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Metacognitions across the continuum of drinking behaviour
Personality and Individual Differences 49 (2010) 425–429
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Personality and Individual Differences journal homepage: www.elsevier.com/locate/paid
Metacognitions across the continuum of drinking behaviour Marcantonio M. Spada a,b,*, Adrian Wells c,d a
London South Bank University, London, UK North East London NHS Foundation Trust, London, UK c University of Manchester, Manchester, UK d Department of Psychology, NTNU, Trondheim, Norway b
a r t i c l e
i n f o
Article history: Received 19 February 2010 Received in revised form 6 April 2010 Accepted 14 April 2010 Available online 10 May 2010 Keywords: Alcohol dependence Metacognitions about alcohol use Negative emotion Problem drinking
a b s t r a c t Research has indicated that metacognitions are involved in problem drinking. To date, however, no study has investigated the presence of metacognitions about alcohol use in alcohol dependent drinkers. A sample of alcohol dependent drinkers (n = 48), problem drinkers (n = 69), and non-problem drinkers (n = 70) completed self-report measures of positive and negative metacognitions about alcohol use, negative emotion, and drinking behaviour. Results indicated that alcohol dependent drinkers scored higher than non-problem drinkers on positive metacognitions about emotional self-regulation. Alcohol dependent drinkers also scored higher than both problem drinkers and non-problem drinkers on positive metacognitions about cognitive self-regulation, negative metacognitions about uncontrollability, and negative metacognitions about cognitive harm. Furthermore on positive metacognitions about cognitive self-regulation problem drinkers scored higher than non-problem drinkers. A logistic regression analysis indicated that negative metacognitions about uncontrollability and depression were significant predictors of classification as an alcohol dependent drinker. These results are consistent with a metacognitive conceptualization of problematic drinking behaviour and further add to our understanding of the role of specific metacognitions across the continuum of drinking behaviour. Ó 2010 Elsevier Ltd. All rights reserved.
1. Introduction According to the metacognitive theory of psychological disorders (Wells & Matthews, 1994, 1996; Wells, 2000) disturbance is maintained by a style of cognitive-affective management that involves perseverative thinking (e.g. rumination and worry), threat monitoring, avoidance, and thought suppression. This style is termed the Cognitive Attentional Syndrome (CAS) and is problematic because: (1) it causes negative thoughts and emotions to persist; and (2) it fails to modify dysfunctional self-beliefs, increasing the accessibility of negative information (Wells, 2000). The activation and persistence of the CAS in response to affective (e.g. low mood) and cognitive (e.g. intrusive thoughts) triggers is dependent on metacognitions. Metacognitions can be defined as ‘‘stable knowledge or beliefs about one’s own cognitive system, and knowledge about factors that affect the functioning of the system; the regulation and awareness of the current state of cognition, and appraisal of the significance of thought and memories” (Wells, 1995, p. 302). Metacognitions are divided into two broad sets: (1) positive beliefs about coping strategies that impact on mental
* Corresponding author at: Department of Mental Health and Learning Disabilities, Faculty of Health and Social Care, London South Bank University, United Kingdom. Tel.: +44 0 20 7815 7815. E-mail address: [email protected] (M.M. Spada). 0191-8869/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2010.04.011
states such as ‘‘smoking will help me get things sorted out in my mind” or ‘‘worrying will help me solve the problem”; and (2) negative beliefs concerning the significance, controllability, and danger of particular types of thoughts, e.g. ‘‘It is bad to think thought X” or ‘‘I need to control thought X”. Metacognitions have been found to be associated with a wide array of psychological and behavioural problems, including: depression (Papageorgiou & Wells, 2003), hypochondriasis (Bouman & Meijer, 1999), nicotine dependence (Nikcˇevic´ & Spada, 2008, 2010; Spada, Nikcˇevic´, Moneta, & Wells, 2007b), obsessive– compulsive symptoms (Wells & Papageorgiou, 1998), pathological procrastination (Fernie, Spada, Nikcˇevic´, Georgiou, & Moneta, 2009; Spada, Hiou, & Nikcˇevic´, 2006a), pathological worry (Wells & Papageorgiou, 1998), perceived stress (Spada, Nikcˇevic´, Moneta, & Wells, 2008b), post-traumatic stress disorder (Roussis & Wells, 2006), predisposition to auditory hallucinations (Morrison, Wells, & Nothard, 2000), state anxiety (Spada, Mohiyeddini, & Wells, 2008a), and test anxiety (Spada, Nikcˇevic´, Moneta, & Ireson, 2006b). Research by Spada and colleagues (Spada, Caselli, & Wells, 2009; Spada, Moneta, & Wells, 2007a; Spada & Wells, 2005, 2006, 2008, 2009; Spada, Zandvoort, & Wells, 2007c) has found evidence that metacognitions play a key role in drinking behaviour. In an initial test of the hypothesis of whether metacognitions are associated with drinking behaviour in a community sample, Spada
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and Wells (2005) observed a positive association between beliefs about the need to control thoughts and alcohol use that is independent of negative emotion. Spada et al. (2007c), in later research, found evidence that these same beliefs and beliefs relating to lack of cognitive confidence (the evaluation of one’s own cognitive functioning in the presence or absence of objective cognitive deficit) predicted classification as a problem drinker independently of negative emotion. More recently, data from a prospective study found that beliefs about the need to control thoughts predict levels of alcohol use and relapse in problem drinkers (Spada et al., 2009). Finally, in a series of semi-structured interviews aimed at exploring the nature of metacognitions in a sample of problem drinkers Spada and Wells (2006) found that this group held both positive and negative metacognitions about alcohol use. Positive metacognitions about alcohol use (e.g. ‘‘Drinking helps me to control my thoughts”) can be conceptualized as a specific form of alcohol expectancy relating to the use of alcohol as a means of controlling cognition and emotion (Spada & Wells, 2008, 2009). From a metacognitive standpoint such beliefs are thought to play a central role in motivating individuals to engage in alcohol use as a means of cognitive-affective regulation (Spada & Wells, 2008, 2009). Negative metacognitions about alcohol use concern the perception of lack of executive control over behaviour (e.g. ‘‘My drinking persists no matter how I try to control it”) and the negative impact of alcohol use on cognitive functioning (‘‘Drinking will damage my mind”). These beliefs can be respectively conceptualized as a specific level of cognitive self-efficacy and negative alcohol outcome expectancy (Spada & Wells, 2008, 2009). From a metacognitive standpoint such beliefs are thought to play a crucial role