Metacognitions, intolerance of uncertainty and worry: An investigation in adolescents

Modeling and controlling the body in maladaptive ways: an active inference perspective on non-suicidal self-injury behaviors

A significant number of persons engage in paradoxical behaviors, such as extreme food restriction (up to starvation) and non-suicidal self-injuries, especially during periods of rapid changes, such as adolescence. Here, we contextualize these and related paradoxical behavior within an active inference view of brain functions, which assumes that the brain forms predictive models of bodily variables, emotional experiences, and the embodied self and continuously strives to reduce the uncertainty of such models. We propose that not only in conditions of excessive or prolonged uncertainty, such as in clinical conditions, but also during pivotal periods of developmental transition, paradoxical behaviors might emerge as maladaptive strategies to reduce uncertainty-by "acting on the body"- soliciting salient perceptual and interoceptive sensations, such as pain or excessive levels of hunger. Although such strategies are maladaptive and run against our basic homeostatic imperatives, they might be functional not only to provide some short-term reward (e.g. relief from emotional distress)-as previously proposed-but also to reduce uncertainty and possibly to restore a coherent model of one's bodily experience and the self, affording greater confidence in who we are and what course of actions we should pursue.

The Association of Child Abuse Experiences and Intolerance of Uncertainty in Young Adults

Objective: Drawing upon the identity disruption model, we investigated the association between child abuse experiences (emotional, physical, and sexual) and intolerance of uncertainty. We also addressed demographic differences in uncertainty intolerance in this study. Methods: Using online survey questionnaires, we collected data from a sample of 302 young adults in Turkey. The data were analyzed using confirmatory factor analysis, structural equation modeling, one-way analysis of variance, and independent samples t-test. Results: The results showed that of the three types of child abuse analyzed, only emotional abuse was significantly and positively associated with intolerance of uncertainty. In contrast, age was negatively associated with intolerance of uncertainty. Regarding demographic differences, we found that the level of intolerance of uncertainty differed based on young adults' gender, psychiatric diagnosis, and education. Specifically, our findings indicated that intolerance of uncertainty is significantly higher in females compared to males. It is also significantly higher in young adults with a diagnosis for psychiatric disorders than those without. Moreover, intolerance of uncertainty is significantly higher in young adults who have a high school graduate degree than their undergraduate and graduate counterparts. We discussed how child abuse is associated with heightened intolerance of uncertainty in young adulthood as well as why demographic differences may exist in uncertainty intolerance. Conclusions: The present study expanded the existing research on the psychological consequences of childhood abuse experiences by linking child abuse to intolerance of uncertainty. Particularly, exposure to emotional abuse in early life can be a risk factor to cope with uncertainty in later life.

COVID-19 associated psychological symptoms in Turkish population: A path model

We investigated the mediator roles of risk factors (intolerance of uncertainty, negative metacognition, and negative prospections) and protective factors (positive prospections and psychological resilience) together on the link between COVID-19-related feelings and behaviors, thoughts, and precautions taken and psychological symptoms with an integrative approach in Turkey. The online sample consisted of Turkish adults. The results of path analyses indicated that feelings and behaviors related to COVID-19, thoughts about COVID-19, and precautions taken related to COVID-19 are significantly associated with intolerance of uncertainty. Intolerance of uncertainty is significantly associated with negative metacognition, negative and positive prospections, psychological symptoms, and psychological resilience. Negative metacognition, negative and positive prospections, and psychological resilience are significantly associated with psychological symptoms. Mediation analysis demonstrated that intolerance of uncertainty significantly mediated the relationship between feelings and behaviors related to COVID-19, thoughts about COVID-19, and precautions taken related to COVID-19 and negative metacognition, psychological resilience, positive and negative prospections, and psychological symptoms. Lastly, negative metacognition, psychological resilience, positive and negative prospections significantly mediated the relationship between intolerance of uncertainty and psychological symptoms. Implications for mental health providers are discussed.

