Costas Papageorgiou

An Empirical Test of a Clinical Metacognitive Model of Rumination and Depression

Rumination has attracted increasing theoretical and empirical interest in the past 15 years. Previous research has demonstrated significant relationships between rumination, depression, and metacognition. Two studies were conducted to further investigate these relationships and test the fit of a clinical metacognitive model of rumination and depression in samples of both depressed and nondepressed participants. In these studies, we collected cross-sectional data of rumination, depression, and metacognition. The relationships among variables were examined by testing the fit of structural equation models. In the study on depressed participants, a good model fit was obtained consistent with predictions. There were similarities and differences between the depressed and nondepressed samples in terms of relationships among metacognition, rumination, and depression. In each case, theoretically consistent paths between positive metacognitive beliefs, rumination, negative metacognitive beliefs, and depression were evident. The conceptual and clinical implications of these data are discussed.

Relationships between worry, obsessive-compulsive symptoms and meta-cognitive beliefs.

The present study had two principal aims. First, the overlap between the revised Padua Inventory (PI-WSUR) a measure of obsessive-compulsive symptoms (Burns et al., 1996) and worry was assessed. Second, the relationship between meta-cognitive beliefs, proneness to pathological worry and obsessive-compulsive symptoms was explored when controlling for the interdependency of worry and obsessive-compulsive measures. The results indicate that whilst the PI-WSUR shows reduced overlap with the Penn State Worry Questionnaire, there are still problematic levels of overlap with a more content-based measure of worry. Results of multiple regression analyses demonstrated that specific sets of meta-cognitive beliefs were associated with worry proneness and obsessive-compulsive symptoms. The present data are consistent with recent formulations of generalized anxiety disorder and obsessive-compulsive disorder.

Metacognitive beliefs about rumination in recurrent major depression

Wells and Matthews (1994, 1996) proposed that perseverative negative thinking, such as depressive rumination and anxious worry, is supported by metacognitive beliefs concerning the functions and consequences of these styles of thinking. However, to date no studies have investigated metacognitive beliefs about rumination. This study examined the presence and content of metacognitive beliefs about rumination in patients with recurrent major depression. To achieve this aim, a semistructured interview was conducted with each patient. The results showed that all patients held positive and negative beliefs about rumination. Positive beliefs appear to reflect themes concerning rumination as a coping strategy. Negative beliefs seem to reflect themes concerning uncontrollability and harm, and interpersonal and social consequences of rumination. The conceptual and clinical implications of the results are discussed.

Positive Beliefs about Depressive Rumination: Development and Preliminary Validation of a Self-Report Scale

Despite the negative consequences of depressive rumination, little is known about the factors that may be linked to a predisposition to ruminate. Wells and Matthews (1994) suggested that rumination is associated with underlying metacognitive beliefs. Papageorgiou and Wells (in press) provided evidence for the presence of positive and negative metacognitive beliefs about rumination in recurrent major depression. A series of studies concerned with the development and validation of a measure of positive beliefs about rumination, the Positive Beliefs About Rumination Scale (PBRS), is reported. Factor analyses of the scale demonstrated a single factor. The PBRS showed high internal consistency and test-retest reliability, and good psychometric properties of concurrent, convergent, and discriminant validity. The scale was used to test relations between positive beliefs, rumination, and depression. The results were consistent with path models in which rumination mediated the effects of positive beliefs about rumination on state and trait depression.

Treatment of recurrent major depression with attention training

This study evaluated the effectiveness of Attention Training ( ATT; Wells, 1990 ) in the treatment of recurrent major depression. This technique is based on an information processing model of emotional disorders ( Wells & Matthews, 1994 ) in which self-focused attention and metacognition maintain dysfunction. ATT was evaluated in a consecutive single-case series of patients referred for treatment of recurrent major depression. Patients were assigned to no-treatment baselines of 3 to 5 weeks, administered five to eight weekly sessions of ATT, and followed up at 3, 6, and 12 months posttreatment. The effects of ATT on depression, anxiety, negative automatic thoughts, rumination, self-focused attention, and metacognition were assessed. Following ATT, all patients showed clinically significant reductions in depression and anxiety. Reductions in negative automatic thoughts, rumination, and attentional and metacognitive factors showed similar improvements. All scores fell within the normal range on completion of ATT. Treatment gains were maintained at the 12-month follow-up assessments. However, randomized controlled trials of ATT are required before firm conclusions can be drawn.