in the perpetuation of alcohol use by becoming activated during and following a drinking episode, and triggering negative emotional states and mental regulation strategies that compel a person to drink more (Caselli et al., 2010; Spada & Wells, 2006). Metacognitive theory implies that metacognitions about alcohol use can be usefully distinguished from ordinary cognitive level beliefs (such as alcohol expectancies) and that they will impart additional control over cognition and action. Indeed existing measures of positive alcohol expectancies do not identify beliefs concerning the usefulness of alcohol as a cognitive control and self-regulation tool aimed at problem-solving, thought control, attentional regulation, and self-image control. Furthermore, negative alcohol expectancies differ from negative metacognitions about alcohol use in as much as they primarily assess general negative outcomes arising from alcohol use (e.g. ‘‘I get a hangover”; ‘‘I feel guilty”) rather than beliefs about the perception of lack of executive control over behaviour (e.g. ‘‘My drinking persists no matter how I try to control it”), and the negative impact of alcohol use on cognitive functioning (e.g. ‘‘Drinking will damage my mind”). Consistent with this view, research has demonstrated that metacognitions about alcohol use play an important role in predicting drinking behaviour beyond that of alcohol expectancies (Spada et al., 2007a). To date no study has investigated the role of metacognitions about alcohol use in alcohol dependent individuals. Indeed the key limitation of previous studies in this area was the use of individuals with moderate levels of problem drinking, thus restricting the generalizability of findings only to this sub-group. Another limitation was the lack of analysis of metacognitions about alcohol use in alcohol dependent individuals compared to problem and nonproblem drinkers. The primary aim of the current study was to explore the differences in metacognitions about alcohol use in established alcohol dependent drinkers, problem drinkers, and non-problem drinkers whilst controlling for negative emotion (anxiety and depression). Negative emotion was included as a covariate because research has demonstrated that emotion regulation is a key motive for prob-
lem drinking (e.g. for a review see Baker, Piper, McCarthy, Majeskie, & Fiore, 2004; Khantzian, 1997; Wills & Shiffman, 1985). Research to date suggests that individuals with alcohol dependence should have higher levels of metacognitions about alcohol use than people at risk (e.g. problem drinkers), who in turn should have higher levels than non-problem drinkers. This could present as higher scores on one or both dimensions (positive and negative) of metacognitions about alcohol use. Elevated scores on both positive and negative metacognitions about alcohol use would be most pathological as individuals would be fearful of the impact of alcohol use on cognitive-emotional functioning and its uncontrollability (negative metacognitions) but feel that they must drink in order to control cognition and emotion (positive metacognitions), a situation that would exacerbate negative emotion, contribute to difficulties with mental control and lead to perseveration in alcohol use. Therefore, we predict that individuals with established alcohol dependence should differ from problem drinkers and non-problem drinkers in terms of higher overall scores on both positive and negative metacognitions about alcohol use.
2. Method 2.1. Participants The clinical sample consisted of a consecutive series of 48 patients (9 females) who contacted a Drugs and Alcohol Addiction Clinic in London, United Kingdom, seeking treatment for alcohol dependence. All participants fulfilled the ICD-10 (World Health Organisation, WHO, 2004) diagnostic criteria for alcohol dependence. A general clinical and biochemical screening was performed to exclude severely impaired individuals. For purposes of inclusion in this study the participants were required to speak English and be at least 18 years of age. The mean age of the sample was 42.2 years (SD = 10.8). The participants consumed an average of 144.9 units per week (SD = 66.5) and their mean score on the AUDIT (Babor, de la Fuente, Saunders, & Grant, 1992) was 28.4 (SD = 5.0). The unit of alcohol is adopted in United Kingdom to quantify alcohol intake. It is defined as 10 ml (8 g) of ethanol (ethyl alcohol) and represents the amount of ethanol an average healthy adult can metabolize in an hour. Mean scores on the anxiety and depression sub-scales of the HADS (Zigmond & Snaith, 1983) were 11.6 (SD = 4.3) and 9.6 (SD = 3.7), respectively. Both the problem and non-problem drinking samples were recruited through leaflets and advertisements placed in a variety of occupational settings (e.g. education, finance, and health). For purposes of inclusion in this study the participants were required to speak English, use alcohol regularly (at least once per week), and be at least 18 years of age. The problem drinking sample consisted of 69 individuals (41 females). Participants were included in this group if they scored between 7 and 20 on the AUDIT. A score of 7 on AUDIT is considered an acceptable cut-off point for problem drinking (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). A score of 20 or above is considered a cut-off point for severe alcohol dependence that warrants further diagnostic evaluation (Babor et al., 2001). The mean age of the sample was 30.5 years (SD = 8.0). The participants consumed an average of 28.5 units per week (SD = 19.1). Their mean score on the AUDIT was 10.4 (SD = 2.2). Mean scores on the anxiety and depression sub-scales of the HADS (Zigmond & Snaith, 1983) were 6.9 (SD = 3.6) and 3.0 (SD = 2.1), respectively. The non-problem drinking sample consisted of 70 individuals (57 females). Participants were included in this sub-group if they scored 6 or less on the AUDIT as this is considered to indicate that the individual is not a problem drinker. The mean age of this sample was 36.8 years (SD = 12.5). The participants consumed an average of 11.1 units per week (SD = 7.2). Their
M.M. Spada, A. Wells / Personality and Individual Differences 49 (2010) 425–429
