The metacognitive model of post-traumatic stress disorder and metacognitive therapy for post-traumatic stress disorder: A systematic review

What to think or how to think - is symptom reduction in posttraumatic symptomatology associated with change in posttraumatic cognitions or perseverative thinking? A latent change score model approach

OBJECTIVE

Patients with posttraumatic stress disorder (PTSD) report changes in what they think of the world and themselves, referred to as posttraumatic cognitions, and changes in how they think, reflected in increased perseverative thinking. We investigated whether pre-post therapy changes in the two aspects of thinking were associated with pre-post therapy changes in posttraumatic symptom severity.

METHOD

219 d clinic patients with posttraumatic stress symptoms received trauma-focused psychotherapy with cognitive behavioral and metacognitive elements. The posttraumatic cognitions inventory (PTCI), the perseverative thinking questionnaire (PTQ), and the Davidson trauma scale (DTS) were applied at two occasions, pre- and post-therapy. Using latent change score models, we investigated whether change in PTCI and change in PTQ were associated with change in DTS and its subscales. We then compared the predictive value of PTQ and PTCI in joint models.

RESULTS

When jointly modeled, change in overall DTS score was associated with change in both PTCI and PTQ. Concerning DTS subscales, reexperiencing and avoidance were significantly associated with change in PTCI, but not in PTQ.

CONCLUSION

Results indicate that both aspects of cognition may be valuable targets of psychotherapy. A focus on posttraumatic cognitions might be called for in patients with severe reexperiencing and avoidance.

Metacognitive Interventions for mental health disorders in adolescents: a scoping review protocol

OBJECTIVE

The aim of this review is to map and summarize metacognitive interventions for adolescents with mental health disorders.

INTRODUCTION

Metacognitive interventions are widely implemented in adults across various types of mental health disorders. Use in adolescents (aged between 10 and 19 years) has already been proposed in the recent literature, despite this knowledge being scattered. Hence, it is necessary to summarize the types of metacognitive interventions, their key characteristics, the mental health disorders they are targeting, and their outcomes.

INCLUSION CRITERIA

This review will consider quantitative and qualitative, as well as mixed methods studies describing metacognitive interventions for adolescents with mental health disorders. All intervention settings will be eligible for inclusion.

METHODS

A 3-step search strategy will be adopted, in line with the JBI methodology for scoping reviews. Databases to search for peer-reviewed papers will include CINAHL Complete (EBSCOhost), PubMed, Web of Science Core Collection, PsycINFO, and Scopus, among others. Gray literature searched on OpenGrey and MedNar will also be included. The reference lists of all selected full-text reviews will be searched. There will be no limitations on the year or language of publication. Screening, selection, and data extraction will be performed by 2 independent reviewers, who will screen titles and abstracts of publications meeting the inclusion criteria as well as review the full text of eligible studies. Disagreements will be resolved through plenary discussion or with the help of an additional reviewer. The extracted data will be summarized narratively and presented in a table.

Detail of this review project can be found in Open Science Framework: https://osf.io/kh2bc.

Personal Narratives in Trauma-Related Disorders: Contributions from a Metacognitive Approach and Treatment Considerations

Traumatic experiences are significant life events that are thought to impact one's personal life narrative and narrative identity. Individuals who have experienced trauma may display fragmented memories and decreased narrative cohesion, resulting in trauma narratives that are disjointed and poorly integrated into the larger picture of their lives. Metacognition, defined as the ability to form increasingly complex and integrated ideas about the self, others, and the wider world, offers a framework to better understand life narratives and has been proposed as a construct that allows personal narratives to evolve in response to new experiences. In this paper, we will review the alterations commonly observed in trauma narratives. We will utilize the integrated model of metacognition as a framework to understand these deviations with an eye toward clinical implications. Although treatments that focus on trauma narratives exist, we argue that the study of metacognition provides unique insights into the process of integration of traumatic experience into an evolving personal narrative and may allow for more complete treatment of trauma-related disorders.

Sex-dependent differences in vulnerability to early risk factors for posttraumatic stress disorder: results from the AURORA study

BACKGROUND

Knowledge of sex differences in risk factors for posttraumatic stress disorder (PTSD) can contribute to the development of refined preventive interventions. Therefore, the aim of this study was to examine if women and men differ in their vulnerability to risk factors for PTSD.

METHODS

As part of the longitudinal AURORA study, 2924 patients seeking emergency department (ED) treatment in the acute aftermath of trauma provided self-report assessments of pre- peri- and post-traumatic risk factors, as well as 3-month PTSD severity. We systematically examined sex-dependent effects of 16 risk factors that have previously been hypothesized to show different associations with PTSD severity in women and men.

