Eating Behaviors 16 (2015) 17–22
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Eating Behaviors
Metacognition in eating disorders: Comparison of women with eating disorders, self-reported history of eating disorders or psychiatric problems, and healthy controls Siri Olstad ⁎, Stian Solem, Odin Hjemdal, Roger Hagen Department of Psychology, University of Science and Technology, Norway
a r t i c l e
i n f o
Article history: Received 13 June 2014 Received in revised form 30 September 2014 Accepted 24 October 2014 Available online 4 November 2014 Keywords: Eating disorder Bulimia Nervosa Anorexia Nervosa Metacognition
a b s t r a c t Objective: The aim of the study was to compare a clinical sample with eating disorders to different control samples on self-report measures of metacognition and eating disorder symptoms, in order to investigate the role of metacognition in eating disorders. Method: The clinical group consisted of 53 female patients with eating disorders who completed the Metacognitions Questionnaire-30 and the Eating Disorder Examination Questionnaire 6.0. One-hundred and fifty women who served as a control group completed the questionnaires as an Internet survey. This control group was divided into three groups based on self-reported history of eating and psychiatric problems (N = 47), other psychiatric problems (N = 37), or no such problems (healthy controls: N = 66). Results: The clinical group scored significantly higher on dysfunctional metacognition than healthy controls, especially on “negative beliefs about uncontrollability and danger”, “need to control thoughts”, and total MCQ30 score. Eating disorder symptomatology was positively correlated with metacognition. Metacognition explained 51% of the variance in eating disorder symptoms after controlling for age and BMI, with “need to control thoughts” as the most important factor. Conclusion: Metacognitive beliefs may be central in understanding eating disorders, and metacognitive treatment strategies could be a promising approach in developing new psychological treatments for eating disorders. © 2014 Elsevier Ltd. All rights reserved.
1. Metacognition in eating disorders The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V, APA, 2013) defines the criteria for different eating disorders such as Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). All these eating disorders share an intense fear of weight gain and a distorted body image that often serve as a basis for negative self-evaluation. Eating disorders are associated with severe physical and psychosocial consequences, and are considered difficult to treat (Fairburn & Harrison, 2003). Cognitive behavioral therapy is considered the treatment of choice for BN (National Institute for Health and Care Excellence [NICE], 2004), but there is insufficient evidence to conclude on a treatment of choice for AN (Bulik, Brownley, Shapiro, & Berkman, 2012). Prognostic indicators suggest that severity of psychiatric comorbidity relates to outcome for BN, while severity and duration of AN relates to outcome for treating AN (Keel & Brown, 2010). These findings may indicate that there is a need for a new understanding of eating disorders which again may pave the way for more efficient ⁎ Corresponding author at: Department of Psychology, Norwegian University of Science and Technology, NTNU, 7491 Trondheim, Norway. Tel.: +47 90962113. E-mail address: [email protected] (S. Olstad).
http://dx.doi.org/10.1016/j.eatbeh.2014.10.019 1471-0153/© 2014 Elsevier Ltd. All rights reserved.
treatments. The metacognitive model has identified transdiagnostic psychological processes that are involved in several disorders (Wells, 2009). It represents a new perspective and as such it may be of interest to explore if it contributes to the understanding of eating disorder symptoms. Metacognitive theory states that psychological disorder results from an inflexible and maladaptive response pattern to cognitive events, which is labeled the Cognitive Attentional Syndrome (CAS). The CAS consists of persistent worry and rumination, threat monitoring and ineffective coping strategies that contribute to the maintenance of the problem (Wells, 2013). The CAS is controlled by erroneous beliefs about trhinking. These beliefs are called metacognitions, which refer to internal cognitive factors that control, monitor and appraise thinking. They are both positive- and negative metacognitive beliefs. Positive metacognitions are concerned with the benefits of worry, rumination, threat-monitoring, and counter-productive coping strategies. Example of a positive metacognition related to eating disorders could be “I must worry about my weight and eating in order to control my weight”. Negative metacognitions are concerned with the uncontrollability and danger of thoughts and cognitive experiences. Example of a negative metacognition in eating disorders could be “Worrying about my body and weight could make me go mad”. For more detailed descriptions of positive and negative metacognition in Anorexia Nervosa see Woolrich, Cooper, and
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Turner (2008). These negative and positive metacognitive beliefs are the driving force of the CAS. Metacognitive treatment aims to eliminate the CAS to enable new learning to take place (Wells & Matthews, 1996). There are several reasons why the metacognitive model could be beneficial for understanding and treating eating disorders. First, eating disorders seem to have many similarities with other types of psychiatric disorders related to worry where metacognitions are central, like generalized anxiety disorder (Konstantellou, Campbell, Eisler, Simic, & Treasure, 2011), and obsessive–compulsive symptoms (Halmi et al., 2005). Second, rumination (e.g. “I think about all my shortcomings, failings, faults, and mistakes”), which is an important aspect in the metacognitive treatment of depression, seems to also be of relevance in patients with bulimic symptoms (Nolen-Hoeksema, Stice, Wade, & Bohon, 2007). Third, eating disorders have a high rate of comorbidity (Hudson, Hiripi, Pope, & Kessler, 2007), and because the metacognitive model focus on common psychological processes that transcend diagnostic borders, this approach could be considered especially relevant in treating eating disorders. Some research has been undertaken to explore the role of worry and rumination in eating disorders which support the potential utility of a metacognitive perspective. Sternheim et al. (2012) investigated the role of worry in patients with AN and BN, and found that they scored significantly higher on the Penn State Worry Questionnaire (Meyer, Miller, Metzger, & Borkovec, 1990) compared to healthy controls. The two groups with eating disorders did not differ from each other on worry. A positive correlation was found between worry and eating disorder symptomatology. Startup et al. (2013) also found elevated scores on measures of worry and rumination in a sample of 62 patients with AN compared to healthy controls. Additionally, they also found a positive correlation for both worry and rumination related to eating disorder symptoms, and that worry and rumination predicted severity of the eating disorder over and above measures of mood. A related study by Woolrich et al. (2008) used a semi-structured interview to compare 15 patients with AN to 17 dieting women and 18 non-dieting controls. Patients with AN believed to a higher degree that their thoughts were abnormal and uncontrollable. Patients with AN were also more likely to use thought control strategies like mental self-punishment, worry and rumination in order to cope with their negative thoughts. Cooper, Grocutt, Deepak, and Bailey (2007) administered the Metacognitions Questionnaire-30 (MCQ-30: Wells & Cartwright-Hatton, 2004) to 16 patients with AN, 15 dieters, and 17 non-dieting controls. They found that patients with AN scored higher on four out of five metacognitive factors namely; need to control thoughts, cognitive self-consciousness, negative beliefs of uncontrollability and danger, and cognitive confidence. The groups did not differ significantly on positive beliefs about worry. McDermott and Rushford (2011) compared MCQ-30 scores in a larger sample than Cooper et al. (2007), where the sample consisted of 74 with AN, and 93 without AN. The same pattern of elevated scores on four out of five subtypes of metacognition was found. Konstantellou and Reynolds (2010) found that problematic eating attitudes were related to higher scores on three out of five factors on the MCQ-30 in a non-clinical sample. Although there has been some studies suggesting that metacognition are important in eating disorders there have been no clinical trials exploring the effects of metacognitive therapy (MCT) for eating disorders. Also, a metacognitive treatment manual for eating disorders has yet to be developed. In general, MCT does not view emotional disorders as linked to content of negative thoughts. Instead it views attentional bias and worry/rumination as strategies for appraising and dealing with threat as essential in maintaining emotional disorders. These are the processes that are addressed in MCT. For a comparison of CBT and MCT confer on Fisher (2009). There is no current treatment for eating disorders which addresses metacognitions directly as specified by Wells' (2009) description of the metacognitive model for emotional disorders. However, existing therapies are likely to change metacognitions indirectly as patients improve by reducing worry,