mean score on the AUDIT was 4.0 (SD = 1.3). Mean scores on the anxiety and depression sub-scales of the HADS (Zigmond & Snaith, 1983) were 5.5 (SD = 2.9) and 2.2 (SD = 1.8), respectively. 2.2. Measures 2.2.1. Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). This scale consists of 14 items, 7 assessing anxiety and 7 assessing depression. The anxiety subscale includes items such as: ‘‘I get a sort of frightened feeling as if something horrible is about to happen”. The depression sub-scale includes items such as: ‘‘I feel as if I am slowed down”. Higher scores represent higher levels of anxiety and depression. The majority of studies examining the factor structure of the HADS in both clinical and general populations have identified two dimensions (Mykletun, Stordal, & Dahl, 2001). The intercorrelation of the anxiety and depression sub-scales has been reported to be in the range of .49–.63 with lower correlations reported in studies with healthy samples (Mykletun et al., 2001). Overall, the scale possesses good validity and reliability (Herrmann, 1997; Mykletun et al., 2001; Zigmond & Snaith, 1983). 2.2.2. The Positive Alcohol Metacognitions Scale (PAMS) (Spada & Wells, 2008). PAMS is a 12-item measure developed to assess positive metacognitions about alcohol use. It consists of two factors: (1) positive metacognitions about emotional self-regulation; and (2) positive metacognitions about cognitive self-regulation. Examples of items relating to emotional self-regulation include: ‘‘Drinking reduces my self-consciousness”. Examples of items relating to cognitive self-regulation include: ‘‘Drinking helps me to control my thoughts”. Higher scores represent higher levels of positive metacognitions about alcohol use. PAMS was initially constructed and factor analysed in a community sample (n = 261) and its factor structure was replicated in a clinical sample (n = 80) (Spada & Wells, 2008). 2.2.3. The Negative Alcohol Metacognitions Scale (NAMS) (Spada & Wells, 2008). NAMS is a 6-item measure developed to assess negative metacognitions about alcohol use. It consists of two factors: (1) negative metacognitions about uncontrollability; and (2) negative metacognitions about cognitive harm. Items relating to uncontrollability include: ‘‘My drinking persists no matter how I try to control it”. Items relating to cognitive harm include: ‘‘Drinking will damage my mind”. Higher scores represent higher levels of negative metacognitions about alcohol use. NAMS was initially constructed and factor analysed in a community sample (n = 261) and its factor structure was replicated in a clinical sample (n = 80) (Spada & Wells, 2008). 2.2.4. The Quantity Frequency Scale (QFS) (Cahalan, Cisin, & Crossley, 1969). QFS is a measure of alcohol consumption levels, with items assessing the dimensions of quantity and frequency of alcohol beverages consumed over a period of 30 days. This measure consists of three questions (‘‘have you been drinking any beer/wine/spirits over the last 30 days?”; ‘‘about how often do you consume beer/wine/spirits?”; and ‘‘about how much beer/wine/spirits did you drink on a typical day when you drink beer/wine/spirits?”). These are repeated for each of the major alcohol beverage categories (beer, wine, and distilled spirits). The total scores from the different alcohol beverage categories are then added together and an estimated daily (or weekly) level of alcohol consumption can be computed. This instrument has been extensively used and possesses good validity and reliability (Hester & Miller, 1995).
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2.2.5. The Alcohol Use Disorders Identification Test (AUDIT) (Babor et al., 1992). AUDIT was developed as a screening tool by the World Health Organisation (WHO) for early identification of problem drinkers. AUDIT consists of 10 questions regarding recent alcohol consumption, alcohol dependence symptoms, and alcoholrelated problems. Respondents are asked to choose one of between 3 and 5 statements (per question) that most applies to their use of alcohol beverages over the past year. Responses are scored from 0 to 4 in the direction of problem drinking. The summary score for the total AUDIT ranges from 0, indicating no presence of problem drinking behaviour, to 40 indicating marked levels of problem drinking behaviour and alcohol dependence. A score of 7 on AUDIT is considered an acceptable cut-off point for problem drinking (Babor et al., 2001). A score of 20 or above is considered a cut-off point for severe alcohol dependence (Babor et al., 2001). This instrument has been extensively used and possesses good validity and reliability (Babor et al., 2001). 2.3. Procedure Ethics approval for the study was obtained from a University ethics board and the local National Health Service Trust. The study was described to participants as an investigation of the role of emotion and thought in alcohol use. All participants were informed that data provided in the study would be treated with the strictest confidence and that participation in the research project was entirely voluntary. Following a brief introduction to the project and the granting of informed consent participants were instructed, in written form, to complete the measures in the following order: AUDIT, HADS, PAMS, and NAMS. All participants were debriefed following completion of the measures. The clinical sample completed the questionnaires individually in a room within the clinic. No explicit cues regarding alcohol use or mood were present. The non-clinical samples completed the questionnaires through a dedicated website and in a location of their choice. 3. Results In order to establish if there was an overall effect from the combination of positive and negative metacognitions about alcohol use sub-scales, a multivariate analysis of covariance (MANCOVA) was conducted with the participant group as a fixed factor, and anxiety, depression, gender, and age as covariates. All the positive and negative metacognitions about alcohol use sub-scales were entered as dependent variables. The correlations between the dependent variables and anxiety ranged from .09 to .37 in alcohol dependent drinkers, from .04 to .17 in problem drinkers, and from .21 to .31 in non-problem drinkers. The correlations between the dependent variables and depression ranged from .02 to .32 in alcohol dependent drinkers, from .10 to .26 in problem drinkers, and from .10 to .18 in non-problem drinkers. The MANCOVA revealed a significant effect [Roy’s Largest Root = 3.05, F(2184) = 138.6, p = .0005]. In order to establish group differences on positive and negative metacognitions about alcohol use sub-scales, a series of one-way analyses of covariance with follow-up Bonferroni pairwise comparisons were conducted (see Table 1) with the participant group as a fixed factor, anxiety, depression, age, and gender as covariates, and individual positive and negative metacognitions about alcohol use sub-scales as the dependent variables. These analyses revealed that alcohol dependent drinkers scored higher than non-problem drinkers on positive metacognitions about emotional self-regulation. Alcohol dependent drinkers also scored higher than both problem drinkers and non-problem drinkers on positive metacognitions about cognitive self-regulation, negative metacognitions about uncontrollability,
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M.M. Spada, A. Wells / Personality and Individual Differences 49 (2010) 425–429
Table 1 Adjusted means and standard errors (in parentheses) for positive and negative metacognitions about alcohol use across groups. Metacognitions
Alcohol dependent drinkers (n = 48)
Problem drinkers (n = 69)
Non-problem drinkers (n = 70)
1. Positive metacognitions about emotional selfregulation 2. Positive metacognitions about cognitive selfregulation 3. Negative metacognitions about uncontrollability 4. Negative metacognitions about cognitive harm
20.6 (1.10)a
18.1 (.70)
16.4 (.73)b
12.2 (.71)a
9.5 (.42)b
6.9 (.46)c
8.9 (.35)a
4.3 (.21)b
4.0 (.23)b
9.1 (.42)a
4.9 (.25)b
5.1 (.27)b
Note: means with different superscripts are significantly different; p-values (p 6 .05) have been adjusted according to the Bonferroni rule.