Process and meta-cognitive dimensions of depressive and anxious thoughts and relationships with emotional intensity

Cognitive theorists have argued that different types of thinking characterize different emotional states. Recently, in an information-processing model of emotional disorder, Wells and Matthews (1994, 1996) argue that it is not only the content of thought but also the process and meta-cognitive dimensions of particular types of thinking that may be implicated in problem maintenance. However, little is known about how different types of thinking overlap and differ. This study compared the process and meta-cognitive characteristics of naturally occurring depressive and anxious thoughts in a non-clinical sample. We also investigated relationships between thought dimensions and intensity of emotional responses for each type of thought. Subjects were provided with a diary for recording and rating the content of their first and second depressive and anxious thoughts occurring during a two-week period. The results showed that although depressive and anxious thoughts were rated similarly on a number of dimensions, significant differences emerged, and particular dimensions of thought, other than belief level, were associated with emotional intensity. The conceptual and clinical implications of these findings are briefly discussed. Copyright

A pilot randomized trial of metacognitive therapy vs applied relaxation in the treatment of adults with generalized anxiety disorder.

Metacognitive Therapy (MCT) and Applied Relaxation (AR) were compared in a pilot treatment trial of generalized anxiety disorder (GAD). Twenty outpatients meeting criteria for DSM-IV-TR GAD were assessed before treatment, after treatment and at 6 m and 12 m follow-up. The patients were randomized and treated individually for 8-12 weekly sessions. There was no drop-out from MCT and 10% at 6 m follow-up from AR. At post-treatment and at both follow-up points MCT was superior to AR. Standardized recovery rates for MCT at post-treatment were 80% on measures of worry and trait-anxiety compared with 10% following AR. At 6 m follow-up recovery rates for MCT were 70% on both measures compared with 10% and 20% for AR. At 12 m follow-up recovery rates for MCT were 80% (worry) and 60% (trait-anxiety) compared with 10% and 20% following AR. The recovery rates for MCT are similar to those obtained in an earlier uncontrolled trial (Wells & King, 2006). The effect sizes and standardized recovery rates for MCT suggest that it is a highly effective treatment.

Effects of attention training on hypochondriasis: a brief case series.

BACKGROUND Empirical evidence indicates that manipulations of attention may facilitate changes in cognition and stress symptoms in emotional disorder. METHODS The present study reports the effects of Attention Training (ATT) in a brief case series of three patients with primary hypochondriasis using an A-B-A design. RESULTS ATT produced clinically significant improvements in self-reported measures of affect, and illness-related behaviour and cognition. Treatment gains were maintained at 6 months follow-up assessments. Measures of body-focused attention indicated that the ATT procedure acted on attentional processes as intended. CONCLUSIONS The present case series extends the effects of ATT to problems of hypochondriasis. A number of studies now suggest that ATT is associated with a reduction in anxiety and negative beliefs across disorders of panic, social phobia and hypochondriasis. Controlled clinical trials are now required to establish firmly the effects of ATT as a component of cognitive therapy.

Brief cognitive therapy for social phobia: a case series.

Social phobia is a common and disabling anxiety disorder. The most effective psychological treatments for social phobia are cognitive therapy and exposure. However, the degree of improvement across these treatments is variable, and their implementation is costly and time-consuming. This study aimed to conduct a preliminary clinical evaluation of the effectiveness of a brief, new form of cognitive therapy based on a recent cognitive model of social phobia. Six consecutively referred patients with social phobia were treated using established single case series methodology. Brief cognitive therapy was effective with all patients demonstrating clinically significant improvements in all measures. Treatment gains were maintained at follow-up. The mean number of treatment sessions delivered was 5.5 and improvements compare favourably with previous treatment studies. Brief cognitive therapy for social phobia appears promising and it is potentially cost-effective. Future randomised and controlled evaluations of this brief treatment are warranted.

Social phobic interoception: effects of bodily information on anxiety, beliefs and self-processing.

It has been suggested that body-state information influences self-perception and negative thinking in social phobia [Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69-93). New York: Guilford Press.]. This study explored the effects of body-state information on anxiety and cognition in patients with generalised social phobia during a feared social interaction. It was hypothesised that information concerning an increase in pulse rate would lead to increments in anxiety, negative beliefs and self-processing whilst information concerning a decrease in pulse rate would have the opposite effect. The results of this study were generally consistent with the hypotheses. These findings are important as they may help to account for fluctuations in anxiety, negative beliefs and self-processing in social situations that do not present objective social threat. In particular, social anxiety appears to be modulated by body-state information. The implications of the present findings for cognitive therapy of social phobia are briefly discussed.