rumination, and maladaptive coping behaviors (e.g. Solem, Håland, Vogel, Hansen, & Wells, 2009). The studies reviewed in the introduction suggest that worry, rumination and metacognition are central in understanding eating disorders, but there is a need for further studies to validate the role of these factors in order develops a metacognitive treatment for eating disorders. As reviewed above, few previous studies have investigated metacognitive beliefs in anorectic patients. In order to improve and extend previous findings we chose to conduct a study using a larger sample, combing different samples of eating disorders, and to compare these against groups with other psychiatric symptoms as well as healthy controls. In order to explore the role of metacognition in eating disorders we used a comparative cross-sectional design, where a clinical sample of patients with eating disorders was compared to control samples with selfreported history of — eating disorders, psychiatric problems, as well as healthy controls. The aim of this study was therefore to investigate metacognition in a clinical sample of patients with eating disorders and control groups. Based on metacognitive theory and earlier research, it was expected that the clinical sample would have a higher score on dysfunctional metacognition compared to healthy controls. Similar patterns, but smaller differences between the clinical and the control groups with self-reported history of eating problems and/or other psychiatric problems was also expected to be found. In addition, it was predicted that eating disorder symptomatology would be positively correlated with dysfunctional metacognition. If metacognitions continue to prove to be of importance in eating disorders, therapeutic interventions aimed at challenging these beliefs could be called for. 2. Method 2.1. Participants 2.1.1. Clinical group The clinical group consisted of 53 women receiving outpatient or inpatient treatment at the Regional Department for Eating Disorders (RASP), Oslo University Hospital and the Regional Competence Center for Eating Disorders (RKSF), at Stjørdal and Levanger in Norway. The mean age in the clinical sample was 28.4 years (SD = 9.3), with a range in age from 17 to 51. The eating disorders diagnoses in the clinical group consisted of 17 patients with AN, 14 with BN, and 22 were classified as EDNOS where five had a body mass index (BMI) in the overweight range. BMI was self-reported. The type of eating disorder was reported by the patients themselves. The duration of their eating disorder had a mean of 12.2 years (SD = 8.8), with a range in duration from 1 to 35 years. BMI was calculated for both their current weight and their lowest weight in adult age, which is presented in Table 1. Employment status was not recorded for the clinical group. 2.1.2. Control groups The control groups consisted of 47 women with self-reported history of eating and psychiatric problems, 37 women with self-reported history of other psychiatric problems, and 66 women who reported no history of psychiatric- or eating disorder problems were classified as healthy controls. The majority of the controls were either in a fulltime job or currently a fulltime student. ANOVA analyses suggested that the mean age of the control samples were not significantly different from the clinical group with eating disorders (see Table 2). 2.2. Measures The Metacognitions Questionnaire-30 (MCQ-30; Wells & Cartwright-Hatton, 2004) measures five factors of metacognition, namely; positive beliefs (e.g.: “Worrying helps me to avoid problems in the future”), negative beliefs about uncontrollability and danger
S. Olstad et al. / Eating Behaviors 16 (2015) 17–22
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Table 1 Description of the clinical sample with eating disorders (N = 53).
N Current BMI Lowest BMI Age Duration of disorder (years) Global EDE-Q Restraint Eating concern Shape concern Weight concern MCQ-30 total Positive beliefs Negative beliefs about uncontrollability and danger Cognitive confidence Need to control thoughts Cognitive self-consciousness
Anorexia
Bulimia
EDNOS
Overweight
17 18.3 (3.1)a 14.6 (2.8) 25.5 (9.0) 10.3 (8.4) 3.3 (1.5) 2.7 (1.6) 2.8 (1.8) 4.3 (1.8) 3.6 (1.8) 73.1 (20.7) 12.9 (4.4) 16.2 (4.6) 13.5 (5.4) 15.5 (5.4) 14.9 (4.4)
14 24.2 (6.2) 16.8 (2.5) 27.1 (8.8) 13.1 (9.4) 4.1 (1.7) 3.3 (1.9) 3.8 (1.8) 4.9 (1.7) 4.5 (1.8) 76.9 (19.1) 14.7 (5.6)b 17.5 (3.5) 15.1 (5.7) 15.9 (4.6) 13.8 (3.3)
17 23.6 (7.2) 17.9 (4.1) 30.6 (9.9) 13.1 (9.5) 3.0 (1.8) 2.1 (1.6) 2.3 (1.5) 3.6 (2.0) 3.2 (2.1) 59.4 (17.1) 10.1 (3.5) 13.5 (5.7) 11.3 (4.6) 11.7 (4.4) 12.8 (3.0)
5 42.5 (6.6) 28.4 (3.7) 34.4 (7.8) 12.3 (6.7) 3.8 (1.3) 1.6 (1.2) 3.8 (2.2) 4.8 (1.2) 4.6 (1.1) 69.8 (21.9) 10.6 (3.6) 17.0 (6.7) 13.8 (6.1) 13.4 (6.9) 15.0 (4.8)
Note. BMI = body mass index. Atypical-Anorexia (N = 9) and -Bulimia (N = 1) coded as Eating Disorder Not Otherwise Specified. a Anorectic and overweight patients have significant different BMI compared to controls. b Higher scores on positive beliefs in bulimic patients than EDNOS.
(e.g.: “My worrying is dangerous for me”), cognitive confidence (e.g.: “I have little confidence in my memory for words and names”), need for control thoughts (e.g.: “If I did not control a worrying thought, and then it happened, it would be my fault”), and cognitive selfconsciousness (e.g.: “I think a lot about my thoughts”). Each item is scored from 1 to 4, and higher scores indicate higher levels of dysfunctional metacognition. The scores on the MCQ-30 can range from 30 to 120 for the total score and from 5 to 30 for the subscales. MCQ-30 has promising psychometric properties in the form of good internal consistency, construct validity and convergent validity (Wells & CartwrightHatton, 2004). Cronbach's alpha for the MCQ-30 subscales in the current study ranged from .83 to .90 (.94 for the total score), although the Norwegian version of MCQ-30 has been used in several studies, the psychometric properties of the translation have not been properly examined. The Eating Disorder Examination Questionnaire 6.0 (EDE-Q 6.0; Fairburn & Beglin, 2008) has 28 items, and measures severity on of eating disorders symptomatology. The item score range from 0 to 6, where a higher score implies more severe levels of eating disorder symptoms. The EDE-Q consists of four subscales which are thought to assess concern about eating (e.g.: “Have you had a definite fear of losing
control over eating”), shape (e.g.: “Have you had a definite desire to have a totally flat stomach”), weight (e.g.: “Have you had a strong desire to lose weight”), and restraint of food intake (e.g.: “Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight?”) (Fairburn & Beglin, 2008). Each subscale is presented as a mean score, and the total score for EDE-Q is the mean score of all the four subscales. The Norwegian translation of the EDE-Q was found to have satisfactory reliability and validity related to clinical use (Rø, Reas, & Lask, 2010). The Cronbach's alpha for the EDE-Q subscales in the total sample of this study ranged from .81 to .94 in the current study (.92 for the total score). 2.3. Procedure The inpatients were recruited by one of the authors and a contact person from each of RKSF's sections providing verbal and written information about the study. The author informed the therapists who then recruited their outpatients. Participation in the study consisted of signing an informed consent and filling out the self-report forms described above. The questionnaires were returned in a closed envelope
Table 2 Descriptive information from the clinical sample, the three control samples (total N = 203), and comparisons from an ANOVA analysis.
N
Clinical sample eating disorders
Eating and psychiatric problems
Other psychiatric problems
Healthy controls
a
b
c
d
Sig.