and negative metacognitions about cognitive harm. Furthermore on positive metacognitions about cognitive self-regulation problem drinkers scored higher than non-problem drinkers. In relation to the effects of anxiety, depression, age, and gender significant effects of these covariates were identified only for depression in relation to negative metacognitions about uncontrollability [F(1184) = 8.50, p = .004] and negative metacognitions about cognitive harm [F(1184) = 8.88, p = .003]. Next the data were analyzed using binary logistic regression analysis which is used to find the odds of being in one category or another. In the current study the category was alcohol dependent drinker or problem drinker. Depression, positive metacognitions about cognitive self-regulation, negative metacognitions about uncontrollability, and negative metacognitions about cognitive harm were entered individually as a block. The results for the final equation were as follows: {2 = 133.8, df = 4, p = .0005, with 96.6% of cases correctly classified. Inspection of the final step (presented in Table 2) indicates that negative metacognitions about uncontrollability and depression were significant independent predictors of classification as an alcohol dependent drinker. Metacognitions concerning uncontrollability had the highest odds-ratio demonstrating they conferred the greatest risk among the variables measured in determining the classification as alcohol dependent versus being a problem drinker.
4. Discussion The goal of this study was to establish the contribution of metacognitions to alcohol dependent drinker status and establish whether they differ across the continuum of drinking behaviour. This is the first study to empirically demonstrate that individuals with alcohol dependence report significantly higher scores on metacognitions about alcohol use than problem drinkers and non-problem drinkers. The findings that alcohol dependent drinkers scored higher than non-problem drinkers on positive metacognitions about emo-
tional self-regulation suggest that these beliefs may play a role in the perseveration of harmful alcohol use. The findings that positive metacognitions about cognitive self-regulation differed significantly across the continuum of drinking behaviour suggests that these beliefs may play a role both as initial factors in the transition from a non-problem drinker to problem drinker status, and in the escalation of drinking behaviour to alcohol dependence levels. The finding that only alcohol dependent drinkers scored higher (than both problem and non-problem drinkers) on negative metacognitions about uncontrollability, and negative metacognitions about cognitive harm supports our prediction that dependent drinkers have the highest metacognitions overall. This group may have a particularly problematic combination involving elevated positive and negative metacognitions about alcohol use compared with non-problem drinkers. The results of the regression analysis extends these findings by demonstrating that independently of depression and positive metacognitions about emotional self-regulation, negative metacognitive beliefs about uncontrollability are the strongest predictors of alcohol dependence. The pattern of findings obtained in this study are consistent with patterns observed in studies of other disorders such as generalized anxiety (Wells & Carter, 2001) and depression (Papageorgiou & Wells, 2003) in which negative metacognitions are direct predictors of disorder. The clinical implication of these findings is that metacognitions may be conceptualized and treated in order to reduce the risk of transition from problem drinker to alcohol dependence, and to reduce the risk of relapse. An important possibility is that negative metacognitions about uncontrollability may interfere with engagement in treatment programmes and will need to be targeted in treatment. Metacognitive therapy (Wells, 2008) consists of specific techniques that enable clients to develop more effective ways of relating to thoughts and challenge metacognitions. It remains to be demonstrated if an approach such as this can be useful in the treatment of alcohol problems. This study has several limitations which will have to be addressed by future research. It relies solely on self-report data (this is unavoidable as there are no objective or interview measures of metacognitions about alcohol use). A cross-sectional design was adopted and this does not allow causal inferences. The presence of concurrent psychological disorder (which could account for the observed differences in metacognitions) was not assessed. However controlling for anxiety and depression does provide a degree of confidence in the specificity of the results. Finally the clinical sample was relatively small in size and some participants had received previous treatment which may have exposed them to the identification and exploration of cognitive constructs. However, standard treatment for problem drinking does not typically include the examination of metacognitions assessed here. Thus, the experience of treatment may not be particularly significant in explaining the current findings. Directions for future research include ascertaining further the role of metacognitions in the predisposition towards, and maintenance of, problematic drinking behaviour, as well as considering the influence of drinking behaviour on metacognitions. It would also be interesting to examine whether changes in metacognitions occur during the process of problem
Table 2 Summary statistics for the logistic regression equation predicting alcohol dependence.
Depression Positive metacognitions about cognitive self-regulation Negative metacognitions about uncontrollability Negative metacognitions about cognitive harm Constant
B
S.E.
Wald
df
p
Exp(B)
.91 .11 1.53 .11 15.6
.32 .12 .74 .38 5.08
7.76 .81 4.36 .08 9.53
1 1 1 1 1
.005 .36 .004 .78 .002
2.47 1.11 4.63 .90 .000
M.M. Spada, A. Wells / Personality and Individual Differences 49 (2010) 425–429
drinking treatment, and if so, if they are associated with discontinuation in drinking.
