studies investigating social
cognition and empathy in OCD might be related to the low statistical
power of individual studies, as many of the available studies have small
sample sizes. It is also important to note that factors including clinical
and demographic characteristics, executive functions, and co-morbid
depressive symptoms can influence the estimated effect sizes for social
cognition and empathy abnormalities in OCD. The current meta-analysis
was conducted to provide a reliable estimate of abnormalities in social
cognition and empathy in OCD. An additional aim was to investigate the
effect of confounding variables on group differences in social cognition
between OCD and healthy controls.
2. Methods
2.1. Study selection
In this meta-analysis, PRISMA guidelines were followed (Moher
et al., 2009). A literature search was conducted using the databases
Pubmed, PsycINFO, ProQuest, and Scopus to identify the relevant
studies (January 1980 to March 2020) using the combination of key­
words as follows: (“Theory of mind” OR “emotion recognition” OR
“social cognition” OR empathy OR mentali*) AND “obsessive-­
compulsive disorder”. Reference lists of published reports were also
reviewed for additional studies. Inclusion criteria were studies that: (1)
Compared ToM, empathy, facial emotion recognition performances of
adult patients with OCD and healthy controls. OCD diagnosis was
required to be based on DSM or ICD criteria using a clinical interview;
(2) reported sufficient data to calculate the effect size and standard error
of the social cognition or empathy measures; (3) had been published in a
peer-reviewed journal indexed in Science Citation Index. Studies
investigating emotion recognition abilities with methods other than
facial recognition were excluded as only a few studies investigated OCD
using such methods (i.e. vocal). Also, behavioral results of fMRI tasks
were not included. Other aspects of social cognition including emotion
regulation and social perception were not included in this meta-analysis
2
Psychiatry Research 316 (2022) 114752
due to an insufficient number of studies investigating these domains in
OCD.
2.2. Social cognition and empathy measures
2.2.1. Social cognition measures
Studies have investigated facial emotion recognition with a variety
of methods (Ekman and Friesen, 1976). Different ToM tasks have been
utilized across studies. The most commonly used ToM tasks included the
Reading the Mind in the Eyes Task (RMET) and the Hinting tasks. Other
studies have included the faux pas recognition (the task involves
recognizing faux pas in series of short stories), false belief tasks, and the
Happe stories (Baron-Cohen et al., 2001; Corcoran et al., 1995; Stone
et al., 1998). In the RMET, individuals are instructed to look at a series of
photographs of the eye region of the face and select the word that best
describes what the person in the photo is thinking or feeling. In the
Hinting task, participants read a number of short passages of dialogues
between 2 characters. In each conversation, one of the characters tries to
indirectly convey a certain request or intention to the other. Participants
are required to correctly infer this request or intention.
There are two separable aspects of TOM: (1) decoding mental states
from perceivable social information such as facial expression, tone of
voice, body posture (i.e., decoding irony from voice tone and facial
expression), and (2) reasoning about mental states by integrating
contextual and historical information about a person (e.g., knowledge,
attitudes, long-term beliefs) (Sabbagh, 2004). The RMET was the only
measure for ToM-decoding (Baron-Cohen et al., 2001; Sabbagh et al.,
2004). All other ToM tasks were measuring ToM-reasoning (Bora and
Köse, 2016; Sabbagh, 2004).
2.2.2. Empathy measures
The interpersonal reactivity index (IRI) was the main measure used
to measure empathy in OCD (Davis, 1980). The IRI has 28-items
answered on a 5-point Likert scale. IRI consists of 4 subscales
including perspective taking, fantasy, personal distress and empathic
concern. The Empathy Quotient (EQ), and the Basic Empathy Scale
(BES) were the other measures that were used to assess empathy (Bar­
on-Cohen and Wheelright, 2004; Jolliffe and Farrington, 2006).
2.3. Data extraction and computation of effect sizes
Data extraction was performed separately by E.B and B.Y (See
acknowledgement section). The quality of the studies included was
assessed using the selection and quality of outcome ascertainment sec­
tions (maximum score = 8) of a modified (for cross-sectional studies)
version of the Newcastle-Ottawa Scale (Wells et al., 2000). The main
outcome measure was the standardized mean effect size (Cohen’s d) for
the studies comparing ToM, facial emotion recognition, or empathy
performances between individuals with OCD and healthy controls. De­
mographic variables (age, gender, duration of education), clinical var­
iables (duration of illness, age of onset of illness), the effect size for the
between-group differences for the measures of executive functions,
mean total scores of the Yale-Brown Obsessive-Compulsive Scale (Y-
BOCS) (Goodman et al., 1989) and ratings for depression symptoms
were also coded.
2.4. Statistical analyses
Effect sizes (Hedges’ g) were calculated for the comparison of OCD vs
healthy controls on facial emotion recognition, ToM, and empathy
scores reported within each study.
ToM: Effect sizes for ToM were calculated. For studies that reported
more than one ToM task, pooled effect sizes (Cohen’s d) were calculated.
Separate effect sizes for ToM-decoding (RMET) and ToM-reasoning were
also calculated.
Facial emotion recognition: Effect sizes for facial emotion recognition
E. Bora Psychiatry Research 316 (2022) 114752

