Journal of Science and today's world 2013, volume 2, issue 1, pages: 83-93

Transcription

1 Scholar Journal Available online: Journal of Science and today's world ISSN x Research Article A Comparison of Metacognition in Schizophrenic and Anxiety Disorder Patients and a Non-Patient Control Group Nima Ganji 1, Zahra Bahadori 2, Amin Asadollahpour 3, Alireza Bagheri 4, Davood Shayan 5, Neda Sheikh Zakaryaei 6 1 Department of Cognitive Science, Institute for Cognitive Science Studies (ICSS), Tehran, Iran 2 CYBER Psychology and Neurofeedback Center, Tabriz, Iran 3 Department of Psychology, University of Tabriz, Tabriz, Iran 4 Department of Psychology, Shahid Chamran University, Ahvaz, Iran 5 Department of Medicine, Tehran University of Medical Science, Tehran, Iran 6 Department of Nursing, Tehran University of Medical Science, Tehran, Iran Received: 1 December 2012 / Accepted: 10 December 2012 / Published: 1 January 2013 Copyright 2013 Nima Ganji et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract The current study has investigated the validity of the hypothesis whether meta-cognitions are different among the vulnerability factors in psychological disorders. It seems that schizophrenic patients and those who suffer from anxiety disorders scored higher on scales of the metacognition deficiencies compared to the non-patient group. The current study is an analyticcomparative study which was conducted in consecutive sessions. The two participant groups of patients were selected from those who were hospitalized in Psychiatry Center and those who referred to the Psychiatry and Psychotherapy Clinic. Based on DSM-IV-TR criteria, the patients were diagnosed as schizophrenic (n=32), those who suffered from obsessive-compulsive disorder (n=26) and the patients with social phobia (n=28) by clinical psychiatrists and psychologists. To increase the validity of the diagnoses a diagnostic interview was conducted with the patients Correspondence should be addressed to Nima Ganji, Department of Cognitive Science, Institute for Cognitive Science Studies (ICSS), Tehran, Iran. ganji_nima@yahoo.com. 83 P a g e

2 based on DSM-IV criteria. The three groups of patients, then, along with the non-patient group (n=30) were evaluated via Metacognition Questionnaire. Results showed that Schizophrenic patients showed higher levels of incongruent meta-cognitive beliefs compared to other groups. Those patients who suffered from anxiety disorders scored lower in comparison with the group of schizophrenic patients and higher in comparison with the non-patient group. Also, the nonpatient group indicated a more congruent and healthier range of meta-cognitive beliefs compared to the patient groups. Meta-cognitive beliefs are different among the common vulnerability factors in psychological disorders, particularly psychopathic disorders. Keywords: Meta-Cognition, Schizophrenia, Obsessive-Compulsive Disorder, Social Phobia 1. Introduction Meta-cognitions refer to those constructions, sciences and psychological processes which deal with controlling, changing and interpreting thoughts and cognitions. Based on the recent hypotheses, meta-cognition is one of the most important factors in the development and continuity of psychological disorders (Wells, 2000; Wells and Matthews, 1994). Self-Regulatory Executive Function model (Wells, 2000; Wells and Matthews, 1996; Wells and Matthews, 1994), in particular, has formed an expanded conceptualization from the meta-cognitive factors as information processing components (that are related to development and continuity of a mental disorder). The main idea in this approach is that beliefs in a psychological disorder are formed by meta-cognitive components. In Self-Regulatory Executive Function model vulnerability to psychological disorder and continuity of the disorder is accompanied by Cognitive Attentional Syndrome (CAS). This syndrome is identified via self-focused intensified attention, menace review, ruminative processing, activating contrasting beliefs and ineffective self-regulatory strategies. This syndrome is stimulated via meta-cognitive beliefs and acts as a source and reference in interpreting and controlling the cognitive events of an individual (Wells, 2000). This model predicts the conflict among the meta-cognitive beliefs in vulnerability and development and continuity of pathological conditions. In line with this view, a positive correlation has been found between positive and negative meta-cognitive beliefs and anxiety disorders (Cartwright & Wells, 1997). Morrison, French and Wells (2007) in their study investigated the effect of meta-cognitive components in psychopathic disorders. The results of the study showed that those patients with psychopathic disorders (Schizophrenia, Schizoaffective and Schizoid) and those patients who are at the risk of psychopathic disorders scored higher with respect to the components of meta-cognitive beliefs compared to the non-patient group. Psychopathic patients also showed higher rate of positive meta-cognitive beliefs compared to the patients that are at the risk of psychopathic disorders, which reveals a wide range of ineffective and useless meta-cognitions. The study by Baker and Morrison (1998) showed that 84 P a g e