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Contents lists available at ScienceDirect
Personality and Individual Differences journal homepage: www.elsevier.com/locate/paid
Metacognitions across the continuum of drinking behaviour Marcantonio M. Spada a,b,*, Adrian Wells c,d a
London South Bank University, London, UK North East London NHS Foundation Trust, London, UK c University of Manchester, Manchester, UK d Department of Psychology, NTNU, Trondheim, Norway b
a r t i c l e
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Article history: Received 19 February 2010 Received in revised form 6 April 2010 Accepted 14 April 2010 Available online 10 May 2010 Keywords: Alcohol dependence Metacognitions about alcohol use Negative emotion Problem drinking
a b s t r a c t Research has indicated that metacognitions are involved in problem drinking. To date, however, no study has investigated the presence of metacognitions about alcohol use in alcohol dependent drinkers. A sample of alcohol dependent drinkers (n = 48), problem drinkers (n = 69), and non-problem drinkers (n = 70) completed self-report measures of positive and negative metacognitions about alcohol use, negative emotion, and drinking behaviour. Results indicated that alcohol dependent drinkers scored higher than non-problem drinkers on positive metacognitions about emotional self-regulation. Alcohol dependent drinkers also scored higher than both problem drinkers and non-problem drinkers on positive metacognitions about cognitive self-regulation, negative metacognitions about uncontrollability, and negative metacognitions about cognitive harm. Furthermore on positive metacognitions about cognitive self-regulation problem drinkers scored higher than non-problem drinkers. A logistic regression analysis indicated that negative metacognitions about uncontrollability and depression were significant predictors of classification as an alcohol dependent drinker. These results are consistent with a metacognitive conceptualization of problematic drinking behaviour and further add to our understanding of the role of specific metacognitions across the continuum of drinking behaviour. Ó 2010 Elsevier Ltd. All rights reserved.
1. Introduction According to the metacognitive theory of psychological disorders (Wells & Matthews, 1994, 1996; Wells, 2000) disturbance is maintained by a style of cognitive-affective management that involves perseverative thinking (e.g. rumination and worry), threat monitoring, avoidance, and thought suppression. This style is termed the Cognitive Attentional Syndrome (CAS) and is problematic because: (1) it causes negative thoughts and emotions to persist; and (2) it fails to modify dysfunctional self-beliefs, increasing the accessibility of negative information (Wells, 2000). The activation and persistence of the CAS in response to affective (e.g. low mood) and cognitive (e.g. intrusive thoughts) triggers is dependent on metacognitions. Metacognitions can be defined as ‘‘stable knowledge or beliefs about one’s own cognitive system, and knowledge about factors that affect the functioning of the system; the regulation and awareness of the current state of cognition, and appraisal of the significance of thought and memories” (Wells, 1995, p. 302). Metacognitions are divided into two broad sets: (1) positive beliefs about coping strategies that impact on mental
* Corresponding author at: Department of Mental Health and Learning Disabilities, Faculty of Health and Social Care, London South Bank University, United Kingdom. Tel.: +44 0 20 7815 7815. E-mail address: [email protected] (M.M. Spada). 0191-8869/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.paid.2010.04.011
states such as ‘‘smoking will help me get things sorted out in my mind” or ‘‘worrying will help me solve the problem”; and (2) negative beliefs concerning the significance, controllability, and danger of particular types of thoughts, e.g. ‘‘It is bad to think thought X” or ‘‘I need to control thought X”. Metacognitions have been found to be associated with a wide array of psychological and behavioural problems, including: depression (Papageorgiou & Wells, 2003), hypochondriasis (Bouman & Meijer, 1999), nicotine dependence (Nikcˇevic´ & Spada, 2008, 2010; Spada, Nikcˇevic´, Moneta, & Wells, 2007b), obsessive– compulsive symptoms (Wells & Papageorgiou, 1998), pathological procrastination (Fernie, Spada, Nikcˇevic´, Georgiou, & Moneta, 2009; Spada, Hiou, & Nikcˇevic´, 2006a), pathological worry (Wells & Papageorgiou, 1998), perceived stress (Spada, Nikcˇevic´, Moneta, & Wells, 2008b), post-traumatic stress disorder (Roussis & Wells, 2006), predisposition to auditory hallucinations (Morrison, Wells, & Nothard, 2000), state anxiety (Spada, Mohiyeddini, & Wells, 2008a), and test anxiety (Spada, Nikcˇevic´, Moneta, & Ireson, 2006b). Research by Spada and colleagues (Spada, Caselli, & Wells, 2009; Spada, Moneta, & Wells, 2007a; Spada & Wells, 2005, 2006, 2008, 2009; Spada, Zandvoort, & Wells, 2007c) has found evidence that metacognitions play a key role in drinking behaviour. In an initial test of the hypothesis of whether metacognitions are associated with drinking behaviour in a community sample, Spada
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and Wells (2005) observed a positive association between beliefs about the need to control thoughts and alcohol use that is independent of negative emotion. Spada et al. (2007c), in later research, found evidence that these same beliefs and beliefs relating to lack of cognitive confidence (the evaluation of one’s own cognitive functioning in the presence or absence of objective cognitive deficit) predicted classification as a problem drinker independently of negative emotion. More recently, data from a prospective study found that beliefs about the need to control thoughts predict levels of alcohol use and relapse in problem drinkers (Spada et al., 2009). Finally, in a series of semi-structured interviews aimed at exploring the nature of metacognitions in a sample of problem drinkers Spada and Wells (2006) found that this group held both positive and negative metacognitions about alcohol use. Positive metacognitions about alcohol use (e.g. ‘‘Drinking helps me to control my thoughts”) can be conceptualized as a specific form of alcohol expectancy relating to the use of alcohol as a means of controlling cognition and emotion (Spada & Wells, 2008, 2009). From a metacognitive standpoint such beliefs are thought to play a central role in motivating individuals to engage in alcohol use as a means of cognitive-affective regulation (Spada & Wells, 2008, 2009). Negative metacognitions about alcohol use concern the perception of lack of executive control over behaviour (e.g. ‘‘My drinking persists no matter how I try to control it”) and the negative impact of alcohol use on cognitive functioning (‘‘Drinking will damage my mind”). These beliefs can be respectively conceptualized as a specific level of cognitive self-efficacy and negative alcohol outcome expectancy (Spada & Wells, 2008, 2009). From a metacognitive standpoint such beliefs are thought to play a crucial role in the