total score were calculated. In addition to the total emotion labeling
score, separate effect sizes for six basic emotions (anger, fear, disgust,
sadness, happiness, surprise) were also calculated.
Empathy: First, effect sizes for total empathy scores were calculated.
In addition, effect sizes for cognitive and affective empathy scores were
calculated. Separate meta-analyses were also conducted for the total and
the 4 subscale scores of the IRI.
Meta-analyses were performed using the “metaphor” package in R
environment (Viechtbauer, 2010). Effect sizes (Hedges’ g) were
weighted using the inverse variance method. 95% confidence intervals
(CI) were also reported. A random-effects model (DerSimonian–Laird
estimate) was used. Homogeneity of the distribution of weighted effect
sizes was tested with the Q and I2 tests (I2 values <50% indicate low
heterogeneity, I2 >50% indicate moderate heterogeneity, and I2 >75%
indicate large heterogeneity). Publication bias was assessed by inspec­
tion of funnel plots, Egger’s test, and trim and fill method. Egger’s test
relies on the theory that studies with significant rather than negative
findings in studies with small sample sizes would be more likely to be
reported while large-scale studies would be more likely to be published
regardless of the significance of the findings. In Egger’s test, the p-value
less than 0.05 implicates publication bias.
Meta-regression analyses were conducted for age, gender (ratio of

Table 1
Characteristics of the studies included.
Study Sample Sex Age Mean (SD) Social cognition and Clinical characteristics Outcome
(male empathy measures
%)