53
47
37
66
23.8 (8.7) 23.1% 26.9% 28.4 (9.3) n.a. n.a. 2.7 (1.9) 3.0 (1.8) 4.3 (1.8) 3.8 (1.9) 3.4 (1.6) 12.3 (4.7) 15.8 (5.1)
23.1 (4.8) 6.4% 21.3% 26.6 (6.6) 42.6% 78.7% 2.7 (1.4) 2.0 (1.8) 3.8 (1.6) 3.2 (1.7) 2.9 (1.5) 10.0 (4.7) 12.8 (5.1)
23.2 (4.2) 5.6% 25.0% 30.4 (7.5) 48.6% 86.5% 1.4 (1.4) .5 (.7) 2.1 (1.6) 1.6 (1.4) 1.4 (1.1) 9.3 (3.9) 11.8 (4.3)
23.5 (6.3) 3.2% 19.0% 27.8 (7.0) 31.8% 92.4% 1.2 (1.1) .5 (.8) 1.7 (1.4) 1.3 (1.1) 1.2 (.9) 8.6 (2.9) 9.4 (3.6)
ns .002 ns ns ns ns a, b N, c, d a N b N c, d a, b N c, d a, b N c, d a, b N c, d a N b, c, d a N b N c, d
13.2 (5.3) 14.2 (5.2) 14.0 (3.7) 69.2 (20.0)
11.0 (4.9) 11.0 (4.8) 13.5 (4.6) 58.3 (18.4)
10.9 (4.9) 9.0 (4.1) 13.1 (4.3) 54.1 (16.8)
9.5 (3.2) 7.9 (2.4) 10.7 (3.3) 46.2 (11.8)
aNd aNbNd a, b, c N d a N b N c, d
M (SD) Current BMI BMI b18.5 BMI N25 Age Civil status (single) Fulltime student/job Restraint Eating concern Shape concern Weight concern Global EDE-Q Positive beliefs Negative beliefs about uncontrollability and danger Cognitive confidence Need to control thoughts Cognitive self-consciousness MCQ-30 total
Note. BMI = body mass index. Post-hoc tests with Tukey or Games-Howell comparisons. Significance level set at p b .001.
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to their therapist, their contact person or the first author of this paper. Inpatients and outpatients with different eating disorder diagnoses were included. Data from control groups were collected as an Internet survey. A link to the survey was posted on social media in order to recruit participants for the healthy control sample. We posted invitations on popular blogs relating to eating disorders in order to recruit participants with problems related to eating disorders. The study was approved by the Regional Committees for Medical and Health Research Ethics in Norway (REK). 2.4. Statistics In order to compare eating disorder symptomatology and metacognition among the samples we conducted ANOVA analyses and post-hoc tests using either Tukey or Games-Howell comparisons. We further explored the relationship between metacognition and eating disorder symptoms by using correlation analyses. Finally we conducted hierarchical regression analyses controlling for age on step 1, BMI on step 2, and then entered MCQ subscales on step 3 in order to explore which metacognition explains the most variance of eating disorder symptoms. There were no missing values in the control samples since the program used did not allow for missing. Missing values on the EDE-Q or the MCQ-30 in the clinical group were replaced by their corresponding mean subscale score. Significance levels were set at p b .001. 3. Results 3.1. Comparison of eating disorder symptoms in the clinical sample and control groups ANOVA analyses were conducted for group comparisons. We expected that the clinical group would show significantly higher scores on the EDE-Q compared to healthy controls. The results of the analyses showed that the clinical group (M = 3.4, SD = 1.6) and the group with a history of self-reported eating problems (M = 2.9, SD = 1.5) scored significantly higher on the EDE-Q than the control group without a history of an eating disorder (M = 1.4, SD = 1.1) and the healthy controls (M = 1.2, SD = .9), F(3, 199) = 38.80, p b .001. Therefore, as expected the clinical group shows more eating disorder symptomatology compared to healthy controls (see Table 2 for further details). 3.2. Comparison of metacognition in the clinical group and control groups Our main hypothesis was that the clinical sample would score significantly higher than healthy controls on the MCQ-30. The results showed that the clinical group had significantly higher scores on the MCQ-30 (M = 69.2, SD = 20.0) than the control groups and especially the healthy controls (M = 46.2, SD = 11.8), F(3, 199) = 19.09, p b .001. ANOVA analyses showed that the mean scores were significantly higher in the clinical sample compared to the healthy controls on all the five MCQ subscales. In addition, the clinical group scored significantly higher than all the three control groups on positive beliefs about worry, negative beliefs about uncontrollability and danger, and on the total MCQ-30 score. Therefore, as hypothesized the results show that the clinical group has higher levels of dysfunctional metacognition compared to healthy controls.
3.3. Relationship between metacognition and eating disorder symptoms The second hypothesis of interest in this study was that eating disorder symptomatology would be significantly positively related to metacognitive beliefs. The results of the analysis (as shown in Table 3) showed that the correlations were significant and ranged from moderate to strong. The global EDE-Q score correlated especially high with the total MCQ-30 score (r = .67) and the MCQ-30 subscale “need to control thoughts” (r = .71). Correlations for the total sample and for the clinical sample showed similar patterns. The EDE-Q subscale “restraint” had the weakest correlations with the MCQ-30, in the weak/moderate range. Therefore, as hypothesized the relationship between metacognitive beliefs and eating disorder symptomatology was found to be significant. A stepwise regression analysis was run to test whether any of the metacognitive factors could predict the severity of eating disorder symptoms in order to explore whether certain metacognitive beliefs appear more important than others in explaining eating disorder symptomatology. The regression entered EDE-Q as dependent variable and controlled for age and BMI separately in the first two steps. The five factors from the MCQ-30 were entered as predictor variables in step three as presented in Table 4. MCQ-30 explained 50.8% of the variance in the total EDE-Q with age and BMI being controlled for. The metacognitive subscale “need to control thoughts” was the only metacognitive factor significantly predicting unique variance in the global EDE-Q score. The collinearity statistics were within the acceptable range. 4. Discussion This study showed that a clinical group of patients with an eating disorder had significantly more dysfunctional metacognition than healthy controls. Metacognition was positively correlated with symptom severity and predicted 51% of the variance in eating disorder symptoms when controlling for age and BMI. The metacognitive factor “need to control thoughts” was the most important factor. 4.1. Comparison of metacognition in the clinical sample and control samples The groups with clinical or self-reported eating disorders reported significantly higher levels of dysfunctional metacognition than the control groups without an eating disorder. This is in line with previous research related to the association between metacognition and symptoms of eating disorders (Cooper et al., 2007; McDermott & Rushford, 2011; Woolrich et al., 2008). The clinical group scoring higher on dysfunctional metacognition than the control groups, could indicate maladaptive metacognition as an underlying psychopathological processes, but longitudinal or experimental studies are needed for further clarification of such a pattern. The MCQ-30 scores found in the current clinical sample resemble levels reported in other studies of generalized anxiety disorder, obsessive–compulsive disorder and schizophrenia (Moritz, Peters, Larøi, & Lincoln, 2010; Solem et al., 2009; Westra, Arkowitz, & Dozois, 2009). This study could therefore support the hypothesis of dysfunctional
Table 3 Pearson product–moment correlations for metacognition and eating disorder symptoms.
Global EDE-Q Restraint Eating concern Shape concern Weight concern
MCQ-30
Positive beliefs
Negative beliefs
Cognitive confidence
Need to control thoughts
Cognitive self-consciousness
.67 (.68) .45 (.40) .66 (.62) .66 (.68) .65 (.69)
.47 (.49) .32 (.30) .49 (.43) .47 (.52) .45 (.50)
.60 (.57) .36 (.25) .31 (.61) .60 (.58) .58 (.57)
.50 (.53) .36 (.37) .49 (.44) .48 (.50) .48 (.54)
.71 (.74) .48 (.45) .70 (.69) .68 (.73) .70 (73)
.44 (.46) .33 (.26) .41 (.37) .45 (.49) .42 (.49)
Note. Values refer to correlations for the total sample while numbers in parentheses are correlations for patient sample only. All correlations are significant p b .001.