3 schizophrenic patients without experiences of hallucination scored higher with respect to low cognitive trust and negative beliefs (superstitions, punishment and responsibility) compared to the non-patient group. Lari and Van der Linden (2005) in a study on the meta-cognitions and susceptibilities to delirium and hallucination found that the subjects susceptible to delirium and hallucination scored significantly higher in some of the sub-scales of the meta-cognitions questionnaire compared to the insusceptible subjects. Fisher and Wells (2005) proposed that meta-cognitive beliefs pertaining to the meaning and the menacing effect of disturbing thoughts (behavioral treatments) are among the major factors for development and continuity of obsessive-compulsive disorder. They reiterated that the reduction in the meta-cognitive beliefs pertaining to disturbing and compelling factors will lead to the reduction in anxiety and obsessive-compulsive disorder. Wells (2000) added that one of the forms of obsessivecompulsive disorder pertains to the tendency towards focusing attention on thinking processes. These thinking processes lead to an increase in cognitive self-awareness, discovery of unwanted thoughts or emergence of disturbing thoughts. Obsessive thoughts activate meta-cognitive beliefs which pertain to meaning of the thought. In such a situation, individuals find beliefs about usefulness of behavioral responses and believe that these responses will help them to reduce as much as possible the evaluated risks caused by obsessive thoughts. According to Wells and Papageorgiou (2001) meta-cognitive beliefs of the patients who suffer from social phobia have deviations compared to those of the non-patient population. These patients pay excessive attention to negative self-evaluative thoughts. This focus and attention is activated via metacognitive processes. Wells and Carter (2001) compared 24 patients who suffered from comprehensive anxiety disorder with 2 groups of patients who suffered from social phobia and panic disorder and a non-patient group with respect to the negative meta-cognitive beliefs and stress. They found that those patients who suffered from comprehensive anxiety disorder scored higher in these fields compared to other groups. Roussis and Wells (2006) investigated the effects of meta-cognitive beliefs and opposing strategies that are accompanied by stress symptom on the continuity of stress symptoms in non-patient population. They found that the strategy to control stressful though and positive-negative meta-cognitions have a positive relationship with stress symptoms. Cognitive insight is an important clinical which seems to be related with metacognition. According to Beck, Baruch, Balter, Steer and Warman (2004) cognitive insight denotes on the ability to evaluate and correct distorted beliefs and incorrect interpretations; this evaluation and correction of distorted beliefs and incorrect interpretations. These evaluations are based on higher levels of meta-cognitive processes (such as the ability to separate one-self from misunderstandings (misinterpretations) and the ability to reevaluate misinterpretations) and are often referred to as meta-cognition. In patients with psychotic disorders related to cognitive insight, the following pathologic components are common: 1. (Identity Disorder and realism about cognitive distortions) Disorder in concreteness and realism about cognitive distortions, 2. Inability to put the distortions at the center of attention and contemplation; 3. Resistance against information and others corrective feedback; 4. Excessive trust in personal inferences. In several studies (Beck and colleagues, 2004; Amador and colleagues, 1994; Warman, Lysaker and 85 P a g e