Aigner et al., 2007 40 OCD40 60% 34.8 (10.4) Emotion recognition OCD criteria: DSM-IVAxis I co- No difference
HC 60% 34.7 (8.7) morbiditiesexcluded.
Altinöz et al. 2019 48 OCD39 44% 33.0 (median) RMET, Hinting OCD criteria: DSM-IVAxis I not RMET impaired in OCD
HC 41% 35.0 (median) excluded
Bozikas et al., 2009 25 OCD25 40% 32.7 (8.9)33.4 Facial emotion OCD criteria: DSM-IVAxis I not No difference
HC 56% (7.3) excluded
Buhlmann et al., 20 OCD20 40% 31.0 (10.5) Facial emotion OCD criteria: DSM-IVAxis I not No difference
2004 HC 35% 32.9 (11.7) excluded
Buhlmann et al. 35 OCD35 51% 34.0 (9.1)32.7 MASC OCD criteria: DSM-IVAxis I not Not impaired
2015 HC 40% (11.0) excluded
Cain et al., 2015 25 OCD25 52% 33.7 (9.1)33.7 IRI OCD criteria: DSM-IVAxis I not OCD is associated with-decreased cognitive
HC 40% (10.8) excluded empathy-increased personal distress
Corcoran et al. 2008 40 OCD36 Facial emotion OCD criteria: DSM-IVAxis I not OCD is associated with impaireddisgust
HC excluded recognition
Fontenelle et al. 53 OCD53 45% 39.3 (13.8) IRI OCD criteria: DSM-IVAxis I not Increased empathic concernand personal
2009 HC 34% 35.5 (13.0) excluded distress in OCD
Jhung et al., 2010 41 OCD37 78% 24.9 (5.3)25.9 Facial emotion OCD criteria: DSM-IVAxis I not No difference in non-ambiguousstimuli
HC 76% (6.0) excluded
Kang et al., 2012 107 67% 27.5 (9.2)26 IRI OCD criteria: DSM-IVAxis I not Decreased perspectivetaking and
OCD130 63% (4.8) excluded increasedpersonal distress in OCD in IRI
HC
Kim et al., 2018 277 29.9 (10.7) IRI OCD criteria: DSM-IVAxis I not Decreased perspectivetaking and
OCD395 22.2 (2.7) excluded increasedpersonal distress in OCD in IRI
HC
Kornreich et al., 22 OCD22 37.3 (8.0)37.2 Facial emotion OCD criteria: DSM-IVAxis I not No difference
2001 HC (9.0) excluded
Liu et al., 2017 40 OCD38 45% 24.6 (4.1)23.3 Yoni OCD criteria: DSM-IVAxis I excluded OCD is associated with
HC 42% (2.7) impairedperformance in second-
orderaffective ToM task
Lochner et al., 2012 20 OCD20 55% 34.1 (11.0) Facial emotion OCD criteria: DSM-IVAxis I excluded No difference
HC 45% 34.8 (10.8)
López-Del-Hoyo 31 OCD30 65% 40.2 (11.9) Hinting, RMET, IRI OCD criteria: DSM-IVAxis I not ToM is impaired in OCD. Increasedpersonal
et al., 2019 HC 23% 46.4 (11.2) excluded distress in OCD
Mavrioglu et al. 20 OCD20 60% 38.1 (10.6) Hinting, faux pas, OCD criteria: DSM-IV andICD 10Axis No difference
2016 HC 60% 38.2 (13.0) facial emotion I not excluded
Mısır et al., 2018 34 OCD30 38% 32.4 (10.0) RMET, ToM stories OCD criteria: DSM-IVAxis I not ToM is impaired in OCD
HC 57% 34.4 (9.7) excluded
Montagne et al., 21 OCD47 43% 36.0 (10.3) Facial emotion OCD criteria: DSM-IVAxis I not A subgroup of OCD patients withchecking
2008 HC 51% 40.6 (12.3) excluded behavior are more sensitiveto fear and
happiness
Parker et al. 2004 15 OCD15 47% 37.7 (10.7) Facial emotion OCD criteria: DSM-IVAxis I not No difference
HC 31.3 (12.2) excluded
Pertusa et al. 2012 31 OCD55 39% 39.0 (13.4) RMET OCD criteria: DSM-IVAxis I not No difference
HC 51% 37.4 (15.4) excluded
Pino et al., 2016 23 OCD24 52% 39.1 (12.9) EQ, BES, RMET OCD criteria: DSM-IVAxis I excluded Cognitive empathy is impairedin OCD
HC 54% 38.7 (11.9)
Salazar-Kampf et al. 64 OCD62 41% 34.2 (9.9)35.8 IRI, EmpaToM OCD criteria: DSM-IVSubstance Increasedpersonal distress in OCD in IRI
2022 HC 39% (10.2) dependenceexcluded
Sayın et al. 2010 30 OCD30 33% 34.3 (11.5) ToM stories, false OCD criteria: DSM-IVMDD is Advanced ToM is impairedin OCD
HC 33% 33.0 (10.6) belief excluded
Toh et al., 2015 19 OCD21 26% 37.0 (10.4) Facial emotion OCD criteria: DSM-IVAxis I not No difference
HC 38% 35.7 (10.6) excluded
Tulaci et al. 2018 80 OCD80 35% 29.5 (9.7) Hinting, RMET, OCD criteria: DSM-IVAxis I not ToM impaired in OCD
HC Faux Pas, excluded (otherthan severe
FalseBelief disorders)