perpetuation of alcohol use by becoming activated during and following a drinking episode, and triggering negative emotional states and mental regulation strategies that compel a person to drink more (Caselli et al., 2010; Spada & Wells, 2006). Metacognitive theory implies that metacognitions about alcohol use can be usefully distinguished from ordinary cognitive level beliefs (such as alcohol expectancies) and that they will impart additional control over cognition and action. Indeed existing measures of positive alcohol expectancies do not identify beliefs concerning the usefulness of alcohol as a cognitive control and self-regulation tool aimed at problem-solving, thought control, attentional regulation, and self-image control. Furthermore, negative alcohol expectancies differ from negative metacognitions about alcohol use in as much as they primarily assess general negative outcomes arising from alcohol use (e.g. ‘‘I get a hangover”; ‘‘I feel guilty”) rather than beliefs about the perception of lack of executive control over behaviour (e.g. ‘‘My drinking persists no matter how I try to control it”), and the negative impact of alcohol use on cognitive functioning (e.g. ‘‘Drinking will damage my mind”). Consistent with this view, research has demonstrated that metacognitions about alcohol use play an important role in predicting drinking behaviour beyond that of alcohol expectancies (Spada et al., 2007a). To date no study has investigated the role of metacognitions about alcohol use in alcohol dependent individuals. Indeed the key limitation of previous studies in this area was the use of individuals with moderate levels of problem drinking, thus restricting the generalizability of findings only to this sub-group. Another limitation was the lack of analysis of metacognitions about alcohol use in alcohol dependent individuals compared to problem and nonproblem drinkers. The primary aim of the current study was to explore the differences in metacognitions about alcohol use in established alcohol dependent drinkers, problem drinkers, and non-problem drinkers whilst controlling for negative emotion (anxiety and depression). Negative emotion was included as a covariate because research has demonstrated that emotion regulation is a key motive for prob-
lem drinking (e.g. for a review see Baker, Piper, McCarthy, Majeskie, & Fiore, 2004; Khantzian, 1997; Wills & Shiffman, 1985). Research to date suggests that individuals with alcohol dependence should have higher levels of metacognitions about alcohol use than people at risk (e.g. problem drinkers), who in turn should have higher levels than non-problem drinkers. This could present as higher scores on one or both dimensions (positive and negative) of metacognitions about alcohol use. Elevated scores on both positive and negative metacognitions about alcohol use would be most pathological as individuals would be fearful of the impact of alcohol use on cognitive-emotional functioning and its uncontrollability (negative metacognitions) but feel that they must drink in order to control cognition and emotion (positive metacognitions), a situation that would exacerbate negative emotion, contribute to difficulties with mental control and lead to perseveration in alcohol use. Therefore, we predict that individuals with established alcohol dependence should differ from problem drinkers and non-problem drinkers in terms of higher overall scores on both positive and negative metacognitions about alcohol use.
2. Method 2.1. Participants The clinical sample consisted of a consecutive series of 48 patients (9 females) who contacted a Drugs and Alcohol Addiction Clinic in London, United Kingdom, seeking treatment for alcohol dependence. All participants fulfilled the ICD-10 (World Health Organisation, WHO, 2004) diagnostic criteria for alcohol dependence. A general clinical and biochemical screening was performed to exclude severely impaired individuals. For purposes of inclusion in this study the participants were required to speak English and be at least 18 years of age. The mean age of the sample was 42.2 years (SD = 10.8). The participants consumed an average of 144.9 units per week (SD = 66.5) and their mean score on the AUDIT (Babor, de la Fuente, Saunders, & Grant, 1992) was 28.4 (SD = 5.0). The unit of alcohol is adopted in United Kingdom to quantify alcohol intake. It is defined as 10 ml (8 g) of ethanol (ethyl alcohol) and represents the amount of ethanol an average healthy adult can metabolize in an hour. Mean scores on the anxiety and depression sub-scales of the HADS (Zigmond & Snaith, 1983) were 11.6 (SD = 4.3) and 9.6 (SD = 3.7), respectively. Both the problem and non-problem drinking samples were recruited through leaflets and advertisements placed in a variety of occupational settings (e.g. education, finance, and health). For purposes of inclusion in this study the participants were required to speak English, use alcohol regularly (at least once per week), and be at least 18 years of age. The problem drinking sample consisted of 69 individuals (41 females). Participants were included in this group if they scored between 7 and 20 on the AUDIT. A score of 7 on AUDIT is considered an acceptable cut-off point for problem drinking (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). A score of 20 or above is considered a cut-off point for severe alcohol dependence that warrants further diagnostic evaluation (Babor et al., 2001). The mean age of the sample was 30.5 years (SD = 8.0). The participants consumed an average of 28.5 units per week (SD = 19.1). Their mean score on the AUDIT was 10.4 (SD = 2.2). Mean scores on the anxiety and depression sub-scales of the HADS (Zigmond & Snaith, 1983) were 6.9 (SD = 3.6) and 3.0 (SD = 2.1), respectively. The non-problem drinking sample consisted of 70 individuals (57 females). Participants were included in this sub-group if they scored 6 or less on the AUDIT as this is considered to indicate that the individual is not a problem drinker. The mean age of this sample was 36.8 years (SD = 12.5). The participants consumed an average of 11.1 units per week (SD = 7.2). Their