The Association between Metacognitions and Worry: The Mediator Role of Experiential Avoidance Strategies

Although experiential avoidance is emphasized as an underlying factor for persevering worry, limited empirical attempt exists to integrate this concept with cognitive models explaining pathological worry. Therefore, the current study aims to investigate the mediator role of different experiential avoidance strategies in the relationship between metacognitions and worry-related symptoms. The study was conducted with a community sample consisting of 563 volunteer participants (405 females, 158 males) whose ages ranged between 18 and 40 (M = 25.56, SD = 4.72). Online data collection of self-report measures including demographic information form, Metacognitions Questionnaire-30, Multidimensional Experiential Avoidance Questionnaire, and Penn State Worry Questionnaire was applied. The results of the hierarchical regression analysis revealed that experiential avoidance predicted worry beyond metacognition. In addition, particular avoidant strategies, aversion/avoidance, procrastination, distraction, and distress endurance explained the associations between positive and negative metacognitive beliefs and worry. Current findings point to different avoidant strategies that might play a role in the intensification and maintenance of worry and suggest the benefits of incorporating acceptance and commitment-based interventions with metacognitive therapy for better therapeutic outcomes.

A cross-lagged panel model for testing the bidirectional relationship between depression and smartphone addiction and the influences of maladaptive metacognition on them in Chinese adolescents

AIMS

Despite the high prevalence of both depression and smartphone addiction among Chinese adolescents, research examining their bidirectional relationship has been limited. Moreover, longitudinal research regarding the influence of maladaptive metacognitive beliefs on smartphone addiction is scarce. This 6-month longitudinal study aimed to address these research gaps by testing a cross-lagged panel model of maladaptive metacognition, depression, and smartphone addiction.

METHODS

Four hundred and fifty-nine Chinese high school students voluntarily completed an anonymous questionnaire at baseline, and 313 of them (36.1% male; age = 14 to 18; M = 16.88, SD = 0.62) completed the same questionnaire at follow-up.

RESULTS

Positive correlations were shown among depression, smartphone addiction, and maladaptive metacognition at both waves (r = 0.16 to 0.57, p < .01). The results of the cross-lagged analysis demonstrated only the prospective effect of depression on smartphone addiction (β = 0.18, p < .001) but not vice versa. Moreover, maladaptive metacognition assessed at baseline significantly predicted subsequent depression (β = 0.14, p < .01) but not smartphone addiction (p>.05). Additional path analysis showed a significant indirect effect of baseline maladaptive metacognition (0.099 [95% CI = 0.042, 0.183]) on subsequent smartphone addiction, via depression.

CONCLUSIONS

Findings of this study showed that the relationship between depression and smartphone addiction was unidirectional rather than bidirectional among Chinese adolescents. Specifically, depression predicted smartphone addiction, while maladaptive metacognition predicted depression. Depression also mediated the relationship between maladaptive metacognition and smartphone addiction. The findings suggest that incorporating metacognition and depression interventions into smartphone addiction prevention designs for adolescents may be beneficial.

Therapist-guided online metacognitive intervention for excessive worry: a randomized controlled trial with mediation analysis

Previous studies have found an association between excessive worrying and negative beliefs about worry. It is unclear if change in these beliefs mediate worry reduction. This study aimed to examine (1) if a simplified online metacognitive intervention can reduce worry, (2) whether changes in negative beliefs about worry mediate changes in worry severity, and (3) moderated mediation, i.e., if the mediating effect is more pronounced in individuals with a high degree of negative beliefs about worry at baseline. Adult excessive worriers (N = 108) were randomized to 10-weeks of the online metacognitive intervention (MCI) aimed at reducing negative beliefs about worry, or to wait-list (WL). Outcomes, mediation, and moderated mediation were examined via growth curve modelling. Results indicated a significant reduction in the MCI group (d = 1.6). Reductions in negative beliefs about worry and depressive symptoms separately mediated changes in worry severity during the intervention, but in a multivariate test only the former remained significant. Sensitivity analysis indicated that the hypothesized mediation was robust to possible violations of mediator-outcome confounding. The moderated mediation hypothesis was not supported. The results from this randomized trial add to the growing literature suggesting that negative beliefs about worry play a key role in worry-related problems. ClinicalTrials.gov Identifier: NCT03393156.