RESULTS

Women reported higher PTSD severity at 3-months post-trauma. Z-score comparisons indicated that for five of the 16 examined risk factors the association with 3-month PTSD severity was stronger in men than in women. In multivariable models, interaction effects with sex were observed for pre-traumatic anxiety symptoms, and acute dissociative symptoms; both showed stronger associations with PTSD in men than in women. Subgroup analyses suggested trauma type-conditional effects.

CONCLUSIONS

Our findings indicate mechanisms to which men might be particularly vulnerable, demonstrating that known PTSD risk factors might behave differently in women and men. Analyses did not identify any risk factors to which women were more vulnerable than men, pointing toward further mechanisms to explain women's higher PTSD risk. Our study illustrates the need for a more systematic examination of sex differences in contributors to PTSD severity after trauma, which may inform refined preventive interventions.

Cognitions and Metacognitive Beliefs in Posttraumatic Stress Disorder

OBJECTIVE

There has been an increasing interest in understanding what contributes to the development and what maintains posttraumatic stress disorder (PTSD). The cognitive model emphasizes that it is a disturbance of the autobiographical memory for the trauma, cognitive beliefs and maladaptive behaviour that maintain trauma symptoms. Interventions are based on cognitive restructuring and behaviour experiments to modify these beliefs. In contrast, the metacognitive model emphasizes that it is the metacognitive beliefs that give rise to the cognitive attentional syndrome (CAS) that maintain trauma symptoms. The focus of treatment is reducing CAS and working on metacognitive beliefs. The aim of this study was to explore the contribution of cognitions and metacognitive beliefs to trauma symptoms and investigate what predicts symptom burden in traumatized patients.

METHOD

Participants (N = 290) diagnosed with PTSD were included, and hierarchical multiple regression analyses were performed to explore if cognitions and metacognitive beliefs explained additional and independent variance in trauma symptoms while controlling for age and gender.

RESULTS

Both cognitions and metacognitive beliefs contributed independently and significantly to predicting trauma symptoms.

CONCLUSION

The results provide further support for investigating what maintains trauma symptoms and what to target in treatment. This may have clinical implications for our theoretical and practical understanding of PTSD.

Relationship Between Post-Traumatic Stress Symptoms and Caregiver Burden In Breast Cancer Patients: The Mediating Role of Anxiety and Depression

Breast cancer impacts not only the physical and mental health of patients but also the people around them-especially their caregivers. This study examined the relationship between post-traumatic stress symptoms (PTSS) and caregiver burden in breast cancer patients through the mediating pathway of anxiety and depression.

METHODS

A total of 236 breast cancer patients from China completed the Chinese Version of the Posttraumatic Stress Disorder Symptom Scale (PSS), the Chinese version of the Patient Health Questionnaire (PHQ-9), the Chinese version of the General Anxiety Symptoms Scale (GAD-7). In addition, caregivers of these breast cancer patients were surveyed by the Caregiver Self-Assessment Questionnaire (CSAQ).

RESULTS

Structural equation model showed that our model fitted well [χ2 /df = 1.966, TLI = 0.959, CFI = 0.994, RMSEA (90% CI) = 0.065 (0-0.12)] and revealed that anxiety, but not depression, mediated the relationship between PTSS in breast cancer patients and caregiver burden.

CONCLUSION

The level of PTSS was positively correlated with anxiety and depression in breast cancer patients, and the level of anxiety and depression was positively related to caregiver burden. The PTSS of patients positively predicted caregiver burden and this relationship appears to be mediated by the patient's anxiety.

A Systematic Review of Interventions for Prevention and Treatment of Post-Traumatic Stress Disorder Following Childbirth

Objective

Postpartum women can develop post-traumatic stress disorder (PTSD) in response to complicated, traumatic childbirth; prevalence of these events remains high in the U.S. Currently, there is no recommended treatment approach in routine peripartum care for preventing maternal childbirth-related PTSD (CB-PTSD) and lessening its severity. Here, we provide a systematic review of available clinical trials testing interventions for the prevention and indication of CB-PTSD.

Data Sources

We conducted a systematic review of PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, and Scopus through December 2022 to identify clinical trials involving CB-PTSD prevention and treatment.

Study Eligibility Criteria

Trials were included if they were interventional, evaluated CB-PTSD preventive strategies or treatments, and reported outcomes assessing CB-PTSD symptoms. Duplicate studies, case reports, protocols, active clinical trials, and studies of CB-PTSD following stillbirth were excluded.

Study Appraisal and Synthesis Methods

Two independent coders evaluated trials using a modified Downs and Black methodological quality assessment checklist. Sample characteristics and related intervention information were extracted via an Excel-based form.

Results

A total of 33 studies, including 25 randomized controlled trials (RCTs) and 8 non-RCTs, were included. Trial quality ranged from Poor to Excellent. Trials tested psychological therapies most often delivered as secondary prevention against CB-PTSD onset (n=21); some examined primary (n=3) and tertiary (n=9) therapies. Positive treatment effects were found for early interventions employing conventional trauma-focused therapies, psychological counseling, and mother-infant dyadic focused strategies. Therapies' utility to aid women with severe acute traumatic stress symptoms or reduce incidence of CB-PTSD diagnosis is unclear, as is whether they are effective as tertiary intervention. Educational birth plan-focused interventions during pregnancy may improve maternal health outcomes, but studies remain scarce.