S. Olstad et al. / Eating Behaviors 16 (2015) 17–22 Table 4 Stepwise multiple regression controlling for age and BMI with metacognition as predictors of global EDE-Q scores and subscores (N = 203).
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preservative thinking, with a strong correlation between the total MCQ-30 score and especially the factor “need to control thoughts” and the EDE-Q scores.
Global EDE-Q F change Step 1 Age Step 2 Age BMI Step 3 Age BMI Positive beliefs Negative beliefs Cognitive confidence Need to control thoughts Cognitive self-consciousness
R2 cha
1.04
.005
.20
.001
β
4.3. Limitations of the study .07
39.68⁎
.07 .03 .508 .11 .04 .02 .09 .06 .59⁎ −.01
⁎ p b .001.
metacognition serving as important transdiagnostic psychopathological processes (Wells, 2009). 4.2. Associations between metacognition and eating disorder symptoms In our study, the scores on the MCQ-30 and the EDE-Q were highly correlated, which suggests that a high score of metacognition is associated with a higher level of eating disorder symptoms. The strongest correlations between metacognition and eating disorder pathology were found between the metacognitive factor “need to control thoughts” and the three EDE-Q subscales concerning “eating-, shape-, and weight concern”. The regression analysis also showed “need to control thoughts” as the only metacognitive subscale significantly predicting unique variance in global EDE-Q score and all the EDE-Q subscales. This result indicates that the metacognitive belief related to the “need to control thoughts” is of especially importance. The importance of ‘need to control thoughts’ is a common finding in studies investigating the relationship between metacognition and emotional disorders. Previous studies have not investigated the relative importance of the MCQ-30 subscales. However, McDermott and Rushford (2011) found that the need for control and negative metacognitive beliefs were the two subscales that differentiated the most between anorectic patients and controls. This metacognitive belief is central in the metacognitive model as it is activated by worry and rumination and its associated symptoms. People with emotional disorders experience a need to control thoughts as symptoms increases and they often attempt to control and regulate these thoughts and symptoms by using maladaptive coping behaviors. Eating disorders symptoms could therefore be viewed as a maladaptive coping behavior in order to control worry and rumination. Metacognitive beliefs explained 51% of the variance in eating disorder symptoms. However, the correlation coefficients in this study related to the EDE-Q subscale “restraint” were noticeably lower compared with the other EDE-Q subscales. The MCQ-30 explained 23.6% of the variance in the “restraint” subscale after controlling for age and BMI. Because the MCQ-30 measures cognitive aspects it is logical that it does not correlate as highly with behavioral aspects (restraint) as compared to cognitive aspects (e.g. shape concern) of eating disorder symptomatology. Metacognitions are assumed to drive cognitive process related to worry and rumination (Wells, 2009). This puts our findings in line with previous research, having found that worry and rumination are associated with eating disorder symptoms (Startup et al., 2013; Sternheim et al., 2012). Earlier studies have shown that eating disorder symptoms correlated significantly with worry (Sternheim et al., 2012), and rumination (Startup et al., 2013). The present study supports the findings related to the association between eating disorder and
Methodological limitations of the study must be taken into consideration when interpreting the findings. First, the data is based on selfreport, which is a limitation. However, the questionnaires in this study are considered as valid and reliable instruments (Rø et al., 2010; Wells & Cartwright-Hatton, 2004). Diagnostic interviews could have been applied for a thorough screening of eating disorder diagnosis, but the validity of the diagnoses was not considered a large problem, considering all participants in the clinical group were included based on their current status as an eating disorder patient in a specialized eating disorder clinic. Second, casual inferences cannot be made due to the crosssectional design of the study, so further research is needed to see whether change in metacognitions will result in a reduction of eating disorder symptoms, as implicated by the S-REF model (Wells & Matthews, 1996). Third, the results could be affected by differences based on how long the participants in the clinical sample had undergone treatment, which should be documented in further investigations. Recovery from eating disorder often takes a long time (Keel & Brown, 2010). Even though the patients in the present study were currently in treatment and it may be reasonable to assume that they would still suffer from eating disorder symptoms to a varying degree. Fourth, the control groups were collected as an Internet survey which included a self-reported history of eating or psychiatric problems. The representativeness of the control groups can therefore be questioned, but the groups with clinical or self-reported history of eating disorder problems scored significantly higher on EDE-Q than the other control groups. There is a possibility that including participants from the internet could bias the sample in that people who are especially interested in eating disorders are recruited. The findings support the categorization of groups in this study as appropriate. This is further supported by the scores on the EDQ indicating a clinical level of eating disorder pathology. Finally, the clinical sample is relatively small, so further studies using larger sample sizes are therefore needed. Future studies should also control for psychiatric comorbidity and time in treatment for further exploration of the role of metacognition. 4.4. Clinical implications and conclusions Understanding the pathological processes in eating disorders is important for developing useful theoretical models and an effective treatment. The current study indicates that metacognition may be a very interesting factor worthy of further studies in eating disorders, and it is also in line with earlier findings related to the association between metacognition and eating disorder symptoms. The findings further underline metacognition as identifying transdiagnostic processes relevant for several disorders. Given the effects found for MCT for other disorders (e.g. Normann, van Emmerik, & Morina, 2014), the results in the paper indicate that developing a specific metacognitive model for eating disorders and test the effect of metacognitive therapy (Wells, 2009) to reduce worry, rumination, threat monitoring and ineffective coping strategies when treating eating disorders may be a very interesting path. Role of funding sources There were no funding sources for this study.
Contributors Olstad and Hagen designed the study. Olstad collected the data from the clinical group, and Solem collected the data from the control groups. Olstad, Solem & Hjemdal conducted the statistical analyses. Olstad wrote the first draft of the manuscript, and all the authors have contributed to the final version and have approved the final manuscript.
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Conflict of interest All authors declare they have no conflict of interest.
Acknowledgments The authors wish to thank the Regional Department for Eating Disorders (RASP), Oslo University Hospital and the Regional Competence Center for Eating Disorders (RKSF), at Stjørdal and Levanger in Norway for participating in the study.
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Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 28(6), 487–495, http://dx.doi.org/10.1016/0005-7967(90)90135-6. Moritz, S., Peters, M. J. V., Larøi, F., & Lincoln, T. M. (2010). Metacognitive beliefs in obsessive–compulsive patients: A comparison with healthy and schizophrenia participants. Cognitive Neuropsychiatry, 15(6), 531–548, http://dx.doi.org/10.1080/ 13546801003783508. National Institute for Health and Care Excellence (2004). Eating disorders: Anorexia nervosa, bulimia nervosa and related eating disorders. No. CG9. London: Author. Nolen-Hoeksema, S., Stice, E., Wade, E., & Bohon, C. (2007). Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents. Journal of Abnormal Psychology, 116(1), 198–207, http://dx.doi.org/10. 1037/0021-843X.116.1.198. Normann, N., van Emmerik, A. A. P., & Morina, N. (2014). The efficacy of metacognitive therapy for anxiety and depression: A meta-analytic review. Depression and Anxiety, 31, 402–411, http://dx.doi.org/10.1002/da.22273. Rø, Ø., Reas, D. L., & Lask, B. (2010). Norms for the Eating Disorder Examination Questionnaire among female university students in Norway. Nordic Journal of Psychiatry, 64(6), 428–432, http://dx.doi.org/10.3109/08039481003797235. Solem, S., Håland, A. T., Vogel, P. A., Hansen, B., & Wells, A. (2009). Change in metacognitions predicts outcome in obsessive–compulsive disorder patients undergoing treatment with exposure and response prevention. Behaviour Research and Therapy, 47(4), 301–307, http://dx.doi.org/10.1016/j.brat.2009.01.003. Startup, H., Lavender, A., Oldershaw, A., Stott, R., Tchanturia, K., Treasure, J., et al. (2013). Worry and rumination in anorexia nervosa. Behavioural and Cognitive Psychotherapy, 41, 301–316, http://dx.doi.org/10.1017/S1352465812000847. Sternheim, L., Startup, H., Saeidi, S., Morgan, J., Hugo, P., Russell, A., et al. (2012). Understanding catastrophic worry in eating disorders: Process and content characteristics. Journal of Behaviour Therapy and Experimental Psychiatry, 43, 1095–1103, http://dx. doi.org/10.1016/j.jbtep.2012.05.006. Wells, A. (2009). Metacognitive therapy for anxiety and depression. New York, NY: The Guilford Press. Wells, A. (2013). Advances in metacognitive therapy. International Journal of Cognitive Therapy, 6(2), 186–201, http://dx.doi.org/10.1521/ijct.2013.6.2.186. Wells, A., & Cartwright-Hatton, S. (2004). A short form of the metacognitions questionnaire: Properties of the MCQ-30. Behaviour Research and Therapy, 42(4), 385–396, http://dx.doi.org/10.1016/S0005-7967(03)00147-5. Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: The S-REF model. Behaviour Research and Therapy, 34, 881–888, http://dx.doi.org/10.1016/ S0005-7967(96)00050-2. Westra, H. A., Arkowitz, H., & Dozois, D. J. A. (2009). Adding a motivational interviewing pretreatment to cognitive behavioral therapy for generalized anxiety disorder: A preliminary randomized controlled trial. Journal of Anxiety Disorders, 23, 1106–1117, http://dx.doi.org/10.1016/j.janxdis.2009.07.014. Woolrich, R. A., Cooper, M. J., & Turner, H. M. (2008). Metacognition in patients with anorexia nervosa, dieting and non-dieting women: A preliminary study. European Eating Disorders Review, 16(1), 11–20, http://dx.doi.org/10.1002/erv.802.