BES=Basic empathy scale, EQ=Empathy Quotient, IRI=Interpersonal reactivity index, RMET=Reading the mind in the eyes test, EQ=Empathy Quotient,.
ToM=Theory of Mind, MASC=Movie for the Assessment of Social Cognition, OCD=Obsessive-Compulsive Disorder, HC– – Healthy controls, MDD= Major Depressive
Disorder.

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E. Bora
males in OCD group) with a random-effects model were using the
restricted-information maximum likelihood method with a significance
level set at p<0.05. Several ToM studies also reported correlations of
ToM with Y-BOCS, depression ratings, and executive functions (using
the Wisconsin Card Sorting Test and verbal fluency tests). Meta-analyses
of correlations (r) for these variables were also conducted for exploring
the influence of these variables on ToM performance in OCD.
3. Results
The current meta-analysis included 25 studies involving 1161
(51.6% males) patients with OCD and 1329 (49.4% males) healthy
controls (Table 1) (see Fig. 1 for the flowchart of the study selection
process). In all of the studies included, OCD was diagnosed based on
Fig. 1. Flow diagram of the meta-analysis.
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Psychiatry Research 316 (2022) 114752
DSM-IV criteria. There was no significant between-group difference for
age (g = 0.01, CI=− 0.09, 0.11, p = 0.87). The duration of education
tended to be shorter in patients with OCD compared to healthy controls
but the between-group difference was not statistically significant (g =
0.14, CI=− 0.01, 0.29, p = 0.06). The mean Y-BOCS score in the included
studies was 24.2. The range of Y-BOCS scores (20.6 to 33.3, reported in
18 studies) across studies suggested that patients included in the current
meta-analysis had predominantly moderate or severe current symptom
severity. The quality scores of the included studies are reported in
Table 1s in the supplement.
E. Bora
3.1. Social cognition
3.1.1. ToM
The distribution of effect sizes for ToM-reasoning was homogeneous
(I2= 0%). The distribution of effect sizes for the ToM-decoding (RMET)
task was extremely heterogeneous (I2=97%) but this heterogeneity was
related to the effect of a single study (López-Del-Hoyo et al., 2019)
reporting an extreme outlier value for ToM-decoding (g = 3.73) (eFig­
ure1). The distribution of effect sizes for ToM-decoding was homoge­
neous after removing this study (I2= 0%). The ToM-decoding
meta-analyses were conducted after removing this outlier study.
The performance of patients with OCD was significantly poorer than
healthy controls for ToM (g = 0.43, CI=0.24, 0.62, k = 11; Fig. 2) (Table-
2). Among ToM domains, both ToM-reasoning (g = 0.54, CI=0.32, 0.77,
k = 8) and ToM-decoding (g = 0.46, CI=0.28, 0.66, k = 5) were
significantly impaired in OCD. There was no evidence of publication
bias.
3.1.2. Emotion recognition
There was no significant difference between OCD and healthy con­
trol groups in total emotion recognition score (g = 0.13, CI=− 0.04, 0.29,
k = 11; Fig. 3) (Table-2). In the analysis of individual emotions, patients
with OCD significantly underperformed controls in recognition of
disgust (g = 0.26, CI=0.04, 0.48, k = 7; Fig. 4), but not in other emotions