A longitudinal examination of the interpersonal fear avoidance model of pain: the role of intolerance of uncertainty

Youth with chronic pain and their parents face uncertainty regarding their diagnosis, treatment, and prognosis. Given the uncertain nature of chronic pain and high comorbidity of anxiety among youth, intolerance of uncertainty (IU) may be critical to the experience of pediatric chronic pain. This study longitudinally examined major tenets of the Interpersonal Fear Avoidance Model of Pain and included parent and youth IU as key factors in the model. Participants included 152 youth with chronic pain (Mage = 14.23 years; 72% female) and their parents (93% female). At baseline, parents and youth reported on their IU and catastrophic thinking about youth pain; youth reported on their fear of pain, pain intensity, and pain interference; and parents reported on their protective responses to child pain. Youth reported on their pain interference 3 months later. Cross-lagged panel models, controlling for baseline pain interference, showed that greater parent IU predicted greater parent pain catastrophizing, which, in turn, predicted greater parent protectiveness, greater youth fear of pain, and subsequently greater youth 3-month pain interference. Youth IU had a significant indirect effect on 3-month pain interference through youth pain catastrophizing and fear of pain. The results suggest that parent and youth IU contribute to increases in youth pain interference over time through increased pain catastrophizing, parent protectiveness, and youth fear of pain. Thus, parent and youth IU play important roles as risk factors in the maintenance of pediatric chronic pain over time and may be important targets for intervention.

Maladaptive metacognitive beliefs mediated the effect of intolerance of uncertainty on depression

Both elevated intolerance of uncertainty (IU) and maladaptive metacognitive beliefs (MBs) were associated with depression. However, the relationship between MBs and IU in clinical depression is unclear. The current study aimed to investigate the putative impairment of MBs and IU in major depressive disorder (MDD) and explore the relationship between these two factors with depressive symptoms. Metacognition Questionnaire-30 Items (MCQ-30), Intolerance of Uncertainty Scale-Short Form (IUS-12) and clinical rating scales were administered to 53 patients with MDD and 56 healthy controls (HCs). Stepwise regressions were performed to explore independent contributions of MBs and IU on depression. Mediation analysis was used to examine associations among variables. Patients with MDD reported higher IUS-12 and MCQ-30 scores than HCs. Stepwise regressions revealed a unique contribution of negative MBs concerning the consequences of not controlling thoughts (MCQ-NC) on depression symptoms while controlling the effects of age, gender, anxiety symptoms and IU. MCQ-NC and negative MBs concerning the uncontrollability and danger of negative thinking (MCQ-NEG) completely mediated the effects of IU on depression and anxiety symptoms. Our results provided clear evidence that maladaptive negative MBs are directly associated with depression symptoms, and mediated the effect of IU on depression and anxiety symptoms, suggesting that IU and MBs influence clinical symptoms in a hierarchical manner.

Potentially Prolonged Psychological Distress from Postponed Olympic and Paralympic Games during COVID-19-Career Uncertainty in Elite Athletes

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on the world of sports due to periods of home quarantine, bans against public gatherings, travel restrictions, and a large number of postponed or canceled major sporting events. The literature hitherto is sparse, but early indications display signs of psychological impact on elite athletes due to the pandemic. However, beyond acute effects from lockdown and short-term interrupted athletic seasons, the postponed and still uncertain Olympic and Paralympic Games may represent a major career insecurity to many athletes world-wide, and may lead to severe changes to everyday lives and potentially prolonged psychological distress. Given the long-term perspective of these changes, researchers and stakeholders should address mental health and long-term job insecurity in athletes, including a specific focus on those with small financial margins, such as many female athletes, parasports athletes, athletes in smaller sports, and athletes from developing countries. Implications and the need for research are discussed.