4 Martin, 2007; Yousefi, Arizi, Sadeqi, 1385; Yousefi, Sadeqi, Jangi Eqdam and Sivanizadeh, 1386) have investigated cognitive insight disorder in psychotic disorders and most of them have indicated that patients with psychopathic disorders (schizophrenia, schizoaffective and Major depressive disorder along with the psychopathic symptoms) have more cognitive deficiencies compared to the patients without psychopathic symptoms. The current study investigates the differences in meta-cognitive beliefs of the patients who suffer from schizophrenia, anxiety disorders (social phobia and obsessive compulsive disorder) and a non-patient group in an indigenous society of Iranian population. The present study also investigates meta-cognitive beliefs with respect to their components in four groups of participants. The current study investigates the hypothesis that patients who suffer from schizophrenia should score higher in the sub-scales of the Meta-cognitions Questionnaire (MCQ) compared to non-patient group. 2. Methods The current study is an analytic-comparative study which was conducted in sessions. Three groups of patients including those who suffered from schizophrenia (n=32), patients with anxiety disorders (social phobia n=26, and obsessive-compulsive disorder n=28) and a non-patient control group (employees of the hospital sectors n=30) participated in the study. All the schizophrenic patients were hospitalized in psychological centers and were diagnosed as schizophrenic based on IV-DSMTR diagnostics criteria by psychiatrists. A clinical psychologist and a psychiatrist conducted diagnostic interviews with all the patients who suffered from social phobia and obsessive-compulsive disorder, based on DSM-IV diagnostic interview. In the case that patients were diagnosed to be suffering from social phobia or obsessive-compulsive disorder based on IV-DSMTR diagnostics criteria, they could participate in the study; otherwise they were excluded from the study. All groups of the patients were evaluated with?; Method and in consecutive sessions. However, the subjects of the non-patient group which had no psychiatric diagnosis were evaluated randomly in the first session Instruments Meta-cognitions Questionnaire In the present study a short version of the meta-cognitions Questionnaire was used which was adopted by Wells and Cartwright (2004) from the long version of the meta-cognitions questionnaire (Cartwright-Hatton and Wells, 1997) (the 65-question version). The short version of the meta-cognitions questionnaire measures several areas of meta-cognitive beliefs by using 30 items. Each individual's score is calculated based on the following five scales: Positive beliefs about worry: stress helps me to categorize the problems in my mind. Being worried helps me to confront my problems. 86 P a g e

5 Negative beliefs about (thought) uncontrollability / danger: Stress is dangerous for me. I cannot ignore my worrisome thoughts. Cognitive confidence: I have a weak memory. Sometimes, my memory makes me make mistakes. Negative beliefs about the need of control: My inability to control thoughts is a sign of weakness. I will be punished because of not being able to control specific thoughts. Cognitive self-consciousness: I am always aware of my thoughts. I review my thoughts. 3. Results Demographic data of the sample groups are reported in Table 1. Table 2 shows the mean and standard deviation of the sample group's scores on the meta-cognitions questionnaire. Table 1. Demographic properties of study groups Groups N Gender Age Education Females Males Mean SD Mean SD Schizophrenia OCD Social Phobia Non-Patient Table 2. Mean and Standard Deviation of the sample group in MCQ Groups Mean SD Schizophrenia OCD P a g e

6 Social Phobia Non-Patient Group The results of Levene's Test revealed that the presupposition about the equality of the both groups' variances is valid (F=1.65, P=0.104). The validity of the supposition about the equality of the variances in society means that score dispersion were the same among the three groups of schizophrenic patients, those who suffered from obsessive-compulsive disorder, the patients with social phobia disorder and the non-patient control group in the society. To compare the difference among three groups of patients and the non-patient control group with respect to age and education (as a companion variable), analysis of covariance (ANCOVA) was used. ANCOVA s results showed that after controlling the 2 disturbing variables of age and education, the difference among the three patient groups and the non-patient control group was significant (P=0.0001, F= ). The significance of difference was 0.96 which means that 96% of the variance of the meta-cognitions scores pertains to the group membership. Statistical power of the study is 1, which means that the precision of the study to find significant differences is 100%. In other words, there was a significant difference among the schizophrenic patients, those who suffered from obsessive-compulsive disorder, the patients with social phobia disorder and the non-patient control group with respect to the deficiencies of cognitive beliefs. To further investigate the difference among the three groups of patients and the non-patient control group and to conduct a paired comparison on the sample group, Scheffe s Post-hoc test was used. The results of Scheffe s Post-hoc test are shown in Table 3. All the comparisons except the one made between the patients who suffered from obsessive-compulsive disorder and the patients with social phobia disorder showed a significant difference. Table3. Paired comparison between 3 groups of patients and the non-patient control group Groups Mean Mean Difference SD (p) Schizophrenia OCD Schizophrenia Social Phobia Schizophrenia Non-Patient P a g e