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mean score on the AUDIT was 4.0 (SD = 1.3). Mean scores on the anxiety and depression sub-scales of the HADS (Zigmond & Snaith, 1983) were 5.5 (SD = 2.9) and 2.2 (SD = 1.8), respectively. 2.2. Measures 2.2.1. Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). This scale consists of 14 items, 7 assessing anxiety and 7 assessing depression. The anxiety subscale includes items such as: ‘‘I get a sort of frightened feeling as if something horrible is about to happen”. The depression sub-scale includes items such as: ‘‘I feel as if I am slowed down”. Higher scores represent higher levels of anxiety and depression. The majority of studies examining the factor structure of the HADS in both clinical and general populations have identified two dimensions (Mykletun, Stordal, & Dahl, 2001). The intercorrelation of the anxiety and depression sub-scales has been reported to be in the range of .49–.63 with lower correlations reported in studies with healthy samples (Mykletun et al., 2001). Overall, the scale possesses good validity and reliability (Herrmann, 1997; Mykletun et al., 2001; Zigmond & Snaith, 1983). 2.2.2. The Positive Alcohol Metacognitions Scale (PAMS) (Spada & Wells, 2008). PAMS is a 12-item measure developed to assess positive metacognitions about alcohol use. It consists of two factors: (1) positive metacognitions about emotional self-regulation; and (2) positive metacognitions about cognitive self-regulation. Examples of items relating to emotional self-regulation include: ‘‘Drinking reduces my self-consciousness”. Examples of items relating to cognitive self-regulation include: ‘‘Drinking helps me to control my thoughts”. Higher scores represent higher levels of positive metacognitions about alcohol use. PAMS was initially constructed and factor analysed in a community sample (n = 261) and its factor structure was replicated in a clinical sample (n = 80) (Spada & Wells, 2008). 2.2.3. The Negative Alcohol Metacognitions Scale (NAMS) (Spada & Wells, 2008). NAMS is a 6-item measure developed to assess negative metacognitions about alcohol use. It consists of two factors: (1) negative metacognitions about uncontrollability; and (2) negative metacognitions about cognitive harm. Items relating to uncontrollability include: ‘‘My drinking persists no matter how I try to control it”. Items relating to cognitive harm include: ‘‘Drinking will damage my mind”. Higher scores represent higher levels of negative metacognitions about alcohol use. NAMS was initially constructed and factor analysed in a community sample (n = 261) and its factor structure was replicated in a clinical sample (n = 80) (Spada & Wells, 2008). 2.2.4. The Quantity Frequency Scale (QFS) (Cahalan, Cisin, & Crossley, 1969). QFS is a measure of alcohol consumption levels, with items assessing the dimensions of quantity and frequency of alcohol beverages consumed over a period of 30 days. This measure consists of three questions (‘‘have you been drinking any beer/wine/spirits over the last 30 days?”; ‘‘about how often do you consume beer/wine/spirits?”; and ‘‘about how much beer/wine/spirits did you drink on a typical day when you drink beer/wine/spirits?”). These are repeated for each of the major alcohol beverage categories (beer, wine, and distilled spirits). The total scores from the different alcohol beverage categories are then added together and an estimated daily (or weekly) level of alcohol consumption can be computed. This instrument has been extensively used and possesses good validity and reliability (Hester & Miller, 1995).
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2.2.5. The Alcohol Use Disorders Identification Test (AUDIT) (Babor et al., 1992). AUDIT was developed as a screening tool by the World Health Organisation (WHO) for early identification of problem drinkers. AUDIT consists of 10 questions regarding recent alcohol consumption, alcohol dependence symptoms, and alcoholrelated problems. Respondents are asked to choose one of between 3 and 5 statements (per question) that most applies to their use of alcohol beverages over the past year. Responses are scored from 0 to 4 in the direction of problem drinking. The summary score for the total AUDIT ranges from 0, indicating no presence of problem drinking behaviour, to 40 indicating marked levels of problem drinking behaviour and alcohol dependence. A score of 7 on AUDIT is considered an acceptable cut-off point for problem drinking (Babor et al., 2001). A score of 20 or above is considered a cut-off point for severe alcohol dependence (Babor et al., 2001). This instrument has been extensively used and possesses good validity and reliability (Babor et al., 2001). 2.3. Procedure Ethics approval for the study was obtained from a University ethics board and the local National Health Service Trust. The study was described to participants as an investigation of the role of emotion and thought in alcohol use. All participants were informed that data provided in the study would be treated with the strictest confidence and that participation in the research project was entirely voluntary. Following a brief introduction to the project and the granting of informed consent participants were instructed, in written form, to complete the measures in the following order: AUDIT, HADS, PAMS, and NAMS. All participants were debriefed following completion of the measures. The clinical sample completed the questionnaires individually in a room within the clinic. No explicit cues regarding alcohol use or mood were present. The non-clinical samples completed the questionnaires through a dedicated website and in a location of their choice. 3. Results In order to establish if there was an overall effect from the combination of positive and negative metacognitions about alcohol use sub-scales, a multivariate analysis of covariance (MANCOVA) was conducted with the participant group as a fixed factor, and anxiety, depression, gender, and age as covariates. All the positive and negative metacognitions about alcohol use sub-scales were entered as dependent variables. The correlations between the dependent variables and anxiety ranged from .09 to .37 in alcohol dependent drinkers, from .04 to .17 in problem drinkers, and from .21 to .31 in non-problem drinkers. The correlations between the dependent variables and depression ranged from .02 to .32 in alcohol dependent drinkers, from .10 to .26 in problem drinkers, and from .10 to .18 in non-problem drinkers. The MANCOVA revealed a significant effect [Roy’s Largest Root = 3.05, F(2184) = 138.6, p = .0005]. In order to establish group differences on positive and negative metacognitions about alcohol use sub-scales, a series of one-way analyses of covariance with follow-up Bonferroni pairwise comparisons were conducted (see Table 1) with the participant group as a fixed factor, anxiety, depression, age, and gender as covariates, and individual positive and negative metacognitions about alcohol use sub-scales as the dependent variables. These analyses revealed that alcohol dependent drinkers scored higher than non-problem drinkers on positive metacognitions about emotional self-regulation. Alcohol dependent drinkers also scored higher than both problem drinkers and non-problem drinkers on positive metacognitions about cognitive self-regulation, negative metacognitions about uncontrollability,
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Table 1 Adjusted means and standard errors (in parentheses) for positive and negative metacognitions about alcohol use across groups. Metacognitions
Alcohol dependent drinkers (n = 48)
Problem drinkers (n = 69)
Non-problem drinkers (n = 70)
1. Positive metacognitions about emotional selfregulation 2. Positive metacognitions about cognitive selfregulation 3. Negative metacognitions about uncontrollability 4. Negative metacognitions about cognitive harm
20.6 (1.10)a
18.1 (.70)
16.4 (.73)b
12.2 (.71)a
9.5 (.42)b
6.9 (.46)c
8.9 (.35)a
4.3 (.21)b
4.0 (.23)b
9.1 (.42)a
4.9 (.25)b
5.1 (.27)b
Note: means with different superscripts are significantly different; p-values (p 6 .05) have been adjusted according to the Bonferroni rule.