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Eating Behaviors
Metacognition in eating disorders: Comparison of women with eating disorders, self-reported history of eating disorders or psychiatric problems, and healthy controls Siri Olstad ⁎, Stian Solem, Odin Hjemdal, Roger Hagen Department of Psychology, University of Science and Technology, Norway
a r t i c l e
i n f o
Article history: Received 13 June 2014 Received in revised form 30 September 2014 Accepted 24 October 2014 Available online 4 November 2014 Keywords: Eating disorder Bulimia Nervosa Anorexia Nervosa Metacognition
a b s t r a c t Objective: The aim of the study was to compare a clinical sample with eating disorders to different control samples on self-report measures of metacognition and eating disorder symptoms, in order to investigate the role of metacognition in eating disorders. Method: The clinical group consisted of 53 female patients with eating disorders who completed the Metacognitions Questionnaire-30 and the Eating Disorder Examination Questionnaire 6.0. One-hundred and fifty women who served as a control group completed the questionnaires as an Internet survey. This control group was divided into three groups based on self-reported history of eating and psychiatric problems (N = 47), other psychiatric problems (N = 37), or no such problems (healthy controls: N = 66). Results: The clinical group scored significantly higher on dysfunctional metacognition than healthy controls, especially on “negative beliefs about uncontrollability and danger”, “need to control thoughts”, and total MCQ30 score. Eating disorder symptomatology was positively correlated with metacognition. Metacognition explained 51% of the variance in eating disorder symptoms after controlling for age and BMI, with “need to control thoughts” as the most important factor. Conclusion: Metacognitive beliefs may be central in understanding eating disorders, and metacognitive treatment strategies could be a promising approach in developing new psychological treatments for eating disorders. © 2014 Elsevier Ltd. All rights reserved.
1. Metacognition in eating disorders The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V, APA, 2013) defines the criteria for different eating disorders such as Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). All these eating disorders share an intense fear of weight gain and a distorted body image that often serve as a basis for negative self-evaluation. Eating disorders are associated with severe physical and psychosocial consequences, and are considered difficult to treat (Fairburn & Harrison, 2003). Cognitive behavioral therapy is considered the treatment of choice for BN (National Institute for Health and Care Excellence [NICE], 2004), but there is insufficient evidence to conclude on a treatment of choice for AN (Bulik, Brownley, Shapiro, & Berkman, 2012). Prognostic indicators suggest that severity of psychiatric comorbidity relates to outcome for BN, while severity and duration of AN relates to outcome for treating AN (Keel & Brown, 2010). These findings may indicate that there is a need for a new understanding of eating disorders which again may pave the way for more efficient ⁎ Corresponding author at: Department of Psychology, Norwegian University of Science and Technology, NTNU, 7491 Trondheim, Norway. Tel.: +47 90962113. E-mail address: [email protected] (S. Olstad).
http://dx.doi.org/10.1016/j.eatbeh.2014.10.019 1471-0153/© 2014 Elsevier Ltd. All rights reserved.
treatments. The metacognitive model has identified transdiagnostic psychological processes that are involved in several disorders (Wells, 2009). It represents a new perspective and as such it may be of interest to explore if it contributes to the understanding of eating disorder symptoms. Metacognitive theory states that psychological disorder results from an inflexible and maladaptive response pattern to cognitive events, which is labeled the Cognitive Attentional Syndrome (CAS). The CAS consists of persistent worry and rumination, threat monitoring and ineffective coping strategies that contribute to the maintenance of the problem (Wells, 2013). The CAS is controlled by erroneous beliefs about trhinking. These beliefs are called metacognitions, which refer to internal cognitive factors that control, monitor and appraise thinking. They are both positive- and negative metacognitive beliefs. Positive metacognitions are concerned with the benefits of worry, rumination, threat-monitoring, and counter-productive coping strategies. Example of a positive metacognition related to eating disorders could be “I must worry about my weight and eating in order to control my weight”. Negative metacognitions are concerned with the uncontrollability and danger of thoughts and cognitive experiences. Example of a negative metacognition in eating disorders could be “Worrying about my body and weight could make me go mad”. For more detailed descriptions of positive and negative metacognition in Anorexia Nervosa see Woolrich, Cooper, and
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Turner (2008). These negative and positive metacognitive beliefs are the driving force of the CAS. Metacognitive treatment aims to eliminate the CAS to enable new learning to take place (Wells & Matthews, 1996). There are several reasons why the metacognitive model could be beneficial for understanding and treating eating disorders. First, eating disorders seem to have many similarities with other types of psychiatric disorders related to worry where metacognitions are central, like generalized anxiety disorder (Konstantellou, Campbell, Eisler, Simic, & Treasure, 2011), and obsessive–compulsive symptoms (Halmi et al., 2005). Second, rumination (e.g. “I think about all my shortcomings, failings, faults, and mistakes”), which is an important aspect in the metacognitive treatment of depression, seems to also be of relevance in patients with bulimic symptoms (Nolen-Hoeksema, Stice, Wade, & Bohon, 2007). Third, eating disorders have a high rate of comorbidity (Hudson, Hiripi, Pope, & Kessler, 2007), and because the metacognitive model focus on common psychological processes that transcend diagnostic borders, this approach could be considered especially relevant in treating eating disorders. Some research has been undertaken to explore the role of worry and rumination in eating disorders which support the potential utility of a metacognitive perspective. Sternheim et al. (2012) investigated the role of worry in patients with AN and BN, and found that they scored significantly higher on the Penn State Worry Questionnaire (Meyer, Miller, Metzger, & Borkovec, 1990) compared to healthy controls. The two groups with eating disorders did not differ from each other on worry. A positive correlation was found between worry and eating disorder symptomatology. Startup et al. (2013) also found elevated scores on measures of worry and rumination in a sample of 62 patients with AN compared to healthy controls. Additionally, they also found a positive correlation for both worry and rumination related to eating disorder symptoms, and that worry and rumination predicted severity of the eating disorder over and above measures of mood. A related study by Woolrich et al. (2008) used a semi-structured