7 OCD Social Phobia OCD Non-Patient Social Phobia Non-Patient To test the specific between-group effects with regard to each sub-scale of the meta-cognitions questionnaire, a one-way ANOVA was used the results of which is shown in Table 4. As the table show there is a significant difference among the three groups of schizophrenic patients, those who suffered from obsessive-compulsive disorder, the patients with social phobia disorder and the non-patient control group with respect to the five sub-scales of the meta-cognitions questionnaire. Table 4. One way ANOVA's result in the sub-scales of the meta-cognition questionnaire sub-scales of the metacognitions questionnaire Schizophreni a OCD Social Phobia Non-Patient F Sig. SD Mean SD Mean SD Mea n SD Mean Positive beliefs about worry Negative beliefs about uncontrollability of thoughts Cognitive confidence Negative beliefs about the need for control Self-Awareness P a g e

8 4. Discussion The results of the study show that patient groups and the non-patient control group are different with regard to the meta-cognitions. Schizophrenic patients, who experience a wide range of cognitive disorders, reveal higher levels of meta-cognitions disorder and malfunction. This group of patients scored higher with regard to the sub-scales of the meta-cognitions questionnaire (Positive beliefs about worry, Negative beliefs about (thought) uncontrollability / danger, Cognitive confidence ) compared to the other two groups of patients who suffered from anxiety disorders (obsessive-compulsive disorder and social phobia) and the non-patient control group. The results of the current study support the Self-Regulatory Executive Function model in psychological disorders and are in accordance with the findings of Cartwright-Hatton and Wells (1997) which verifies a correlation between disturbed meta-cognitive beliefs and anxiety disorders. These findings can lead us to evidences which verify the general hypothesis that there is a relationship between the meta-cognitions and meta-cognitive beliefs and psychological disorders. When a disorder has wide dimensions, the relationship is closer and stronger. This hypothesis is shown via the comparison made between the higher scores of meta-cognitions disorders and malfunctions in schizophrenic patients, those who suffered from obsessivecompulsive disorder, those with the social phobia and the non-patient control group. Based on the results of the analysis, the first hypothesis of the study which says that meta-cognitive beliefs are widely disturbed in schizophrenic patients is verified. This finding seems to be in line with the findings of Morrison and colleagues (2007), Larry and Linden (2005), Morrison and colleagues (1995), Morrison and colleagues (2000) about the existence of a relationship between meta-cognitive beliefs and psychopathic experiences (hallucination and delirium) and the severity of meta-cognitions disorder in this type of patients; since in the current study schizophrenic patients showed a higher level of disorder and malfunction in meta-cognitive components. Among different types of psychopathic disorders, schizophrenia has the widest range of pathologic fields, and cognitions as one of the important aspects of this disorder in parallel with meta-cognitive beliefs which control these cognitions can be prone to disorder and confusion. Investigating the effect of meta-cognitive beliefs in phenomena including hallucination and delirium is worth noticing and contemplating. The second hypothesis which proposes that those patients who suffer from anxiety disorders have a higher rate of disturbed meta-cognitive beliefs is also verified. This finding was also investigated and verified in the studies of Wells and Papageorgiou (2001), Fisher and Wells (2005), Wells and Carter (2001), Roussis and Wells (2006) and Wells (2007). To further clarify, these disorders can be structural, i.e. they have their routes in patient s thoughts and even more important than that in the processes or strategies that patients use to evaluate and control their thoughts (Well, 1995; Wells, 2000). Meta-cognition hypothesis puts the emphasis on the factors that control thinking and change the situation of the mind. Meta-cognitive factors by creating useless and inharmonious thinking strategies lead to the maintenance of negative stress and malfunction and the continuity of psychological disorders. The other interesting point is that disorder occurrence in metacognitive beliefs in schizophrenic patients seems to be related to the concept of cognitive insight 90 P a g e

