Metacognitive beliefs in the at-risk mental state: A systematic review and meta-analysis
Introduction
Metacognition has been broadly defined as ‘thinking about thinking’ (Flavell, 1979), and includes the processes involved in the control, modification and interpretation of thought (Wells & Cartwright-Hatton, 2004). Certain metacognitive beliefs have been proposed to contribute to the development and maintenance of a range of mental health problems, including anxiety disorders (Ellis and Hudson, 2010, Hezel and McNally, 2015, Wells, 1995), alcohol abuse (Spada, Zandvoort, & Wells, 2007), eating disorders (Olstad, Solem, Hjemdal, & Hagen, 2015) and depression (Papageorgiou & Wells, 2003).
Much of the research into the relationship between maladaptive metacognitive beliefs and psychopathology has been based on the self-regulatory executive function (S-REF) model proposed by Wells and Matthews (1996). This was originally developed to account for processes underlying affective disorders and refers to a cognitive-attentional syndrome in which heightened self-focused attention, reduced efficiency of cognitive functioning and repetitive rumination drive psychological dysfunction. Preoccupation with thoughts results in the depletion of resources needed to process information incompatible with dysfunctional beliefs. It also primes similar dysfunctional beliefs and makes the individual more sensitive to internal and external belief-congruent information.
The most commonly used tools for assessing metacognitive beliefs are the Metacognitions Questionnaire (MCQ) (Cartwright-Hatton & Wells, 1997) and Metacognitions Questionnaire - short form (MCQ-30) (Wells & Cartwright-Hatton, 2004). Based on the S-REF model, these self-report scales assess five dimensions of dysfunctional metacognitive beliefs originally derived using factor analyses; (1) ‘positive beliefs about worry’, which includes items suggesting worrying is beneficial for avoiding problems, remaining organised and helping one to cope; (2) ‘negative beliefs about uncontrollability of thoughts and corresponding danger’, which includes items emphasising the importance of controlling one's thoughts and potential mental and physical dangers associated with not doing so; (3) ‘cognitive confidence’, which includes items concerned with perceived lack of self-confidence in one's memory and attention; (4) ‘negative beliefs about thoughts in general’, which is based around themes of superstition and punishment and includes items relating to the potential outcome of thoughts and feelings of responsibility for preventing those outcomes; (5) ‘cognitive self-consciousness’, which includes items reflecting one's tendency to be aware of and monitor one's thinking. Participants score individual items on a 4-point Likert scale based on the strength of their agreement with each statement. Relevant items are then summed to provide subscale scores for each of the five factors, with higher scores indicating more dysfunctional beliefs.
High levels of dysfunctional metacognitive beliefs are reported among people with psychotic disorders (Sellers et al., 2016). These have been proposed to play a potential role in the onset and persistence of psychotic symptoms such as hallucinations and delusions (Morrison, 2001, Morrison et al., 2000, Morrison et al., 2011). Positive beliefs about psychotic symptoms (for example that suspiciousness is good and keeps an individual safe) are argued to contribute to more frequent and severe symptoms, whereas negative beliefs about these thoughts (such as that they are uncontrollable or dangerous) are posited to lead to distress (Morrison, 2001, Morrison et al., 2015).
Over the past two decades, criteria have been developed to identify individuals vulnerable to developing a psychotic disorder (Miller et al., 2002, Yung et al., 1996, Yung et al., 2003). These have been referred to as the prodromal, ultra-high risk (UHR), clinical high-risk (CHR) and at-risk mental state (ARMS) criteria (Fusar-Poli et al., 2013). Recent estimates suggest approximately 36% of this group will go on to develop a psychotic disorder over the following 3 years (Fusar-Poli et al., 2012a), though people continue to be at risk of transition upwards of ten years after initially presenting to clinical services (Nelson et al., 2013). In addition, young people with ARMS frequently present with, or go on to develop, high rates of mood and anxiety disorders (Addington et al., 2011, Fusar-Poli et al., 2014, Lin et al., 2015). Maladaptive metacognitive beliefs are therefore a potentially relevant target for clinical intervention for a range of mental health problems in this population. However, no reviews to our knowledge have examined metacognitive dysfunction in the ARMS group. Reducing both psychiatric symptom severity and associated distress may ultimately lead to reduced vulnerability to both psychotic and non-psychotic clinical outcomes.
The aim of this review was to examine whether young people with ARMS report more maladaptive metacognitive beliefs compared with healthy controls, help-seeking individuals who do not meet ARMS criteria, and people diagnosed with psychotic disorders. We also sought to examine the relationship between metacognitive beliefs and clinical symptoms in the ARMS group.
Section snippets
Method
This review was conducted in line with the PRISMA guidelines for reporting systematic reviews and meta-analyses (Moher, Liberati, Tetzlaff, Altman, & PRISMAGroup, 2009).
Eligible studies
The study selection process is summarised in Fig. 1. We identified eleven papers eligible for inclusion in the narrative synthesis, collectively reporting data obtained from six unique ARMS samples (due to multiple publication) (Table 1). The meta-analyses included data from each of these six samples: metacognitive beliefs in five ARMS samples were compared to healthy controls (Brett et al., 2009, Leicester, 2013, Morrison et al., 2007, Morrison et al., 2006, Taylor, 2010, Welsh et al., 2014),
Summary of results
These results suggest that young people with ARMS were more likely to view their thoughts as dangerous and uncontrollable and had greater concerns over their memory and attention compared to both healthy and help-seeking controls. They were also more likely to monitor and be aware of their thoughts compared to healthy controls. However, people with ARMS did not significantly differ from people with full-threshold psychotic disorders on any of the MCQ subscales. Overall, these findings were
Conclusions
Maladaptive metacognitive beliefs are common in young people meeting ARMS criteria. Further research is needed to clarify the relationship between metacognitive dysfunction and the development and persistence of both psychotic and non-psychotic clinical symptoms. Assessment and treatment aimed at alleviating metacognitive dysfunction may be useful for improving a range of clinical outcomes.
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