interview to compare 15 patients with AN to 17 dieting women and 18 non-dieting controls. Patients with AN believed to a higher degree that their thoughts were abnormal and uncontrollable. Patients with AN were also more likely to use thought control strategies like mental self-punishment, worry and rumination in order to cope with their negative thoughts. Cooper, Grocutt, Deepak, and Bailey (2007) administered the Metacognitions Questionnaire-30 (MCQ-30: Wells & Cartwright-Hatton, 2004) to 16 patients with AN, 15 dieters, and 17 non-dieting controls. They found that patients with AN scored higher on four out of five metacognitive factors namely; need to control thoughts, cognitive self-consciousness, negative beliefs of uncontrollability and danger, and cognitive confidence. The groups did not differ significantly on positive beliefs about worry. McDermott and Rushford (2011) compared MCQ-30 scores in a larger sample than Cooper et al. (2007), where the sample consisted of 74 with AN, and 93 without AN. The same pattern of elevated scores on four out of five subtypes of metacognition was found. Konstantellou and Reynolds (2010) found that problematic eating attitudes were related to higher scores on three out of five factors on the MCQ-30 in a non-clinical sample. Although there has been some studies suggesting that metacognition are important in eating disorders there have been no clinical trials exploring the effects of metacognitive therapy (MCT) for eating disorders. Also, a metacognitive treatment manual for eating disorders has yet to be developed. In general, MCT does not view emotional disorders as linked to content of negative thoughts. Instead it views attentional bias and worry/rumination as strategies for appraising and dealing with threat as essential in maintaining emotional disorders. These are the processes that are addressed in MCT. For a comparison of CBT and MCT confer on Fisher (2009). There is no current treatment for eating disorders which addresses metacognitions directly as specified by Wells' (2009) description of the metacognitive model for emotional disorders. However, existing therapies are likely to change metacognitions indirectly as patients improve by reducing worry,
rumination, and maladaptive coping behaviors (e.g. Solem, Håland, Vogel, Hansen, & Wells, 2009). The studies reviewed in the introduction suggest that worry, rumination and metacognition are central in understanding eating disorders, but there is a need for further studies to validate the role of these factors in order develops a metacognitive treatment for eating disorders. As reviewed above, few previous studies have investigated metacognitive beliefs in anorectic patients. In order to improve and extend previous findings we chose to conduct a study using a larger sample, combing different samples of eating disorders, and to compare these against groups with other psychiatric symptoms as well as healthy controls. In order to explore the role of metacognition in eating disorders we used a comparative cross-sectional design, where a clinical sample of patients with eating disorders was compared to control samples with selfreported history of — eating disorders, psychiatric problems, as well as healthy controls. The aim of this study was therefore to investigate metacognition in a clinical sample of patients with eating disorders and control groups. Based on metacognitive theory and earlier research, it was expected that the clinical sample would have a higher score on dysfunctional metacognition compared to healthy controls. Similar patterns, but smaller differences between the clinical and the control groups with self-reported history of eating problems and/or other psychiatric problems was also expected to be found. In addition, it was predicted that eating disorder symptomatology would be positively correlated with dysfunctional metacognition. If metacognitions continue to prove to be of importance in eating disorders, therapeutic interventions aimed at challenging these beliefs could be called for. 2. Method 2.1. Participants 2.1.1. Clinical group The clinical group consisted of 53 women receiving outpatient or inpatient treatment at the Regional Department for Eating Disorders (RASP), Oslo University Hospital and the Regional Competence Center for Eating Disorders (RKSF), at Stjørdal and Levanger in Norway. The mean age in the clinical sample was 28.4 years (SD = 9.3), with a range in age from 17 to 51. The eating disorders diagnoses in the clinical group consisted of 17 patients with AN, 14 with BN, and 22 were classified as EDNOS where five had a body mass index (BMI) in the overweight range. BMI was self-reported. The type of eating disorder was reported by the patients themselves. The duration of their eating disorder had a mean of 12.2 years (SD = 8.8), with a range in duration from 1 to 35 years. BMI was calculated for both their current weight and their lowest weight in adult age, which is presented in Table 1. Employment status was not recorded for the clinical group. 2.1.2. Control groups The control groups consisted of 47 women with self-reported history of eating and psychiatric problems, 37 women with self-reported history of other psychiatric problems, and 66 women who reported no history of psychiatric- or eating disorder problems were classified as healthy controls. The majority of the controls were either in a fulltime job or currently a fulltime student. ANOVA analyses suggested that the mean age of the control samples were not significantly different from the clinical group with eating disorders (see Table 2). 2.2. Measures The Metacognitions Questionnaire-30 (MCQ-30; Wells & Cartwright-Hatton, 2004) measures five factors of metacognition, namely; positive beliefs (e.g.: “Worrying helps me to avoid problems in the future”), negative beliefs about uncontrollability and danger
S. Olstad et al. / Eating Behaviors 16 (2015) 17–22
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Table 1 Description of the clinical sample with eating disorders (N = 53).
N Current BMI Lowest BMI Age Duration of disorder (years) Global EDE-Q Restraint Eating concern Shape concern Weight concern MCQ-30 total Positive beliefs Negative beliefs about uncontrollability and danger Cognitive confidence Need to control thoughts Cognitive self-consciousness
Anorexia
Bulimia
EDNOS
Overweight
17 18.3 (3.1)a 14.6 (2.8) 25.5 (9.0) 10.3 (8.4) 3.3 (1.5) 2.7 (1.6) 2.8 (1.8) 4.3 (1.8) 3.6 (1.8) 73.1 (20.7) 12.9 (4.4) 16.2 (4.6) 13.5 (5.4) 15.5 (5.4) 14.9 (4.4)
14 24.2 (6.2) 16.8 (2.5) 27.1 (8.8) 13.1 (9.4) 4.1 (1.7) 3.3 (1.9) 3.8 (1.8) 4.9 (1.7) 4.5 (1.8) 76.9 (19.1) 14.7 (5.6)b 17.5 (3.5) 15.1 (5.7) 15.9 (4.6) 13.8 (3.3)
17 23.6 (7.2) 17.9 (4.1) 30.6 (9.9) 13.1 (9.5) 3.0 (1.8) 2.1 (1.6) 2.3 (1.5) 3.6 (2.0) 3.2 (2.1) 59.4 (17.1) 10.1 (3.5) 13.5 (5.7) 11.3 (4.6) 11.7 (4.4) 12.8 (3.0)
5 42.5 (6.6) 28.4 (3.7) 34.4 (7.8) 12.3 (6.7) 3.8 (1.3) 1.6 (1.2) 3.8 (2.2) 4.8 (1.2) 4.6 (1.1) 69.8 (21.9) 10.6 (3.6) 17.0 (6.7) 13.8 (6.1) 13.4 (6.9) 15.0 (4.8)
Note. BMI = body mass index. Atypical-Anorexia (N = 9) and -Bulimia (N = 1) coded as Eating Disorder Not Otherwise Specified. a Anorectic and overweight patients have significant different BMI compared to controls. b Higher scores on positive beliefs in bulimic patients than EDNOS.