and negative metacognitions about cognitive harm. Furthermore on positive metacognitions about cognitive self-regulation problem drinkers scored higher than non-problem drinkers. In relation to the effects of anxiety, depression, age, and gender significant effects of these covariates were identified only for depression in relation to negative metacognitions about uncontrollability [F(1184) = 8.50, p = .004] and negative metacognitions about cognitive harm [F(1184) = 8.88, p = .003]. Next the data were analyzed using binary logistic regression analysis which is used to find the odds of being in one category or another. In the current study the category was alcohol dependent drinker or problem drinker. Depression, positive metacognitions about cognitive self-regulation, negative metacognitions about uncontrollability, and negative metacognitions about cognitive harm were entered individually as a block. The results for the final equation were as follows: {2 = 133.8, df = 4, p = .0005, with 96.6% of cases correctly classified. Inspection of the final step (presented in Table 2) indicates that negative metacognitions about uncontrollability and depression were significant independent predictors of classification as an alcohol dependent drinker. Metacognitions concerning uncontrollability had the highest odds-ratio demonstrating they conferred the greatest risk among the variables measured in determining the classification as alcohol dependent versus being a problem drinker.
4. Discussion The goal of this study was to establish the contribution of metacognitions to alcohol dependent drinker status and establish whether they differ across the continuum of drinking behaviour. This is the first study to empirically demonstrate that individuals with alcohol dependence report significantly higher scores on metacognitions about alcohol use than problem drinkers and non-problem drinkers. The findings that alcohol dependent drinkers scored higher than non-problem drinkers on positive metacognitions about emo-
tional self-regulation suggest that these beliefs may play a role in the perseveration of harmful alcohol use. The findings that positive metacognitions about cognitive self-regulation differed significantly across the continuum of drinking behaviour suggests that these beliefs may play a role both as initial factors in the transition from a non-problem drinker to problem drinker status, and in the escalation of drinking behaviour to alcohol dependence levels. The finding that only alcohol dependent drinkers scored higher (than both problem and non-problem drinkers) on negative metacognitions about uncontrollability, and negative metacognitions about cognitive harm supports our prediction that dependent drinkers have the highest metacognitions overall. This group may have a particularly problematic combination involving elevated positive and negative metacognitions about alcohol use compared with non-problem drinkers. The results of the regression analysis extends these findings by demonstrating that independently of depression and positive metacognitions about emotional self-regulation, negative metacognitive beliefs about uncontrollability are the strongest predictors of alcohol dependence. The pattern of findings obtained in this study are consistent with patterns observed in studies of other disorders such as generalized anxiety (Wells & Carter, 2001) and depression (Papageorgiou & Wells, 2003) in which negative metacognitions are direct predictors of disorder. The clinical implication of these findings is that metacognitions may be conceptualized and treated in order to reduce the risk of transition from problem drinker to alcohol dependence, and to reduce the risk of relapse. An important possibility is that negative metacognitions about uncontrollability may interfere with engagement in treatment programmes and will need to be targeted in treatment. Metacognitive therapy (Wells, 2008) consists of specific techniques that enable clients to develop more effective ways of relating to thoughts and challenge metacognitions. It remains to be demonstrated if an approach such as this can be useful in the treatment of alcohol problems. This study has several limitations which will have to be addressed by future research. It relies solely on self-report data (this is unavoidable as there are no objective or interview measures of metacognitions about alcohol use). A cross-sectional design was adopted and this does not allow causal inferences. The presence of concurrent psychological disorder (which could account for the observed differences in metacognitions) was not assessed. However controlling for anxiety and depression does provide a degree of confidence in the specificity of the results. Finally the clinical sample was relatively small in size and some participants had received previous treatment which may have exposed them to the identification and exploration of cognitive constructs. However, standard treatment for problem drinking does not typically include the examination of metacognitions assessed here. Thus, the experience of treatment may not be particularly significant in explaining the current findings. Directions for future research include ascertaining further the role of metacognitions in the predisposition towards, and maintenance of, problematic drinking behaviour, as well as considering the influence of drinking behaviour on metacognitions. It would also be interesting to examine whether changes in metacognitions occur during the process of problem
Table 2 Summary statistics for the logistic regression equation predicting alcohol dependence.
Depression Positive metacognitions about cognitive self-regulation Negative metacognitions about uncontrollability Negative metacognitions about cognitive harm Constant
B
S.E.
Wald
df
p
Exp(B)
.91 .11 1.53 .11 15.6
.32 .12 .74 .38 5.08
7.76 .81 4.36 .08 9.53
1 1 1 1 1
.005 .36 .004 .78 .002
2.47 1.11 4.63 .90 .000
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drinking treatment, and if so, if they are associated with discontinuation in drinking.
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