Metacognitions and emotional schemas: a new cognitive perspective for the distinction between unipolar and bipolar depression

Abstract

Introduction

Clinicians need to make the differential diagnosis of unipolar and bipolar depression to guide their treatment choices. Looking at the differences observed in the metacognitions, and the emotional schemas, might help with this differentiation, and might provide information about the distinct psychotherapeutical targets.

Methods

Three groups of subjects (166 unipolar depressed, 140 bipolar depressed, and 151 healthy controls) were asked to fill out the Metacognitions Questionnaire–30 (MCQ-30), and the Leahy Emotional Schema Scale (LESS). The clinicians diagnosed the volunteers according to the criteria of DSM-IV-TR with a structured clinical interview (MINI), and rated the moods of the subjects with the Montgomery Asberg Depression Rating Scale (MADRS), and the Young Mania Rating Scale (YMRS). Statistical analyses were undertaken to identify the group differences on the MCQ-30, and the LESS.

Results

The bipolar and unipolar depressed patients' scores on the MCQ-30 were significantly different from the healthy controls, but not from each other. On the LESS dimensions of guilt, duration, blame, validation, and acceptance of feelings, all three groups significantly differed from each other. There were no statistically different results on the LESS dimensions of comprehensibility, consensus, and expression. The mood disordered groups scored significantly different than the healthy controls on the LESS dimensions of simplistic view of emotions, numbness, rationality, rumination, higher values, and control.

Conclusions

These results suggest that the metacognitive model of unipolar depression might be extrapolated for patients with bipolar depression. These results are also compatible to a great extent with the emotional schema theory of depression.

Introduction

Since the revolutionary conceptualization of depression as a disorder of dysfunctional cognitions rather than an emotional disorder [1], the cognitive theory of depression has evolved and broadened its scope with a variety of new therapy approaches [2], [3], [4], [5], [6], [7], including metacognitive therapy [8] and emotional schema therapy [9]. Although the cognitive model of unipolar depression is extensively studied [1], [10], [11], little is known about the distinctive features of the cognitive model of bipolar depression [12], [13], [14], [15]. Clinical and demographic variables may be helpful to some extent in the distinction between these two different phenomenological syndromes [16], [17], [18], but there still is a high rate of misdiagnosis [19], [20], [21].

From the view point of a cognitive behavioural psychotherapist, bipolar depression seems to be very similar to unipolar depression, as observed by previous researchers [14], [22], [23], [24]. Some of these similarities can be summarized as increased rumination, an implicit pessimistic attributional style, low self-esteem, and dysfunctional attitudes towards the self [15], [22], [24], [25], [26]. Thus, bipolar patients have been described as having (1) concerns with perfectionism, autonomy and self-criticism, (2) complex patterns of self-esteem that depend upon the phase of illness, (3) pronounced short-term fluctuations in mood and self-esteem, and (4) an increased need for social approval [15], [23], [24], [27], [28]. Furthermore, as noted in a study by Van der Gucht [29], negative cognitive styles observed in bipolar patients, which are characterized by sociotropy, autonomy, behavioural inhibition and rumination, are mostly evident during the depressive phase, but may still be present in an attenuated form even during the euthymic period. Although these cognitive styles and the similarities between unipolar and bipolar depression have been reported for a long time, little research has been undertaken to investigate the between group differences of depressed individuals.

Research involving the cognitive structure of bipolar disorder has generally focused on the content of irrational beliefs, i.e. automatic thoughts, dysfunctional attitudes and core beliefs [14], [30], [31], [32], [33]. Yet, cognitions consist of more elements than simply the above mentioned ones, e.g. metacognitions [8]. Metacognition is defined as “an orchestra conductor, who appraises, monitors or controls cognitions” [34]. It is postulated that people have positive or negative beliefs (metacognitions) of their appraisal of the events they encounter, and such metacognitions are believed to be the underlying process of the maintenance of psychopathology [8], [34], [35]. In a disorder like bipolar disorder, which has two opposite poles regarding its clinical phenomenology, it is of great importance to investigate the specific metacognitions. Nonetheless, there are yet just two studies in the literature [36], [37] (and only one of them is written in English) comparing unipolar and bipolar depression's metacognitions. These studies have shown that the metacognitions, as measured by the metacognitions questionnaire, differ between the mood disordered groups on some metacognitive aspects [36], and that some of the metacognitions of bipolar type II depressed patients might be predictive of their dysfunctional attitudes [37].

As cognitive theory's scope broadened, emotions have become a more respected area of research, and this has led to the birth of an innovative therapy approach, i.e. emotional schema therapy [9]. Leahy (2002) has built upon the metacognitive information processing model of Wells [38], [39], and named the plans, modalities and strategies to an emotion as emotional schemas [40]. According to Leahy's emotional schema model, the differences in individuals' interpretations, evaluations, action tendencies, and behavioural strategies for their emotions may result in negative beliefs about their emotions, such as the belief that their emotions do not make sense, that they will last indefinitely and overwhelm them, that they are shameful and unique to them, that they cannot be expressed, and that they will never be validated. These individuals are more likely to utilize problematic and maladaptive coping styles, such as rumination, worry, avoidance, drinking, bingeing, or dissociating [9]. In one of the pivotal articles on his model of emotional schemas, Leahy (2007) states that “although noticing, labeling, and differentiating emotions are part of an essential first step in emotional processing, individuals also differ in their interpretations and strategies of their own emotions once they recognize that they have an emotion” [41]. Furthermore, as Pennebaker et al. suggest (1997) emotional processing reflects the disinhibition of emotions, and allows for increased self-understanding, and positive self-reflection. They continue to conclude that simply emotional expression per se may not be enough, and that facilitating acceptance, understanding, decreasing guilt, and differentiating emotions have a greater impact on consequent depression [40], [41], [42]. Emotional schemas, therefore, may be of interest in differentiating various types of psychopathology, e.g. unipolar depression and bipolar depression. Yet, no study can be found in the literature focusing on this distinction.

This study primarily focuses on the distinction of unipolar and bipolar depression in terms of metacognitions and emotional schemas, thereby intending to make some yet rarely illustrated contribution to the literature on how to differentiate these two separate clinical conditions.