(e.g.: “My worrying is dangerous for me”), cognitive confidence (e.g.: “I have little confidence in my memory for words and names”), need for control thoughts (e.g.: “If I did not control a worrying thought, and then it happened, it would be my fault”), and cognitive selfconsciousness (e.g.: “I think a lot about my thoughts”). Each item is scored from 1 to 4, and higher scores indicate higher levels of dysfunctional metacognition. The scores on the MCQ-30 can range from 30 to 120 for the total score and from 5 to 30 for the subscales. MCQ-30 has promising psychometric properties in the form of good internal consistency, construct validity and convergent validity (Wells & CartwrightHatton, 2004). Cronbach's alpha for the MCQ-30 subscales in the current study ranged from .83 to .90 (.94 for the total score), although the Norwegian version of MCQ-30 has been used in several studies, the psychometric properties of the translation have not been properly examined. The Eating Disorder Examination Questionnaire 6.0 (EDE-Q 6.0; Fairburn & Beglin, 2008) has 28 items, and measures severity on of eating disorders symptomatology. The item score range from 0 to 6, where a higher score implies more severe levels of eating disorder symptoms. The EDE-Q consists of four subscales which are thought to assess concern about eating (e.g.: “Have you had a definite fear of losing
control over eating”), shape (e.g.: “Have you had a definite desire to have a totally flat stomach”), weight (e.g.: “Have you had a strong desire to lose weight”), and restraint of food intake (e.g.: “Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight?”) (Fairburn & Beglin, 2008). Each subscale is presented as a mean score, and the total score for EDE-Q is the mean score of all the four subscales. The Norwegian translation of the EDE-Q was found to have satisfactory reliability and validity related to clinical use (Rø, Reas, & Lask, 2010). The Cronbach's alpha for the EDE-Q subscales in the total sample of this study ranged from .81 to .94 in the current study (.92 for the total score). 2.3. Procedure The inpatients were recruited by one of the authors and a contact person from each of RKSF's sections providing verbal and written information about the study. The author informed the therapists who then recruited their outpatients. Participation in the study consisted of signing an informed consent and filling out the self-report forms described above. The questionnaires were returned in a closed envelope
Table 2 Descriptive information from the clinical sample, the three control samples (total N = 203), and comparisons from an ANOVA analysis.
N
Clinical sample eating disorders
Eating and psychiatric problems
Other psychiatric problems
Healthy controls
a
b
c
d
Sig.
53
47
37
66
23.8 (8.7) 23.1% 26.9% 28.4 (9.3) n.a. n.a. 2.7 (1.9) 3.0 (1.8) 4.3 (1.8) 3.8 (1.9) 3.4 (1.6) 12.3 (4.7) 15.8 (5.1)
23.1 (4.8) 6.4% 21.3% 26.6 (6.6) 42.6% 78.7% 2.7 (1.4) 2.0 (1.8) 3.8 (1.6) 3.2 (1.7) 2.9 (1.5) 10.0 (4.7) 12.8 (5.1)
23.2 (4.2) 5.6% 25.0% 30.4 (7.5) 48.6% 86.5% 1.4 (1.4) .5 (.7) 2.1 (1.6) 1.6 (1.4) 1.4 (1.1) 9.3 (3.9) 11.8 (4.3)
23.5 (6.3) 3.2% 19.0% 27.8 (7.0) 31.8% 92.4% 1.2 (1.1) .5 (.8) 1.7 (1.4) 1.3 (1.1) 1.2 (.9) 8.6 (2.9) 9.4 (3.6)
ns .002 ns ns ns ns a, b N, c, d a N b N c, d a, b N c, d a, b N c, d a, b N c, d a N b, c, d a N b N c, d
13.2 (5.3) 14.2 (5.2) 14.0 (3.7) 69.2 (20.0)
11.0 (4.9) 11.0 (4.8) 13.5 (4.6) 58.3 (18.4)
10.9 (4.9) 9.0 (4.1) 13.1 (4.3) 54.1 (16.8)
9.5 (3.2) 7.9 (2.4) 10.7 (3.3) 46.2 (11.8)
aNd aNbNd a, b, c N d a N b N c, d
M (SD) Current BMI BMI b18.5 BMI N25 Age Civil status (single) Fulltime student/job Restraint Eating concern Shape concern Weight concern Global EDE-Q Positive beliefs Negative beliefs about uncontrollability and danger Cognitive confidence Need to control thoughts Cognitive self-consciousness MCQ-30 total
Note. BMI = body mass index. Post-hoc tests with Tukey or Games-Howell comparisons. Significance level set at p b .001.
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to their therapist, their contact person or the first author of this paper. Inpatients and outpatients with different eating disorder diagnoses were included. Data from control groups were collected as an Internet survey. A link to the survey was posted on social media in order to recruit participants for the healthy control sample. We posted invitations on popular blogs relating to eating disorders in order to recruit participants with problems related to eating disorders. The study was approved by the Regional Committees for Medical and Health Research Ethics in Norway (REK). 2.4. Statistics In order to compare eating disorder symptomatology and metacognition among the samples we conducted ANOVA analyses and post-hoc tests using either Tukey or Games-Howell comparisons. We further explored the relationship between metacognition and eating disorder symptoms by using correlation analyses. Finally we conducted hierarchical regression analyses controlling for age on step 1, BMI on step 2, and then entered MCQ subscales on step 3 in order to explore which metacognition explains the most variance of eating disorder symptoms. There were no missing values in the control samples since the program used did not allow for missing. Missing values on the EDE-Q or the MCQ-30 in the clinical group were replaced by their corresponding mean subscale score. Significance levels were set at p b .001. 3. Results 3.1. Comparison of eating disorder symptoms in the clinical sample and control groups ANOVA analyses were conducted for group comparisons. We expected that the clinical group would show significantly higher scores on the EDE-Q compared to healthy controls. The results of the analyses showed that the clinical group (M = 3.4, SD = 1.6) and the group with a history of self-reported eating problems (M = 2.9, SD = 1.5) scored significantly higher on the EDE-Q than the control group without a history of an eating disorder (M = 1.4, SD = 1.1) and the healthy controls (M = 1.2, SD = .9), F(3, 199) = 38.80, p b .001. Therefore, as expected the clinical group shows more eating disorder symptomatology compared to healthy controls (see Table 2 for further details). 3.2. Comparison of metacognition in the clinical group and control groups Our main hypothesis was that the clinical sample would score significantly higher than healthy controls on the MCQ-30. The results showed that the clinical group had significantly higher scores on the MCQ-30 (M = 69.2, SD = 20.0) than the control groups and especially the healthy controls (M = 46.2, SD = 11.8), F(3, 199) = 19.09, p b .001. ANOVA analyses showed that the mean scores were significantly higher in the clinical sample compared to the healthy controls on all the five MCQ subscales. In addition, the clinical group scored significantly higher than all the three control groups on positive beliefs about worry, negative beliefs about uncontrollability and danger, and on the total MCQ-30 score. Therefore, as hypothesized the results show that the clinical group has higher levels of dysfunctional metacognition compared to healthy controls.
3.3. Relationship between metacognition and eating disorder symptoms The second hypothesis of interest in this study was that eating disorder symptomatology would be significantly positively related to metacognitive beliefs. The results of the analysis (as shown in Table 3) showed that the correlations were significant and ranged from moderate to strong. The global EDE-Q score correlated especially high with the total MCQ-30 score (r = .67) and the MCQ-30 subscale “need to control thoughts” (r = .71). Correlations for the total sample and for the clinical sample showed similar patterns. The EDE-Q subscale “restraint” had the weakest correlations with the MCQ-30, in the weak/moderate range. Therefore, as hypothesized the relationship between metacognitive beliefs and eating disorder symptomatology was found to be significant. A stepwise regression analysis was run to test whether any of the metacognitive factors could predict the severity of eating disorder symptoms in order to explore whether certain metacognitive beliefs appear more important than others in explaining eating disorder symptomatology. The regression entered EDE-Q as dependent variable and controlled for age and BMI separately in the first two steps. The five factors from the MCQ-30 were entered as predictor variables in step three as presented in Table 4. MCQ-30 explained 50.8% of the variance in the total EDE-Q with age and BMI being controlled for. The metacognitive subscale “need to control thoughts” was the only metacognitive factor significantly predicting unique variance in the global EDE-Q score. The collinearity statistics were within the acceptable range. 4. Discussion This study showed that a clinical group of patients with an eating disorder had significantly more dysfunctional metacognition than healthy controls. Metacognition was positively correlated with symptom severity and predicted 51% of the variance in eating disorder symptoms when controlling for age and BMI. The metacognitive factor “need to control thoughts” was the most important factor. 4.1. Comparison of metacognition in the clinical sample and control samples The groups with clinical or self-reported eating disorders reported significantly higher levels of dysfunctional metacognition than the control groups without an eating disorder. This is in line with previous research related to the association between metacognition and symptoms of eating disorders (Cooper et al., 2007; McDermott & Rushford, 2011; Woolrich et al., 2008). The clinical group scoring higher on dysfunctional metacognition than the control groups, could indicate maladaptive metacognition as an underlying psychopathological processes, but longitudinal or experimental studies are needed for further clarification of such a pattern. The MCQ-30 scores found in the current clinical sample resemble levels reported in other studies of generalized anxiety disorder, obsessive–compulsive disorder and schizophrenia (Moritz, Peters, Larøi, & Lincoln, 2010; Solem et al., 2009; Westra, Arkowitz, & Dozois, 2009). This study could therefore support the hypothesis of dysfunctional
Table 3 Pearson product–moment correlations for metacognition and eating disorder symptoms.