(Table 2). The distributions of effect sizes for emotion recognition var­
iables, except recognition of happiness, were homogenous (Table-2).
There was no evidence of publication bias (Table-2).
3.2. Empathy
3.2.1. Cognitive empathy
In meta-analyses of empathy, OCD was associated with reduced
cognitive empathy (g = 0.44, CI=0.10, 0.78, k = 7) (Fig. 5). There was
significant heterogeneity in the distribution of effect sizes for cognitive
empathy (I2=85%). When a meta-analysis of cognitive empathy was
conducted using only the IRI Perspective taking score, cognitive
empathy impairment in OCD remained significant (g = 0.33, CI=0.03,
0.63). However, there was significant heterogeneity in the distribution
Fig. 2. Forest plot of effect sizes and 95% confidence intervals for ToM diffences between patients with OCD and healthy controls using random effects model.
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Psychiatry Research 316 (2022) 114752
of effect sizes for the IRI Perspective-taking subscale (I2=81%). As ex­
pected, there was no between-group difference for the Fantasy subscale
of the IRI (g=− 0.05, CI=− 0.24,0.10).
There was no evidence of publication bias for any of the cognitive
empathy measures.
3.2.2. Affective empathy
Contrary to the findings for cognitive empathy, OCD was associated
with a higher total affective empathy score (g=− 0.44, CI=− 0.16, − 0.73,
k = 7; Fig. 6) which was more robust when the analysis was restricted to
the IRI total affective empathy score (g=− 0.54, CI=− 0.37, − 0.72).
There was a significant heterogeneity in the distribution of effect sizes
for affective empathy (I2=79%). However, heterogeneity in this analysis
was related to the effect of the psychometric differences between the
affective empathy measures used. The distribution of affective empathy
was less heterogenous when this analysis was conducted only with the
IRI affective empathy score (I2=40%).
Further analyses of the IRI subscales suggested that affective
empathy enhancement in OCD was related to increased personal distress
subscale (g=− 0.93, CI=− 0.74, − 1.13; Fig. 7). There was no significant
difference in the IRI empathic concern between patients with OCD and
healthy controls (g=− 0.16, CI=− 0.42, 0.10) (Table-2). The distribu­
tions of effect sizes for affective empathy subscales of the IRI were
homogenous.
There was no evidence of publication bias for any of the affective
empathy measures.
3.3. Meta-regression and correlational meta-analyses
In study-level meta-regression analyses, age and gender had no sig­
nificant effect on between-group differences in social cognition. The
between-group differences in duration of education were not signifi­
cantly related to effect sizes for ToM (Z = 0.07, p = 0.95), empathy
(Z=− 1.34, p = 0.18), and emotion recognition (Z = 1.24, p = 0.22)
differences between patients with OCD and healthy controls. The quality
score of studies included had no significant effect on group differences in
ToM (Z = 0.47, p = 0.54), empathy (Z=− 0.68, p = 0.49), and emotion
recognition (Z = 0.53, p = 0.60) between patients with OCD and healthy
E. Bora Psychiatry Research 316 (2022) 114752

