Post on 12-May-2023
ORIGINAL ARTICLE
Metacognitions and Thought Control Strategies in UnipolarMajor Depression: A Comparison of Currently Depressed,Previously Depressed, and Never-Depressed Individuals
Marianne Halvorsen • Roger Hagen • Odin Hjemdal • Marianne S. Eriksen •
Ase J. Sørli • Knut Waterloo • Martin Eisemann • Catharina E. A. Wang
� Springer Science+Business Media New York 2014
Abstract Few studies have explored the importance of
worry-related metacognitions and thought control strate-
gies in major depressive disorder. The present study
explored how metacognitions and thought control strate-
gies differentiated currently depressed (n = 37), previ-
ously depressed (n = 81) and never-depressed individuals
(n = 50). Discriminant function analysis was performed to
investigate group differences on the Metacognitions
Questionnaire-30, Thought Control Questionnaire, and
Ruminative Response Scale. The analysis revealed that
currently depressed participants scored significantly higher
than previously depressed participants and that previously
depressed participants scored higher than never-depressed
participants on negative metacognitive beliefs, rumination,
worry and the use of punishment as a thought control
strategy. The discriminant function analysis further showed
that previously depressed participants had a higher use of
the thought control strategy reappraisal, along with lower
dysfunctional metacognitions concerning the need to con-
trol their thoughts, higher confidence in their cognitive
function and lower levels about the need to worry, com-
pared to both the currently and never-depressed groups.
The results indicate that metacognitions and thought
control strategies could be promising vulnerability markers
for depression.
Keywords Major depressive disorder � Metacognition �Thought control strategies � Rumination
Introduction
Major depressive disorder (MDD) is a highly relapsing and
recurrent disorder (Andrade et al. 2003; Kessler et al. 2003).
Therefore, it is important to identify vulnerability factors for
becoming depressed to both prevent and treat the disorder.
Cognitive-behavioral therapy (CBT) has been considered to
be one of the most effective psychotherapeutic treatments
for major depression. Although CBT has been proven to be
effective, there seems to be a high relapse rate of depression
after treatment into remission; follow-up studies show
relapse rates of approximately 50 % in patients treated with
CBT (Dimidjian et al. 2006; Roth and Fonagy 2005). This
high relapse rate could indicate that a depressive episode
may result in lasting psychosocial changes in individuals
who had been depressed. This theory has often been referred
to as the ‘‘scar hypothesis’’ (Lewinsohn et al. 1981),
although recent research has failed to support this claim
(Beevers et al. 2007).
In addition to the high relapse rate at follow up, a sub-
stantial number of depressed individuals do not respond to
CBT with full remission at the termination of treatment
(Dimidjian et al. 2006; DeRubeis et al. 2005). These
findings suggest that while CBT focuses on aspects of
cognition and behavioral changes that can result in symp-
tom relief, there may be further domains that would
deserve specific attention to treat this disorder more
effectively.
M. Halvorsen (&)
Department of Pediatric Rehabilitation, University Hospital of
North Norway, 9038 Tromsø, Norway
e-mail: marianne.halvorsen@unn.no
R. Hagen � O. Hjemdal
Department of Psychology, Norwegian University of Science
and Technology, Trondheim, Norway
M. S. Eriksen � A. J. Sørli � K. Waterloo � M. Eisemann �C. E. A. Wang
Department of Psychology, Faculty of Health Sciences, UiT
The Arctic University of Norway, Tromsø, Norway
123
Cogn Ther Res
DOI 10.1007/s10608-014-9638-4
The main treatment target of CBT has been the cogni-
tive content of depressive thoughts and schemas (Beck
et al. 1979; Beck 1987; Ingram et al. 1998; Wells and
Pagageorgiou 2004). A more recent theory, Metacognitive
Therapy (MCT; Wells 2000, 2009) offers another approach
towards the understanding of depression. MCT emphasizes
the role of thinking styles and metacognitions related to
thinking—not the contents of the thoughts, but rather, how
people relate to them (Wells 2000).