Intolerance of uncertainty in youth: Psychometrics of the Intolerance of Uncertainty Index-A for Children

Intolerance of uncertainty (IU) is a cognitive vulnerability for pathological anxiety. The current study adapted the Intolerance of Uncertainty Index-A for Children (IUI-A-C), and created a single-item Intolerance of Uncertainty Clinician-Rated Index (IUCR), both of which assess a youth's general inability to endure uncertainty. Psychometric properties of these two measures were evaluated. Participants were 146 youth aged 7-17 years seeking treatment for anxiety. The IUI-A-C evidenced individual item performance (i.e., correlations between each item and the total remainder score > .40, ps <.001), internal consistency, convergent validity with the IUCR and self-report measures of anxiety and functional impairment, divergent validity with ADHD severity, and retest reliability with a mean interval of over four weeks. The IUCR also evidenced convergent validity with the IUI-A-C and self-report measures of anxiety and functional impairment and divergent validity with ADHD severity. The IUI-A-C predicted composite principal diagnosis severity but did not predict composite GAD diagnosis severity. The IUI-A-C and IUCR have utility as measures of IU in youth. The role of IU in specific anxiety disorders and future research are discussed.

Individual differences in anger and displaced aggression: The role of metacognitive beliefs and anger rumination

Metacognitive model is a theoretical approach aimed to explain emotion dysregulation and others emotion-related issues, such anger, and aggressive behavior. From this model, people having higher maladaptive metacognitive beliefs (e.g., "I can't control my thoughts") are more likely to activate and maintain anger rumination and, in turn, to experience higher levels of anger and to act aggressively. Preliminary evidence shows the role of metacognitive beliefs on anger rumination and anger levels, whereas no studies have examined its association with aggressive behavior. This study first examined the associations between metacognitive beliefs, anger rumination, anger levels, and the propensity to engage in displaced aggression, and second, the mediation role of anger rumination in the relations among metacognitive beliefs and anger and displaced aggression. Participants were 947 students and non-students from general population recruited in two different countries (Australia and Spain). Correlational analyses revealed a similar pattern of results in the Australian and Spanish sample, with participants having dysfunctional metacognitive beliefs also showing higher anger rumination, higher levels of anger and a higher tendency to act aggressively. Structural equation analyses revealed the associations of metacognitive beliefs with anger levels and displaced aggression was fully mediated by anger rumination in both samples. These results suggest that metacognitive beliefs should be considered in comprehensive models and in the therapy of anger problems and aggression.

Factorial validity and measurement invariance of the uncertainty response scale

This study presents the adaptation of the Uncertainty Response Scale (Greco & Roger, Pers. Individ. Differ, 31:519-534, 2001) to Portuguese. This instrument was administered to a non-clinical community sample composed of 1596 students and professionals, allowing a thorough validity and invariance analysis by randomly dividing participants into three subsamples to perform: an exploratory factor analysis (sample one: N = 512); a preliminary confirmatory factor analysis to identify the final solution for the scale (sample two: N = 543); and the confirmatory factor analysis (sample three: N = 541). Samples two and three were also used for multi-group analysis to assess measurement invariance, invariance across gender, sociocultural levels, and students versus active professionals. Results showed the scale reflects the original factorial structure, as well as good internal consistency and overall good psychometric qualities. Invariance results across groups reached structural invariance which provides a confident invariance measurement for this scale, while invariance across gender and sociocultural levels reached metric invariance. Accordingly, differences between these groups were explored, by comparing means with multi-group analysis to establish the scale's sensitivity toward social vulnerability, by demonstrating the existence of statistically significant differences regarding gender and sociocultural levels on how individuals cope with uncertainty, specifically in terms of emotional strategies, as a self-defeating strategy. Thus, females scored higher on emotional uncertainty, as well as low sociocultural levels, compared with higher ones. Therefore, it is proposed that this scale could be a sound alternative to explore strategies for coping with uncertainty, when considering social, economic, or other environmental circumstances that may affect them.

