The role of unhelpful metacognitive beliefs in psychosis: Relationships with positive symptoms and negative affect
Introduction
The Self-Regulatory Executive Function (s-REF) model (Wells and Matthews, 1994, Wells and Matthews, 1996) is an information processing approach to psychological disorder that emphasises the role of unhelpful metacognitive beliefs and self-regulation strategies. The model assumes that a core Cognitive Attentional Syndrome (CAS) is associated with the maintenance of unhelpful thinking styles that maintain symptoms and distress. The CAS is underpinned by the presence of unhelpful metacognitive beliefs that can be positive and negative in content, and often co-occur. Positive metacognitive beliefs reflect an individual's beliefs regarding the usefulness of some cognitive enterprises (e.g. “worrying about danger will mean I’m always prepared”), whilst negative metacognitive beliefs reflect an individual's beliefs about the danger or uncontrollability of thoughts (e.g. “my thoughts will cause harm”). A core assumption of the model is that unhelpful metacognitive beliefs lead to conflicts in self-regulation, and negative metacognitive beliefs are considered particularly important in distress (Wells, 2009, p17). The model is distinct from other research within the psychosis literature that also uses the term “metacognition” such as Lysaker's work on theory of mind deficits and social cognition (Lysaker et al., 2010); and Moritz’ series of studies investigating metacognitive training focusing on awareness and modification of cognitive biases associated with attributional style and reasoning Moritz et al. (2010).
The role of metacognitive beliefs in psychosis has received considerable attention. However, the specific nature of this relationship is currently unclear. Initial accounts suggested that metacognitive beliefs may have a causal role in positive symptoms, such as auditory hallucinations. Morrison et al. (1995) suggested that the misattribution of internal thoughts as external voices is influenced by the beliefs that an individual holds about the importance of thought control, thought consistency and the danger of certain thoughts. Consistent with this, a number of studies found people with experiences of psychosis report higher levels of unhelpful metacognitive beliefs. For example, research using non-clinical samples found that people with higher proneness to hallucinations and delusions tend to report more positive and negative metacognitive beliefs (Laroi and Van der Linden, 2005; Morrison et al., 2000). Research using people at risk of developing psychosis found that at risk mental state (Morrison et al., 2006) and subsequent transition (Barbato et al., 2013, Morrison et al., 2002) is associated with a greater endorsement of negative metacognitive beliefs.
A recent meta-analysis, however, found limited support for a causal role of metacognitive beliefs in hallucinatory experiences. The authors found that when controlling for comorbid symptoms, such as delusional beliefs and emotional distress, associations between metacognitive beliefs and hallucinations were reduced (Varese and Bentall, 2011). This suggests that metacognitive beliefs may instead have a more general role related to symptom maintenance, help-seeking, and distress. Consistent with this, subsequent studies have shown that elevated metacognitive beliefs are associated with increased distress (Barbato et al., 2013, Brett et al., 2009, Hill et al., 2012; van Oosterhout et al., 2013) and a more severe and chronic course of illness (Austin et al., 2015).
Co-morbid symptoms of anxiety and depression are common throughout the course of illness in people with psychosis (Buckley et al., 2009). Negative affect and emotional state appear to have an important role in the psychosis prodrome (e.g. Debbane et al., 2009; Yung and McGorry, 1996) and are thought to influence the content of positive symptoms (Freeman and Garety, 2003). According to the S-REF model, metacognitive beliefs are associated with enduring psychological distress (i.e. anxiety and depression) because they guide unhelpful coping strategies such as worry, rumination and threat monitoring (i.e. the CAS). These strategies are counterproductive because they increase detection of threat and prolong negative emotional states. If metacognitive beliefs have a role related to distress in psychosis, it would be expected that higher levels of unhelpful metacognitive beliefs would predict higher levels of negative affect in people with the diagnosis. In addition it might be expected that this relationship would be independent of the frequency or characteristics of positive symptoms alone.
In order to investigate these predictions, this research will test whether metacognitive beliefs predict negative affect over and above topological characteristics of positive symptoms (e.g. symptom frequency) in people with psychosis. The following research questions will be addressed: 1) Are unhelpful metacognitive beliefs associated with positive symptoms of psychosis? 2) Are unhelpful metacognitive beliefs associated with negative affect? 3) Do metacognitive beliefs predict negative affect over and above symptom frequency, and other dimensions of psychotic symptoms captured by the Psychotic Symptoms Rating Scale (Haddock et al., 1999).
Section snippets
Participants
A total of 159 people took part in this study. The mean age was 35.7 years (SD=12.2; range=17–47) and the male: female ratio was 92:67. All participants had either a diagnosis of psychotic disorder according to the Diagnostic Statistical Manual of Mental Disorders fourth edition (American Psychiatric Association, 2000) or met threshold for early intervention in psychosis using the Positive and Negative Syndrome Scale (Kay et al., 1987) defined as a score of four on hallucinations or delusional
Data screening
First, data were screened for missing values. Five participants had not completed the MCQ-30 and were excluded from analyses. There were 26 individual item scores missing across the remaining dataset (<1%) and missing values analysis confirmed there were no patterns to the missing data. Expectation maximisation was utilised to estimate and replace these values. Second, data were screened for outliers. Visual inspection of box-plots indicated no evidence of univariate outliers. Data were
Discussion
The first aim of this research was to test whether unhelpful metacognitive beliefs are associated with positive symptoms and negative affect in people with psychosis. The second aim was to test whether the relationship between unhelpful metacognitive beliefs and negative affect is substantive in this group by partialling out covariance's with topological characteristics of positive symptoms (e.g. symptom frequency assessed using the Psychotic Symptoms Rating Scale).
The findings indicated that
Conclusions
Consistent with the metacognitive model, our results suggest that people with positive symptoms of psychosis also have unhelpful metacognitive beliefs. In particular, unhelpful metacognitive beliefs were associated with negative affect. More specifically, the presence of unhelpful negative beliefs predicted emotional distress over and above the frequency of positive symptoms.
Fundings
ŁG is financed by the Polish Ministry for Science and Higher Education (0295/E-393/STY/10/2015 and MOBILITY PLUS programme 1258/MOB/IV/2015/0).
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