MCT is based on a self-regulatory executive function
model (S-REF) of emotional disorders (Wells and Matthews
1994, 1996). The S-REF model emphasizes how the top-
down or strategic processing and regulation of responses to
negative thoughts gives rise to depression. A central tenet of
the metacognitive model is cognitive attentional syndrome
(CAS). CAS consists of perseverative thinking, such as
rumination and worry, threat monitoring, and the use of
maladaptive coping strategies. CAS is driven by metacog-
nitions, which could be conceptualized as ‘‘aspects of cog-
nition that control the way a person thinks and behaves in
response to a thought, belief or feeling’’ (Wells 2009, p. 4).
The S-REF model differentiates between positive and neg-
ative metacognitive beliefs. More specifically, internal cues,
such as dysphoric thoughts (e.g., ‘‘Why do I feel this way’’),
activate positive metacognitive beliefs about the need to
engage in extended negative processing in the form of
rumination or worry to cope with this thought. A positive
metacognitive belief about rumination could be ‘‘Ruminat-
ing will help me understand the reasons why I am depres-
sed’’. Further, the activation of negative meta-beliefs about
the uncontrollability and danger of rumination and worry
contributes to symptom maintenance and recurrent episodes
of depression. Negative metabeliefs include the following:
‘‘When I start ruminating I cannot stop’’ and ‘‘Thinking this
way is caused by an imbalance in my brain.’’ Metacognitive
theory suggests that positive metacognitive beliefs may
represent a vulnerability for developing depression through
the use of inappropriate thought control strategies (rumina-
tion, worry and suppression), and negative metacognitive
beliefs lead to and sustain emotional distress because the
individual feels that these processes are uncontrollable and
threatening (Wells 2009). It is important to explore how
these metacognitions vary across clinical and non-clinical
samples to better understand their relevance.
MCT provides a promising basis for the understanding
of the relapsing and recurrent nature of depression.
Rumination has been noted as a major contributing factor
for depressive symptoms (Nolen-Hoeksema et al. 2008).
Rumination has also been found to act both as a vulnera-
bility factor related to the onset of depression, even while
maintaining the disorder (for a review see Nolen-Hoek-
sema et al. 2008; Smith and Alloy 2009). MCT suggests
that the harmful effects of rumination (i.e., depressive
symptoms) are closely associated with metacognitive
beliefs and coping processes in initiating and perpetuating
ruminative thoughts. Indeed, Papageorgiou and Wells
(2003) found, in a cross-sectional sample of depressed
individuals (N = 200) using structural equation modelling,
that the relationship between rumination and depression
was mediated by negative metacognitive beliefs.
Despite some promising results related to positive
associations among rumination, metacognitions and
depression (Papageorgiou and Wells 2001, 2003, 2009),
the association between these constructs is scarcely
investigated in the course of MDD. Existing studies have
focused either on healthy samples or already depressed
individuals (Papageorgiou and Wells 2001, 2003; Sarisoy
et al. 2013; Spada et al. 2008; Wells and Carter 2001).
Thus, studies that include and compare both healthy and
depressed individuals are needed.
In addition, MCT suggests that worry is a component of
depression. Depressed individuals monitor themselves for
signs and symptoms of depression, which, when found, are
perceived as threatening because they signal depression. It
is plausible to assume that previously depressed individuals
could also be sensitive to mood fluctuations due to fear of
becoming depressed again. This tendency was regarded by
Wells (2009) as a sort of threat monitoring, potentially
bringing up worries among previously depressed individ-
uals and strongly suggesting that a further investigation of
metacognitions related to worry in depression is warranted.