But what will the results be?: Learning to tolerate uncertainty is associated with treatment-produced gains

The current study examined the association between changes in intolerance of uncertainty (IU) and treatment outcomes for anxious youth. Participants were youth ages 7 to 17 who received cognitive behavioral therapy for anxiety (N = 73). Youth and their primary caregivers completed a diagnostic interview and self- and parent-report measures at pre- and post-treatment, including the Intolerance of Uncertainty Scale for Children (IUS-C/P; Przeworski, 2006), the Coping Questionnaire (CQ-C/P; Kendall, 1994) and the Multidimensional Anxiety Scale for Children (MASC-C/P; March et al., 1997). Hierarchical regression analyses evaluated the role of change in IU (the IUS-C/P) in predicting changes in functional impairment, coping efficacy, and anxiety severity post-treatment, controlling for demographic variables (age and gender), and baseline levels of IU, anxiety severity, functional impairment, and coping efficacy. Results demonstrated that treatment was associated with improvements across child-, parent- and clinician-report, and decreased IU from pre- to post-treatment was associated with (a) decreased functional impairment, (b) increased coping efficacy and (c) decreased anxiety severity. The findings indicate that a greater reduction in IU over treatment is associated with better outcomes in children and adolescents with anxiety across informants, suggesting the possibility that an increased focus on IU during treatment for youth anxiety may improve treatment outcomes. Future research should assess the causality of this relationship.

Assessing metacognitive beliefs about worry: validation of German versions of the Why Worry Scale II and the Consequences of Worry Scale

Background

Metacognitive beliefs have been proposed to play a key role in initiating and maintaining worry. The Why Worry-Scale-II (WW-II) and Consequences of Worry Scale (COWS) are self-report questionnaires assessing positive and negative metacognitive beliefs. The main goal of this study was to validate German versions of these two questionnaires.

Method

N = 603 participants completed a questionnaire battery, including the two self-report measures of metacognitive beliefs. We conducted confirmatory factor analyses, calculated internal consistencies, and examined convergent and divergent validity. In addition, the questionnaires’ power in predicting worry, repetitive negative thinking (RNT) and generalized anxiety disorder (GAD) symptoms were investigated.

Results

The factor structure of the original versions could be replicated for both measures. Furthermore, the translated questionnaires demonstrated excellent internal consistency and evidence of convergent and divergent validity. Importantly they also possessed predictive power in explaining worry, RNT and GAD symptoms, even over and above the Metacognitions Questionnaire-30 (MCQ-30) as the current gold standard.

Conclusions

Overall, our findings suggest that the WW-II and COWS show solid psychometric properties and are useful in measuring metacognitive beliefs independently from the MCQ-30.

Intolerance of Uncertainty, anxiety, and worry in children and adolescents: A meta-analysis

BACKGROUND

Intolerance of uncertainty (IU) has been implicated in the development and maintenance of worry and anxiety in adults and there is an increasing interest in the role that IU may play in anxiety and worry in children and adolescents.

METHOD

We conducted a systematic review and meta-analysis to summarize existing research on IU with regard to anxiety and worry in young people, and to provide a context for considering future directions in this area of research. The systematic review yielded 31 studies that investigated the association of IU with either anxiety or worry in children and adolescents.

RESULTS

The meta-analysis showed that IU accounted for 36.00% of the variance in anxiety and 39.69% in worry. Due to the low number of studies and methodological factors, examination of potential moderators was limited; and of those we were able to examine, none were significant moderators of either association. Most studies relied on questionnaire measures of IU, anxiety, and worry; all studies except one were cross-sectional and the majority of the studies were with community samples.

LIMITATIONS

The inclusion of eligible studies was limited to studies published in English that focus on typically developing children.

CONCLUSIONS

There is a strong association between IU and both anxiety and worry in young people therefore IU may be a relevant construct to target in treatment. To extend the existing literature, future research should incorporate longitudinal and experimental designs, and include samples of young people who have a range of anxiety disorders.

Negative metacognitive beliefs moderate the influence of perceived stress and anxiety in long-term anxiety

Metacognitive theory of emotional disorders (Matthews and Wells, 1994; Wells, 2009) suggests that metacognitive beliefs can play a causal role in the development and maintenance of anxiety symptoms. In this prospective study, we examine the relationships between metacognitive beliefs, perceived stress and anxiety in a non-clinical sample. Participants were 135 undergraduate students who completed a battery of questionnaire at two time points (3- months apart). Results revealed metacognitive beliefs do not predict long-term anxiety independently. However, moderation analyses demonstrated negative beliefs about uncontrollability and danger prospectively moderated the relationship between perceived stress and Time 2 anxiety. Negative metacognitive beliefs also interacted with baseline anxiety to predict the change in anxiety symptoms. The results confirm metacognitions play a causal role in anxiety and have implications for cognitive models and the treatment of anxiety.