Fig. 3. Forest plot of effect sizes and 95% confidence intervals for emotion recognition differences between patients with OCD and healthy controls using random
effects model.

Fig. 4. Forest plot of effect sizes and 95% confidence intervals for disgust recognition differences between patients with OCD and healthy controls using random
effects model.

controls. was possible to conduct correlational meta-analyses for these variables.

Meta-regression analyses have limitations as they are based on study-
level rather than individual-level data. Unfortunately, most studies have
not reported correlations between social cognition/empathy and most of
the other demographic and clinical variables. However, as an exception,
some studies reported results of correlation between ToM and the Y-
BOCS scores, depression ratings, and executive functions. Therefore, it
In correlation meta-analyses of studies investigating ToM (k = 4–7), Y-
BOCS (r=− 0.05, CI=0.08, − 0.17, Z = 0.70, p = 0.48, 259 patients with
OCD) and depression ratings (r = 0.04, CI= − 0.14, 0.21, Z = 0.40, p =
0.69, 131 patients with OCD) were not significantly associated with ToM
scores in OCD. However, executive function performance was signifi­
cantly associated with ToM scores in OCD (r = 0.20, CI=0.03, 0.36, Z =

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E. Bora Psychiatry Research 316 (2022) 114752

Table 2
. mean weighted effect sizes for social cognitive and empathy differences between OCD and healthy controls.
Test k OCD HC g 95% CI Z P Q test Q-test p I2 Bias

Emotion recognition 11 283 303 0.13 − 0.04 0.29 1.54 0.12 7.5 0.68 0 0.97
Happy 5 115 143 − 0.15 − 0.58 0.28 0.68 0.50 10.8 0.03 64 0.65
Sad 7 196 216 0.09 − 0.11 0.29 0.91 0.36 8.3 0.22 0 0.58
Anger 6 156 176 0.19 − 0.10 0.47 1.28 0.20 8.2 0.15 38 0.74
Fear 6 156 176 0.07 − 0.18 0.32 0.51 0.61 6.2 0.29 23 0.60
Disgust 7 176 196 0.26 0.04 0.48 2.32 0.02 6.2 0.40 10 0.61
Surprise 4 75 103 − 0.06 − 0.51 0.39 0.26 0.80 6.2 0.10 52 0.88
ToM 11 436 443 0.43 0.24 0.62 4.38 <0.001 19.4 0.04 48 0.93
-ToM-reasoning 8 318 302 0.54 0.32 0.77 4.78 <0.001 12.6 0.08 45 0.45
-ToM-decoding (RMET) 5 216 228 0.46 0.28 0.66 4.83 <0.001 4.0 0.40 0 0.82
Empathy
-Cognitive empathy 7 580 719 0.44 0.10 0.78 2.55 0.01 26.7 <0.01 85 0.08
-IRI PT 6 557 695 0.33 0.03 0.64 2.16 0.03 18.3 0.003 81 0.21
-Affective empathy 7 580 719 − 0.44 − 0.16 − 0.73 3.06 0.002 18.9 0.004 79 0.77
-Affective empathy (IRI) 6 557 695 − 0.54 − 0.37 − 0.72 6.22 <0.001 8.1 0.15 40 0.48
-IRI EC 6 557 695 − 0.16 − 0.42 0.10 1.21 0.23 15.3 <0.01 74 0.91
-IRI PD 6 557 695 − 0.93 − 1.13 − 0.74 9.3 <0.001 10.1 0.07 50 0.13
-IRI F 6 557 695 − 0.05 − 0.24 0.15 0.45 0.65 10.9 0.06 56 0.25

OCD=Obsessive-Compulsive Disorder, ToM=Theory of mind, HC– –Healthy controls, IRI=Interpersonal reactivity index, PT=Perspective taking, EC=Empathic
Concern, PD=Personal Distress, F=Fantasy, Bias= p value for the Egger’s test, g=Hedges g.

Fig. 5. Forest plot of effect sizes and 95% confidence intervals for cognitive empathy differences between patients with OCD and healthy controls using random
effects model.

2.32, p = 0.03, 138 patients with OCD).
4. Discussion
The current meta-analysis investigated social cognition and empathy
in patients with OCD compared to healthy controls. The findings of this
meta-analysis showed that patients with OCD performed significantly
poorer than healthy controls in ToM and they also had mild impairment
in recognition of disgust. OCD was significantly associated with reduced
cognitive empathy but affective empathy was significantly enhanced in
OCD compared to healthy controls. Moreover, enhanced affective
empathy in OCD was related to the increased the IRI personal distress
rather than the IRI empathic concern.
In OCD, the recognition of basic emotions was mostly intact
compared to healthy controls. Mild impairment in recognition of disgust
was the only exception (g = 0.26). This finding seemingly contradicts the
well-known enhanced reactivity to disgust which is evident in many
patients with OCD (Bhikram et al., 2017; Knowles et al., 2018; Olatunji
et al., 2019). However, recognition and appraisal of disgust are separate
processes. Current findings suggest that the exacerbated disgust
response in OCD is not related to the enhancement of perceptual/emo­
tional recognition of aversive stimuli. Disgust proneness in OCD is more
likely to be the result of abnormalities in the appraisal of disgust and
other aversive stimuli which might be related to functional abnormal­
ities in the orbitofrontal cortex (Bhikram et al., 2017; Evans et al. 2004).
Impairment in recognition of disgust, which was mild but relatively
more pronounced than other emotions, is compatible with the findings
in major depression (Dalili et al., 2015).
In the current meta-analysis, OCD was associated with medium-sized
deficits in ToM (g = 0.43). Both decoding and reasoning aspects of ToM
were impaired (g = 0.46, 0.54). The severity of impairment in ToM was
comparable in magnitude to other neurocognitive deficits as reported in