However, very few studies have investigated worry-related
metacognitions in depression. Sarisoy et al. (2013) used the
Metacognitions Questionnaire (MCQ-30; Wells and Cart-
wright-Hatton 2004) and found that the MCQ factor
‘Negative beliefs about worry concerning uncontrollability
and danger’ was elevated both in unipolar (n = 51) and
bipolar depressed individuals (n = 45) compared to the
non-depressed control group (n = 60). Wells and Carter
(2001) also found that patients with MDD (n = 24) and
patients with panic disorder (n = 24) had similar levels of
elevated scores on MCQ ‘Negative beliefs about worry
concerning uncontrollability and danger’. In a community
sample (n = 399), Spada et al. (2008) found that MCQ
‘Negative beliefs about worry concerning uncontrollability
and danger’ predicted significant variance in both anxiety
and depression scores. Taken together, with the exception
of Sarisoy et al. (2013), the principal aims of these studies
were not to investigate metacognitions related to worry in
depression per se, but rather, to compare depressed patients
with individuals with anxiety disorders. None of the studies
investigated the presence of metacognitions in individuals
in different phases of MDD.
Furthermore, few studies have investigated a broader
range of thought control strategies in the course of
depression. Wells and Davies (1994) developed the
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123
Thought Control Questionnaire (TCQ) to assess individual
differences in thought control strategies when coping with
unwanted and negative thoughts. The TCQ has been mostly
used in samples suffering from anxiety disorders with
findings indicating that the TCQ Punishment factor (e.g., ‘‘I
tell myself not to be so stupid’’) and the TCQ Worry factor
(e.g., ‘‘I think about past worries instead’’) seem to be
positively associated with indices of emotional vulnera-
bility and psychopathology (Fehm and Hoyer 2004; Luci-
ano et al. 2006; Rassin and Diepstraten 2003). Reynolds
and Wells (1999) found negative correlations between
depressive symptoms and the TCQ Distraction factor (e.g.,
‘‘I occupy myself with work instead’’) and the TCQ
Reappraisal factor (e.g., ‘‘I try to reinterpret the thought’’)
among patients with MDD (n = 61). In the same study,
TCQ Distraction and TCQ Reappraisal predicted the
recovery of depressive symptoms in a mixed sample of
depressed and PTSD patients (n = 18), suggesting that
recovery was associated with the increased use of distrac-
tion and reappraisal as thought control strategies.
The principal aim of the present study was to explore the
presence of worry-related metacognitions and a broader
range of thought control strategies among patients with
current depression, those who had recovered, and never-
depressed individuals. By comparing previously depressed
with currently and never-depressed individuals in a cross-
sectional design, the present study also offers a unique
opportunity to examine the metacognitions and coping
strategies associated with MDD.
Methods
Participants
One hundred and sixty-eight participants, consisting of
currently depressed (n = 37), recovered previously depres-
sed (n = 81) and never-depressed individuals (n = 50),
took part in the study. One-hundred-and three participants
were recruited from a previous study on depression and
cognitive vulnerability (see Wang et al. 2005, 2006) and
reassessed in the present study. The participants in the ori-
ginal study consisted of a mixture of undergraduate students
and patients consulting their general practitioner (GP). Ini-
tially, we succeeded in contacting 133 of the total 149 par-
ticipants from the original study. Eighteen were unwilling to
participate, and 12 participants were excluded due to the
diagnostic criteria described below. The remaining 65 par-
ticipants were recruited through GPs and ads in a local
newspaper (Halvorsen et al. 2009, 2012).
Diagnoses were based on the Diagnostic and Statistical
Manual of Mental Disorders-IV, Text Revision, (DSM-IV-
TR; APA 2000), using the Structured Clinical Interview for
DSM-IV, Axis I (SCID-I; First et al. 1997). Based on the
information given in the clinical interview, the participants
were grouped as (a) currently depressed; (b) having pre-
viously experienced a depressive episode in the past and
fully recovered for at least the last 8 weeks or longer (i.e.,
during the past 2 months, no significant signs or symptoms
of a major depressive episode were present); or (c) having
never been clinically depressed. Participants meeting the
criteria for a major depressive episode in partial remission,
an on-going or past manic/hypomanic episode, dysthymic
disorder, or psychotic symptoms were not included in the
study. Participants with a history of known brain damage or
a major depressive episode due to a general medical con-
dition were excluded as well. Accordingly, only currently
depressed and previously depressed patients with a history
of major depression and only never-depressed without any
on-going or past Axis I disorders were included in the
study. All participants in the study were non-hospitalized.