Conclusions

An array of early psychological therapies delivered in response to traumatic childbirth, rather than universally, in the first postpartum days and weeks, may potentially buffer CB-PTSD development. Rather than one treatment being suitable for all, effective therapy should consider individual-specific factors. As additional RCTs generate critical information and guide recommendations for first-line preventive treatments for CB-PTSD, the psychiatric consequences associated with traumatic childbirth could be lessened.

Did Cognitive Attentional Syndrome Symptoms Predict Stress- and Trauma-Related Symptoms in the Initial Phase of the COVID-19 Pandemic? Results from a Two-Wave Study on a Sample of Polish Internet Users

BACKGROUND

According to metacognitive theory, Cognitive Attentional Syndrome (CAS) is a transdiagnostic factor and a main mechanism of psychopathology maintenance. The main goal of this study is to examine whether CAS predicted stress- and trauma-related symptomatology in the first months of the COVID-19 pandemic and three months later.

METHODS

Initially, 1792 participants were recruited online via social media; the data were collected at two time points. The measures included the Cognitive Attentional Syndrome Questionnaire, the Adjustment Disorder-New Module 20, the International Trauma Questionnaire, and additional measures.

RESULTS

Structural equation modeling was conducted in order to determine the relations between the reported stressors, CAS, and symptomatology. At both time points, CAS was a significant mediator between the stressors and symptoms of adjustment disorder. Despite the decrease in the intensity of adjustment disorder symptoms between waves, it was a significant predictor of other psychopathologies at both time points, except for traumatic stress.

CONCLUSIONS

The findings confirm the assumption that CAS is a transdiagnostic factor of psychopathology and has a mediating role in the relationship between stressors and adjustment disorder and co-occurring symptomatology. The effect was particularly significant in the initial phase of the pandemic, which was highly stressful for many people.

Depressive Symptoms are Associated with More Negative Global Metacognitive Biases in Combat Veterans, and Biases Covary with Symptom Changes over Time

Metacognitive awareness, insight into one's abilities, is thought to be disrupted in depression and posttraumatic stress disorder (PTSD), with more negative metacognitive biases and reduced awareness, respectively. However, studies have rarely examined global aspects of metacognitive awareness in depression and PTSD, instead using task-specific measures. In 467 trauma-exposed post-9/11 veterans, we administered assessments of PTSD and depression, self-report and objective measures of cognitive functioning (neuropsychological battery of memory, attention, and executive function measures), and self-report and objective measures of general health (index of five cardiometabolic factors). We used self-report/objective correlations to measure metacognitive sensitivity and 'self-report minus objective' scores to measure bias. We also examined associations between changes in metacognitive awareness and changes in PTSD and depression over time. Metacognitive sensitivity was comparable between individuals with and without PTSD and depression. However, metacognitive bias was significantly more negative in those with greater depressive symptoms (i.e., underconfidence) across cognition and health, independent of PTSD symptoms. Notably, metacognitive bias changes covaried with depressive and PTSD symptom changes two years later. This shows that, in trauma-exposed veterans, negative metacognitive biases are specifically related to depressive symptoms and these biases may be relatively domain general. Further, our longitudinal results suggest that, rather than being a stable trait, metacognitive biases change with PTSD/depressive symptoms over time.

Metacognition vulnerabilities in time of crisis: Who to protect from suicidal risk?

INTRODUCTION

During stressful events, we are all trying to cope. We may not be equal depending on our emotional, psychological, and mental states. During the COVID-19 pandemic, we could try to avoid negative information processing and anxiogenics content to prevent unhealthy thinking processes. One of the processes we can observe regarding our way of thinking and its impact on our psychological well-being is Metacognition.

METHODS

We recruited 104 outpatients in 2018. In 2020, during the pandemic, we recruited 216 outpatients and 176 healthy controls. We assessed their level of metacognition with the MCQ30 scale together with Suicidal risk and Hopelessness.

RESULTS

All three groups showed significant differences, with the nonclinical sample having higher scores in MCQ30. Regression revealed the different profiles where Hopelessness was the only predictor for the clinical sample, whereas metacognition was an adjunctive predictor of suicidal risk for the nonclinical sample.

CONCLUSION

Our results showed that the COVID-19 crisis influenced metacognitive levels for the nonclinical sample but not for the clinical population. Moreover, Hopelessness predicted suicide risk for both populations, but Metacognition was also a predictive factor for the nonclinical sample. We conclude with the possible impact of preventive measures based on Metacognitive work that can be created out of these results.