7
E. Bora Psychiatry Research 316 (2022) 114752

Fig. 6. Forest plot of effect sizes and 95% confidence intervals for affective empathy differences between patients with OCD and healthy controls using random
effects model.

Fig. 7. Forest plot of effect sizes and 95% confidence intervals for IRI Personal Distress differences between patients with OCD and healthy controls using random
effects model.

a previous meta-analysis in OCD (Shin et al., 2014). OCD is associated
with abnormalities in prefrontal brain regions that have a role in ToM
and social cognition (Del Casale et al. 2017; Rasgon et al., 2017;
Thorsen et al., 2018). ToM impairment in OCD might be likely related to
abnormalities in the ventromedial prefrontal cortex and its subcortical
connections. However, there is a paucity of studies directly investigating
the neural correlates of ToM deficits in OCD. Another consideration is
the relationship between state factors and ToM in OCD. ToM impairment
in OCD was not significantly related to the severity of
obsessive-compulsive symptoms. These findings might suggest that ToM
impairment is potentially a trait feature of the illness but further studies
are necessary to investigate the relationship between
obsessive-compulsive symptoms and social cognition/empathy. The ef­
fects of cognitive deficits on ToM impairment in OCD is another
important consideration. A preliminary meta-analysis of correlational
data provided evidence for a significant but modest association between
executive functions and ToM suggesting that cognitive impairment
might influence the effect size of ToM impairment in OCD.
OCD was associated with a reduction in the self-reported cognitive
empathy score (g = 0.44). This finding was in accordance with ToM
impairment in this meta-analysis. Contrary to the findings of the meta-
analysis of cognitive empathy, affective empathy was not reduced in