Global EDE-Q Restraint Eating concern Shape concern Weight concern
MCQ-30
Positive beliefs
Negative beliefs
Cognitive confidence
Need to control thoughts
Cognitive self-consciousness
.67 (.68) .45 (.40) .66 (.62) .66 (.68) .65 (.69)
.47 (.49) .32 (.30) .49 (.43) .47 (.52) .45 (.50)
.60 (.57) .36 (.25) .31 (.61) .60 (.58) .58 (.57)
.50 (.53) .36 (.37) .49 (.44) .48 (.50) .48 (.54)
.71 (.74) .48 (.45) .70 (.69) .68 (.73) .70 (73)
.44 (.46) .33 (.26) .41 (.37) .45 (.49) .42 (.49)
Note. Values refer to correlations for the total sample while numbers in parentheses are correlations for patient sample only. All correlations are significant p b .001.
S. Olstad et al. / Eating Behaviors 16 (2015) 17–22 Table 4 Stepwise multiple regression controlling for age and BMI with metacognition as predictors of global EDE-Q scores and subscores (N = 203).
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preservative thinking, with a strong correlation between the total MCQ-30 score and especially the factor “need to control thoughts” and the EDE-Q scores.
Global EDE-Q F change Step 1 Age Step 2 Age BMI Step 3 Age BMI Positive beliefs Negative beliefs Cognitive confidence Need to control thoughts Cognitive self-consciousness
R2 cha
1.04
.005
.20
.001
β
4.3. Limitations of the study .07
39.68⁎
.07 .03 .508 .11 .04 .02 .09 .06 .59⁎ −.01
⁎ p b .001.
metacognition serving as important transdiagnostic psychopathological processes (Wells, 2009). 4.2. Associations between metacognition and eating disorder symptoms In our study, the scores on the MCQ-30 and the EDE-Q were highly correlated, which suggests that a high score of metacognition is associated with a higher level of eating disorder symptoms. The strongest correlations between metacognition and eating disorder pathology were found between the metacognitive factor “need to control thoughts” and the three EDE-Q subscales concerning “eating-, shape-, and weight concern”. The regression analysis also showed “need to control thoughts” as the only metacognitive subscale significantly predicting unique variance in global EDE-Q score and all the EDE-Q subscales. This result indicates that the metacognitive belief related to the “need to control thoughts” is of especially importance. The importance of ‘need to control thoughts’ is a common finding in studies investigating the relationship between metacognition and emotional disorders. Previous studies have not investigated the relative importance of the MCQ-30 subscales. However, McDermott and Rushford (2011) found that the need for control and negative metacognitive beliefs were the two subscales that differentiated the most between anorectic patients and controls. This metacognitive belief is central in the metacognitive model as it is activated by worry and rumination and its associated symptoms. People with emotional disorders experience a need to control thoughts as symptoms increases and they often attempt to control and regulate these thoughts and symptoms by using maladaptive coping behaviors. Eating disorders symptoms could therefore be viewed as a maladaptive coping behavior in order to control worry and rumination. Metacognitive beliefs explained 51% of the variance in eating disorder symptoms. However, the correlation coefficients in this study related to the EDE-Q subscale “restraint” were noticeably lower compared with the other EDE-Q subscales. The MCQ-30 explained 23.6% of the variance in the “restraint” subscale after controlling for age and BMI. Because the MCQ-30 measures cognitive aspects it is logical that it does not correlate as highly with behavioral aspects (restraint) as compared to cognitive aspects (e.g. shape concern) of eating disorder symptomatology. Metacognitions are assumed to drive cognitive process related to worry and rumination (Wells, 2009). This puts our findings in line with previous research, having found that worry and rumination are associated with eating disorder symptoms (Startup et al., 2013; Sternheim et al., 2012). Earlier studies have shown that eating disorder symptoms correlated significantly with worry (Sternheim et al., 2012), and rumination (Startup et al., 2013). The present study supports the findings related to the association between eating disorder and
Methodological limitations of the study must be taken into consideration when interpreting the findings. First, the data is based on selfreport, which is a limitation. However, the questionnaires in this study are considered as valid and reliable instruments (Rø et al., 2010; Wells & Cartwright-Hatton, 2004). Diagnostic interviews could have been applied for a thorough screening of eating disorder diagnosis, but the validity of the diagnoses was not considered a large problem, considering all participants in the clinical group were included based on their current status as an eating disorder patient in a specialized eating disorder clinic. Second, casual inferences cannot be made due to the crosssectional design of the study, so further research is needed to see whether change in metacognitions will result in a reduction of eating disorder symptoms, as implicated by the S-REF model (Wells & Matthews, 1996). Third, the results could be affected by differences based on how long the participants in the clinical sample had undergone treatment, which should be documented in further investigations. Recovery from eating disorder often takes a long time (Keel & Brown, 2010). Even though the patients in the present study were currently in treatment and it may be reasonable to assume that they would still suffer from eating disorder symptoms to a varying degree. Fourth, the control groups were collected as an Internet survey which included a self-reported history of eating or psychiatric problems. The representativeness of the control groups can therefore be questioned, but the groups with clinical or self-reported history of eating disorder problems scored significantly higher on EDE-Q than the other control groups. There is a possibility that including participants from the internet could bias the sample in that people who are especially interested in eating disorders are recruited. The findings support the categorization of groups in this study as appropriate. This is further supported by the scores on the EDQ indicating a clinical level of eating disorder pathology. Finally, the clinical sample is relatively small, so further studies using larger sample sizes are therefore needed. Future studies should also control for psychiatric comorbidity and time in treatment for further exploration of the role of metacognition. 4.4. Clinical implications and conclusions Understanding the pathological processes in eating disorders is important for developing useful theoretical models and an effective treatment. The current study indicates that metacognition may be a very interesting factor worthy of further studies in eating disorders, and it is also in line with earlier findings related to the association between metacognition and eating disorder symptoms. The findings further underline metacognition as identifying transdiagnostic processes relevant for several disorders. Given the effects found for MCT for other disorders (e.g. Normann, van Emmerik, & Morina, 2014), the results in the paper indicate that developing a specific metacognitive model for eating disorders and test the effect of metacognitive therapy (Wells, 2009) to reduce worry, rumination, threat monitoring and ineffective coping strategies when treating eating disorders may be a very interesting path. Role of funding sources There were no funding sources for this study.
Contributors Olstad and Hagen designed the study. Olstad collected the data from the clinical group, and Solem collected the data from the control groups. Olstad, Solem & Hjemdal conducted the statistical analyses. Olstad wrote the first draft of the manuscript, and all the authors have contributed to the final version and have approved the final manuscript.
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S. Olstad et al. / Eating Behaviors 16 (2015) 17–22
Conflict of interest All authors declare they have no conflict of interest.
Acknowledgments The authors wish to thank the Regional Department for Eating Disorders (RASP), Oslo University Hospital and the Regional Competence Center for Eating Disorders (RKSF), at Stjørdal and Levanger in Norway for participating in the study.
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