Metacognitive Beliefs in Post-Traumatic Stress Disorder

Danielle Hett, Heather D. Flowe, Melanie K. T. Takarangi

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Over 80% of people in the United States have been exposed to a traumatic event (e.g., interpersonal violence, physical injury, fear of being killed) at some point in their lives (Kilpatrick et al., 2013). While the majority of people will demonstrate an astonishing capacity to recover and continue to live normal lives, some will struggle to cope and may even develop a psychopathological response to trauma known as post-traumatic stress disorder (PTSD). PTSD is a psychiatric disorder that according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) consists of four distinct symptom clusters. These include re-experiencing (e.g., intrusive memories or flashbacks about the event), avoidance (e.g., avoiding any reminders of the traumatic event), negative cognitions and mood (e.g., persistent negative and distorted beliefs about the event, such as believing it was one’s fault) and arousal (e.g., constantly feeling on edge and alert to threat). The DSM-5 states that these symptoms have to persist for over one month for an individual to be diagnosed with PTSD.

Why are some people more resilient than others after experiencing a traumatic event? This question has sparked much research interest. Psychological resilience seems to involve the interplay of a multitude of biological, psychological and environmental factors. What is more, there is evidence that people may be able to hone their psychological skills to enhance resilience. For instance, research thus far has identified key psychological factors, which, when strengthened, boost resilience. These factors include having adequate social support, having a tendency towards positive self-efficacy (i.e., believing that one has the capability to succeed; see Bandura, 1977) and certain cognitive factors, such as having a positive appraisal style (i.e., a positive evaluation and interpretation of a situation). Should these factors take on the wrong form—such as having poor social support, low self-efficacy, or a negative appraisal style—people will tend to not cope as well following exposure to a stressful event. One important area of research that may help us to understand how to boost resilience and protect against the development of PTSD is the study of metacognition, and the related study of metamemory.

Metacognition is broadly defined as beliefs about one’s own cognition, and it is involved in the monitoring, control and appraisal (i.e., the interpretation) of one’s own thoughts. Metacognition serves as an internal guide that allows people to recognise their own thoughts, helping to allow them to take action. Everyday examples of metacognition include awareness that you have forgotten the name of the person you have just met, or realising that you need to refocus your attention because your mind has been wandering as you have been reading this paragraph. Metacognition plays a role in all aspects of our lives; therefore, perhaps unsurprisingly, it has been implicated in the development of psychological disorders. Metacognition can either be helpful or a hindrance when people try to recover after suffering a traumatic event. For instance, believing that worrying is helpful (Worrying helps me cope . . . I must worry in order to be prepared) or believing that holding negative beliefs about thoughts is dangerous (My worrying is dangerous for me . . . When I start worrying I cannot stop) are examples of maladaptive metacognition that can negatively impact a person’s appraisal style and ability to cope (Wells & Cartwright–Hatton, 2004). Metamemory is a type of metacognition that refers to the processes whereby people are able to examine the content of their memories, both prospectively and retrospectively, and make judgements about them. Thus, metamemory does not refer to memory itself, but rather it is the judgements and assessments that we make about our own memories. For instance, although evidence for the experience of disorganised memory in PTSD is inconsistent (due in part to difficulties in operationally defining and measuring these types of memories), simply believing or perceiving one’s memory to be disorganised can be problematic (e.g., Bennett & Wells, 2010; Segovia, Strange & Takarangi, 2015).

The metacognitive model (Wells, 2000; Wells & Sembi, 2004) proposes that metacognitions play an integral role in the development of PTSD. According to this model, immediately after a traumatic event, symptoms, including memory intrusions, increased arousal (e.g., heart racing, sweating, rapid breathing) and startle responses, emerge. The model suggests that these symptoms are a sign that an individual is attempting to emotionally process the trauma and adjust in a way that promotes future coping. These symptoms are all normal responses that stem from an in-built reflexive adaptation process (RAP). The goal of the RAP is to develop new procedures (metacognitions) for controlling cognition and to develop plans for dealing with any future threats. For most people, this process continues uninterrupted, and symptoms tend to naturally subside. However, for some people, these symptoms persist and can lead to PTSD. According to the metacognitive model, psychological disorders are caused by an extended pattern of thinking that is known as cognitive attentional syndrome (CAS). The CAS consists of three processes: worry and rumination, threat monitoring, and (poor) coping strategies. The CAS maintains symptoms and prevents cognition from re-tuning to the normal, threat-free mode of processing. The CAS is driven by both positive and negative metacognitive beliefs. Positive metacognitive beliefs are those beliefs that are perceived to have positive effect on coping, such as worrying about possible future threats (e.g., If I worry, bad things will not happen), rumination (e.g., I must go over the event to make sense of it), and dwelling on memory and filling in any memory gaps (e.g., I must have a complete memory to feel normal). Negative metacognitive beliefs concern the uncontrollability and negative evaluation of thoughts (e.g., My worrying is uncontrollable). These types of beliefs, alongside the persistent use of maladaptive thought control strategies, represent an attempt to regulate emotion; instead, however, they serve to maintain a sense of threat and lead to persistence in PTSD symptoms according to the metacognitive model.

The metacognitive model of PTSD—in particular, the role of worry and rumination in PTSD—is continuing to gather support. For instance, Roussis and Wells (2006) found that PTSD sufferers who endorse maladaptive beliefs post-trauma (e.g., positive beliefs about worry) exhibit greater stress symptoms. Consistent with the predictions of the metacognitive model, the use of worry as a way to control thoughts was positively associated with stress symptoms. The use of worry as a coping strategy is thought to obstruct the RAP, causing the persistence of symptoms, although, as of yet, there is no direct evidence regarding the role of the RAP in the development and maintenance of PTSD. Therefore, the RAP and its link to PTSD remains a tentative idea.

Nevertheless, a growing number of studies support the role of metacognitive beliefs in psychological disorders, including PTSD. For example, a longitudinal study reported that rumination following exposure to a stressful life event was associated with increased levels of subsequent stress and depression (Nolen–Hoeksema, 2000). Additionally, Bennett and Wells (2010) found that metacognitive beliefs about the trauma predicted PTSD symptoms. For example, positive (e.g., I need to have a complete memory for what happened so that I can learn from the event) and negative (e.g., Gaps in my memory are preventing me from getting over it) metamemory beliefs, negative beliefs about the uncontrollability of thoughts and danger, beliefs about the need to control thought, and rumination were all significantly associated with PTSD symptoms. These findings are in line with the metacognitive model of PTSD, suggesting that maladaptive metacognitions and rumination as a thought control strategy disrupt the natural recovery process. Taken together, these studies highlight the promising role played by metacognitive beliefs in the development of PTSD.

Yet, little research has examined the role of metacognitive and metamemory beliefs in predicting the development of PTSD following trauma exposure. These issues hold great clinical significance because, through early intervention, these maladaptive beliefs could be targeted (via training and psychoeducation), leading to increased psychological resilience. For example, occupational groups frequently exposed to high levels of trauma (such as military personnel and first responders) could benefit from such support.

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