9 including patients self-awareness, his/her ability to reevaluate and correct distorted beliefs and incorrect interpretations of the disorder and its consequences. Insight s clarifying components are dependent on the higher levels of cognitive processes i.e. meta-cognitions. Beck and colleagues (2004) proposed two factors related to cognitive insight: 1. Self-contemplation (introspection, practicality and identity (concreteness), tendency to acknowledge fallibility, openness and acceptance) and 2. Self-confidence (individual s confidence in beliefs, judgments, personal deductions, resistance against other s feedback and self-righteousness) It seems that the said evaluations and judgments in the concept of cognitive insight are dependent on the information developing process which is being controlled and launch by meta-cognitions. The present study was faced with 2 limitations in the cognitive method: 1. First the fact that self-reporting tools were the only tool for gathering the data. The other limitation was the small size of the patients sample group which was due to the small number of the patients with diagnosis of disorder; in a way that measurement and evaluation were carried out in consecutive sessions. That is why it is suggested that any exclusive relationship between the specific meta-cognitive dimensions and special psychopathic disorders should be further investigated. If meta-cognitions are considered to be important causative factors in developing or continuing psychopathic symptoms, therapeutic meta-cognitive strategies Wells (2000) should be added to the wide range of therapeutic techniques as a useful method to correct meta-cognitive beliefs and improve executive control on attention. References [1] Amador, X. F., Flaum, M., Andreasen, N. C., Strauss, D. H., Yale, S. A.,Clak, S.C., & Gorman, M. (1994). Awareness of illness in schizophrenia and schizoaffective and mood disorder. Archives of General Psychiatry, 51, [2] American Psychiatric Association. (1994). Diagnostic and statistical of mental disorders (4 th ed). Washington, DC: Author. [3] Bake, C., & Morrison, A. P. (1998). Metacognition, intrusive thoughts and auditory hallucinations. Psychological Medicine, 28, [4] Beck, A. T., Baruch, E., J. M., Steer, R. A., & Warman, D. M. (2004). A new instrument for measuring insight: The beck cognitive insight scale. Schizophernia Research, 68, [5] Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and instruction: The matacognitions questionnaire and its correlates. Journal of Anaxity Disorder, 11, [6] Fisher, P. L., & Wells, A. (2005). Experimental modification of beliefs in obsessivecompulsive disorder: A test of the metacognitive model. Behaviour Research and Therapy, 43(6), P a g e

10 [7] Lari, F. & Van der Linden, M. (2005). Metacognitions in proneness towards hallucination and delusions. Behaviour Research and Therapy, 43, [8] Marrison, A. P.,Haddock, G., Tarrier, N., (1995) Intrusive thoughts and auditory hallucinations: A cognitive approach. Behavioural and cognitive Psychotherapy, 23, [9] Marrison, A. P., Wells, A., Nothard, S., (2000) Cognitive factors in predisposition to auditory and visual hallucinations. British Journal of Clinical Psychology, 39, [10] Marrison, A. P., French. P., & Wells, A. (2007). Metacognitive beliefs across the continuum of psychosis: Comparisons between patients with psychotic disorder, patient at ultra-high risk and non-patients. Behaviour Research and Therapy, 45(9), [11] Roussis, P., & Wells, A. (2006). Post-traumatic stress symptoms: Test of relationships with thougth control strategies and bliefs as predicted by the metacognitive model. Personality and Individual Difference, 40(1), [12] Warman, D. M., & Lysaker, P. H., & Martin. J. M. (2007). Cognitive insight and psychotic disorder: The impact of active delusions. Schizophernia Research, 90, [13] Marrison, A. P., & Martin, J. M. (2006). Cognitive insight and delusion proneness: Investigating using the Beck Cognitive Insight Scale. Schizophernia Research, 84, [14] Wells, A. (2007). Cognition about cognjition: Metacognitive therapy and chang in generalized anaxiety disorder and social phobia. Cognitive and Behavioral Practice, 14(1), [15] Wells, A., & Cartwright-Hatton, S. (2004). A short form of the metacognitions questionnaire: Properties of the MCQ-30. Behaviour Research and Therapy, 42(4), [16] Wells, A. (2000). Emotional disorder and metacognition: Innovative cognitive therapy, UK: Wiley. [17] Wells, A., &Carter, K. (2001). Further tests of a cognitive model of generalized anxiety disorder: Metacognitions and worry in GAD, panic disorder, social phobia, depression, and nonpatients. Behavior Therapy, 32, [18] Wells, A., &Mattews, G. (1994). Attention and emotion: A clinical perspective. UK: Lawrence Erlbaum Associates. [19] Wells, A., (1995) Metacognition and Worry: A cognitive model of generalized anaxiety disorder. Behavioural and Cognitive Psychotherapy, 23, [20] Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: The S-REF model. Behaviour Research and Therapy, 34, P a g e

11 [21] Wells, A., & Papageorgiou, C. (2001). Social phobic interoception: Effect of bodily information on anxity, beliefs, and self-processing. Behaviour Research and Therapy, 39(1), P a g e