8
E. Bora
OCD, and actually, patients with OCD had a robust enhancement in the
IRI Personal Distress (g = 0.93) domain of affective empathy. This was
the most robust finding of the current meta-analysis. Increasing evi­
dence suggests that elevated personal distress, the tendency to feel self-
oriented anxiety and worry (as an emotional contagion) when exposed
to the misfortune or suffering of others, is a transdiagnostic feature of
many psychopathological conditions including anxiety disorders, major
depression, anorexia nervosa and borderline personality disorder
(Dziobek et al., 2011; Flashback et al. 2017; Kerr-Gaffney et al., 2019;
Schreiter et al., 2013). The IRI Personal Distress might be a develop­
mental precursor of affective empathic concern and might be an indi­
cator of the level of affective empathy when co-expressed with empathic
concern. However, it is important to note that elevated the IRI personal
distress might reflect state-related factors (i.e. current depressive
symptoms or nonspecific anxiety) rather than genuine trait-related
enhanced personal distress and emotional contagion. Elevated PD
might potentially simply reflect general sensitivity to negative stimuli in
a broader context (not only in response to the comprehension of others’
mental states). In the current meta-analysis, only the IRI Personal
Distress but not the IRI Empathic Concern was enhanced in OCD sug­
gesting that there might not be an actual change in affective empathy
levels in OCD. Therefore, further studies investigating the personal
distress aspect of empathy in OCD using experimental procedures, rather
than a psychometric measure, are necessary.
Interestingly, the pattern and magnitude of social cognitive deficits
in OCD in this meta-analysis were very similar to what was found for
major depressive disorder (MDD) in earlier meta-analyses (Bora and
Berk, 2016; Dalili et al., 2015; Screiter et al. 2013). Both OCD and MDD
seem to be associated with enhanced IRI Personal Distress score, ab­
normality in recognition of disgust, and deficits in ToM and cognitive
empathy. MDD is a very common comorbidity in OCD and most of the
patients in this meta-analysis had mild depression. Therefore, it is
important to investigate the effect of depressive symptoms on social
cognitive impairment, and empathy abnormalities in OCD. Unfortu­
nately, only a few of the studies included in the current meta-analysis
explored individual level direct correlations between depression rat­
ings and emotion recognition or empathy. Therefore, a meta-analysis of
such correlations was not possible. However, it was possible to conduct a
preliminary meta-analysis of correlational data for the relationship be­
tween ToM and depression ratings. In this analysis, no significant rela­
tionship between ToM and depression scores was evident. Differences in
the levels of insight in OCD samples across studies might also be an
important moderator (Liu et al., 2017; Tulaci et al. 2018; Jansen et al.,
2020). However, it was not possible to investigate the relationship be­
tween insight and social cognition as the vast majority of the included
studies have not reported this variable. It is also important to investigate
the moderating effects of other psychopathological variables on the ef­
fect sizes for the relationship between OCD and social cognition/em­
pathy. One important candidate is autism spectrum disorder, which is
robustly associated with deficits in social cognition and empathy (Bora
and Pantelis, 2016; Harmsen et al. 2019). Autistic traits are significantly
prevalent in patients with OCD compared to controls (Bejerot et al.,
2001; Griffiths et al., 2017; Ivarsson et al. 2008; Wikramanayake et al.,
2018). It is likely that deficits in social cognition and empathy might be
evident mostly in OCD patients with autistic features. Unfortunately,
previous studies have not investigated these potential associations.
Therefore, it was not possible to include autistic traits and other
co-morbidities (i.e., personality disorders) as moderators in the current
quantitative systematic review. In the future studies, it would be
important to ascertain whether or not deficits in social cognition and
empathy in OCD are characteristics of particular clinical subgroups of
this disorder.
The current findings might have clinical implications. Abnormalities
in social cognition and empathy are likely candidates for playing a sig­
nificant role in interpersonal dysfunction in OCD. Further studies are
needed to directly investigate the relationship between social cognition
9
Psychiatry Research 316 (2022) 114752
and the level of functional impairment in OCD. Previous studies have
shown positive effects of social cognitive training on ToM and emotion
recognition in other psychiatric conditions including major depression
and schizophrenia (Prikken et al., 2019; Zhu et al., 2018). However,
social cognitive training has not been systematically explored in OCD.
Social cognitive training, in the subgroup of patients presenting with
difficulties in social cognition and cognitive empathy, might be a po­
tential approach in the management of OCD.
There were several limitations of the current meta-analysis. The
number of available studies was relatively small. Another limitation was
the lack of neurocognitive assessment in most studies included, so it was
not possible to explore the contribution of cognitive impairment on
observed between-group differences except for ToM. Also, the self-
report nature of empathy scales used in the available studies is one of
the important considerations, as there might be a discrepancy between
performance-based empathy tasks and how empathetic individuals
perceive themselves to be. However, similar levels of impairment in self-
report empathy and performance-based ToM measures were found in
this meta-analysis, which increases the confidence in the current
findings.
As a conclusion, the findings of this meta-analysis provided sub­
stantial evidence for deficits in social cognition and cognitive empathy
in OCD. Future research should examine the influence of comorbid
psychopathological traits and neurocognitive difficulties on social
cognition in OCD.
Financial support
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
None
Acknowledgements
I would like to thank to Berna Yalınçetin for her support in coding the
data and literature search.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.psychres.2022.114752.
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