Metacognitive and metamemory beliefs in the development and maintenance of posttraumatic stress disorder

Can metacognition increase trauma sufferers’ risk for developing and maintaining posttraumatic stress disorder (PTSD)? We assessed the role of a range of cognitive and metacognitive belief domains—including meta-memory—in PTSD symptoms. Adult participants reported their existing meta/cognitions and lifetime exposure to trauma, then twelve weeks later, they reported meta/cognitions and PTSD symptoms in relation to new trauma exposure since the initial assessment. Participants with more PTSD symptoms held more problematic metacognitions than participants with fewer distress symptoms. Moreover, people who endorsed maladaptive metacognitions before trauma exposure were more likely to experience symptoms of PTSD after exposure. Metacognition predicted the maintenance of elevated PTSD symptoms over the twelve-week delay. Our findings support the metacognitive model of PTSD and highlight the importance of meta-memory, an understudied factor in PTSD research. METACOGNITION, META-MEMORY AND PTSD 3 Metacognitive and Meta-Memory Beliefs in the Development and Maintenance of Posttraumatic Stress Disorder Exposure to a sudden or sustained stressful experience can lead to psychological problems such as posttraumatic stress disorder (PTSD). Hallmark symptoms of PTSD include repeated and unwanted re-experiencing of the event, negative alterations in arousal, reactivity, cognition and mood, and active avoidance of trauma reminders (American Psychiatric Association, 2013). Yet, attesting to human resilience, not all trauma-exposed people develop PTSD (Lee, 2006). Determining why some trauma-exposed people develop serious psychopathology when others do not is of critical clinical significance. Recently, metacognition—beliefs about thinking that guide our thinking and coping—has received attention for its role in PTSD (Wells, 2000). PTSD sufferers who endorse maladaptive metacognitive beliefs post-trauma tend to exhibit more PTSD symptoms (e.g., Roussis & Wells, 2006). However, research to date has not examined the role metacognition might play in trauma reactions over time. Here, we examined whether dysfunctional metacognition pretrauma predicted PTSD symptomatology post-trauma, and whether metacognitive beliefs predicted the maintenance of elevated PTSD symptom levels over time. Wells’ (2000; Wells & Sembi, 2004) metacognitive model focuses on how people’s metacognitive beliefs can lead to PTSD. It stipulates that intrusions, startle responses and increased arousal are normal responses to trauma, forming part of a self-righting, reflexive adaptation process (RAP) that initiates automatically and determines adjustment and recovery. The RAP’s goal is to simulate plans for future threats. Thus, symptoms should subside once a satisfactory plan is established. However, metacognitive beliefs that encourage dysfunctional thinking styles or maintain focus on danger or the person’s unsatisfactory reactions to trauma—worry/rumination, thought suppression, threat METACOGNITION, META-MEMORY AND PTSD 4 monitoring—can obstruct the RAP and thus interfere with spontaneous recovery from trauma (Wells & Sembi, 2004). Researchers have investigated a range of maladaptive cognitive and metacognitive beliefs trauma-exposed people hold. We know people who negatively appraise their traumatic experience are at increased risk of pathology (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) and people who interpret their intrusive memories negatively are less able to overcome their posttraumatic symptoms (e.g., Ehlers, Mayou, & Bryant, 1998; Halligan, Michael, Clark, & Ehlers, 2003). Recent evidence suggests that training people to adopt a positive appraisal style regarding their ability to appropriately respond to trauma led to fewer analogue symptoms (Woud, Holmes, Postma, Dalgleish & Mackintosh, 2012). Moreover, Kleim et al. (2013) found that changes in dysfunctional trauma-related appraisals led to decreased PTSD symptoms among PTSD patients who received trauma-focused cognitive behavior therapy. Indeed, people who hold maladaptive beliefs pre-trauma may be predisposed to develop PTSD. Bryant and Guthrie (2005) found that trainee firefighters with a pre-existing tendency for negative self-appraisal—but not cognition concerning self-blame or the world as unsafe—were more symptomatic six months later. These results suggest that studying people’s cognition—and perhaps their metacognition—pre-trauma may help identify people most at risk for PTSD symptomatology. Indeed, Bennett and Wells (2010) found student nurses who endorsed negative metamemory beliefs (e.g., “having gaps in memory of the event means I am not normal”) were more likely to exhibit PTSD symptoms after a distressing event during their training. Moreover, such beliefs predicted PTSD better than objective indicators of memory problems in participants’ recall narratives. These data suggest that metacognitive beliefs about memorial problems may be an important area for further research. METACOGNITION, META-MEMORY AND PTSD 5 In summary, extant research demonstrates that dysfunctional meta/cognition may render people more vulnerable to increased PTSD symptomatology. Does metacognition also play a role in maintaining posttraumatic stress? Some studies show that post-trauma cognition independently predicts PTSD when measured between several months and one-year post trauma (e.g., Ehlers et al., 1998; Halligan et al., 2003), and, in children, mediates the relationship between initial and longer-term PTSD symptoms (Meiser-Stedman, Dalgleish, Glucksman, Yule & Smith, 2009). However, to our knowledge, no study has investigated whether metacognition contributes to the maintenance of persistent PTSD symptoms in adults over time. The Present Study We investigated the role of cognitive and metacognitive factors in predicting and maintaining PTSD among a non-clinical adult population. Even short research timeframes can capture a high prevalence of trauma in non-clinical populations (e.g., eight weeks; Frazier et al., 2009). However, to increase the likelihood that we would capture trauma, we assessed participants over twelve-weeks. We measured participants’ trauma-related cognition, metacognition and PTSD symptoms preand postany recent trauma exposure. Our aims were threefold. First, we examined the cross-sectional relationship between a range of cognitive and metacognitive belief domains—including positive and negative meta-memory beliefs—and PTSD reactions to traumatic events. Second, we examined whether pre-existing metacognitive beliefs (T1) increased PTSD symptomatology after trauma (T2). Third, we investigated whether metacognition predicted the maintenance of elevated PTSD symptom