Thinking about worry: Investigation of the cognitive components of worry in children

BACKGROUND

Despite being extensively studied in adults, investigation of worry and it's associated cognitive variables remains in its infancy in paediatric samples.

AIMS

This study aimed to investigate 1) whether the child cognitive variables of intolerance of uncertainty (IU), positive beliefs about worry (PBW), negative beliefs about worry (NBW), negative problem orientation (NPO) and cognitive avoidance (CA) were associated with child worry, 2) whether parental worry and cognitive variables were associated with child worry, 3) whether the relationship between child and parent worry was mediated by child cognitive variables and 4) whether the relationships between specific parent cognitive factors and child worry were mediated by specific child cognitive factors.

METHOD

Participants were 114 children plus one of their parents. Parents and children completed questionnaires assessing each of the five cognitive variables and worry.

RESULTS

When examined together, child NBW and CA significantly predicted child worry. Parent worry, IU and CA were significantly and positively related to child worry. The relationship between parent worry and child worry was mediated by child NBW and CA. The relationship between parent IU, NPO and CA and child worry was mediated by child IU, NPO and CA respectively.

CONCLUSIONS

Child NBW and CA may be particularly important to child worry and may represent potential treatment targets. Parental worry and cognitive variables may play a role in the development and / or maintenance of child worry.

Concurrent and prospective associations of intolerance of uncertainty with symptoms of prolonged grief, posttraumatic stress, and depression after bereavement

This study examined associations of Prospective IU and Inhibitory IU with symptom-levels of Prolonged Grief Disorder (PGD), Posttraumatic Stress-Disorder (PTSD), and depression in a sample of bereaved individuals. Specifically, 265 bereaved individuals completed measures of IU, PGD, PTSD, and depression in the first year after the death of a loved one; 134 participants again completed symptom-measures six months later. Cross-sectional analyses showed that Inhibitory IU (but not Prospective IU) was positively associated with symptom-levels of PTSD and depression (but not PGD), even when controlling for neuroticism, worry, and rumination. Prospective analyses showed that Prospective IU (but not Inhibitory IU) at baseline, predicted PGD severity six months later (but not PTSD or depression at follow-up) while controlling for baseline symptom-levels. The findings support the notion that IU is a vulnerability factor for different emotional problems, including those developing after the death of a loved one. Clinical implications of these findings are discussed.

Do Metacognitions and Intolerance of Uncertainty Predict Worry in Everyday Life? An Ecological Momentary Assessment Study

Cognitive models of generalized anxiety disorder (GAD) suggest that excessive worry is due to positive and negative metacognitive beliefs and/or intolerance of uncertainty. Empirical support mainly derives from cross-sectional studies with limited conclusiveness, using self-report measures and thereby possibly causing recall biases. The aim of the present study therefore was to examine the power of these cognitive variables to predict levels of worry in everyday life using Ecological Momentary Assessment (EMA). Metacognitions and intolerance of uncertainty were assessed using well-established self-report questionnaires in 41 nonclinical participants who subsequently completed ratings on worry intensity and burden on a portable device for 1week at seven times a day once every 2hours. Results showed significant associations of negative metacognitive beliefs and intolerance of uncertainty, but not positive metacognitive beliefs, with worry in everyday life. In multilevel regression analyses, a substantial proportion of variance of everyday worry could be accounted for by negative metacognitions over and above trait worry and daily hassles. Intolerance of uncertainty likewise emerged as a valid predictor when tested in isolation, but did not explain additional variance once negative metacognitions were controlled. The findings support current cognitive models of excessive worry and highlight the role of negative metacognitions. By using EMA to assess levels of worry in everyday life, they extend earlier findings focusing exclusively on retrospective questionnaire measures.