The SCID interview was carried out by clinical psychol-
ogists or postgraduate psychology students who had been
extensively trained in its administration by a highly qualified
supervisor. All of the interviews were digitally recorded, and
30 of them, ten from each group, were subsequently ran-
domly sampled for reliability testing. The inter-rater agree-
ment (Cohen’s kappa) between two independent raters per
group (never-depressed, previously depressed and currently
depressed) was .90. When the kappa was calculated for rating
participants who had never experienced a depressive episode
(i.e., never-depressed) and those who had (i.e., previously
depressed and currently depressed), the agreement was total.
These results indicate a highly satisfactory reliability of the
group assignments. For a further description of the design
and samples, see Halvorsen et al. (2009, 2010, 2011).
The demographic and clinical characteristics of the three
groups of participants are presented in Table 1. Three
participants in the currently depressed group had a chronic
major depressive episode (i.e., the full criteria for a major
depressive episode had been continuously met for at least
2 years). The three groups did not differ significantly
concerning gender, age, or years of education. As expected,
the groups differed significantly on the Beck Depression
Inventory (Beck et al. 1996) and also on the Beck Anxiety
Inventory (Beck and Steer 1990). Few individuals were
currently on antidepressant medications.
The regional medical research ethics committee
approved this study. All participants gave written informed
consent and were paid NOK 150 (€18.80) per hour for their
participation.
Measures
The Beck Depression Inventory—Second Edition (BDI-II;
Beck et al. 1996) is a 21-item self-report inventory for
Cogn Ther Res
123
assessing the presence and severity of depressive symp-
toms. Each item is rated on a four-point Likert-type scale
ranging from 0 to 3, indicating the severity of the symptom.
Beck et al. (1996) categorized BDI-II total scores as fol-
lows: 0–13 minimal, 14–19 mild, 20–28 moderate and
29–63 severe. The BDI-II proved highly internally con-
sistent (Cronbach’s alpha [.90), and its 1-week test–retest
reliability was high (r = .93) (Beck et al. 1996). For more
on the psychometric properties of the BDI-II, see Steer
et al. (1999). In the present study, the BDI-II was admin-
istered the same day as the as the diagnostic interview and
the following day, combined with other measures. The
Cronbach’s alpha for the total score on the BDI-II was .95.
The Beck Anxiety Inventory (BAI; Beck and Steer 1990) is
a 21-item self-report inventory for assessing the presence
and severity of anxiety symptoms. Each item is rated on a
four-point Likert-type scale ranging from 0 to 3, indicating
the severity of each symptom. Beck and Steer (1990) cate-
gorized the BAI total scores as follows: 0–7 minimal, 8–15
mild, 16–25 moderate, and 26–63 severe. The BAI proved
highly internally consistent (Cronbach’s alpha = .94) and
acceptably reliable over an average time lapse of 11 days
(r = .67). For further psychometric properties of the BAI,
see Steer and Ranieri (1993). In the present study, the
Cronbach’s alpha for the total score was .92.
The Metacognitions Questionnaire-30 (MCQ-30; Wells
and Cartwright-Hatton 2004) consists of 30 items in a self-
report inventory for assessing individual differences in
metacognitive beliefs. The items are scored on a four-point
Likert-type scale ranging from 1 (I do not agree) to 4 (I totally
agree), allowing a range from 30 to 120. Higher scores are
associated with higher scores on depressive symptoms
(Hjemdal et al. 2013). The 30 items are grouped within the
five subscales: Positive beliefs about worry (e.g., ‘‘Worrying
helps me to solve problems’’), Negative beliefs about worry
concerning uncontrollability and danger (e.g., ‘‘When I start
worrying I cannot stop’’), Cognitive confidence (e.g., ‘‘I do
not trust my memory’’), Need of control (e.g., ‘‘It is bad to
think certain thoughts’’), and Cognitive self-consciousness,
which is the tendency to be aware of one’s thoughts (e.g., ‘‘I
monitor my thoughts’’). The MCQ-30 proved good internal
consistency (Cronbach’s alphas from .72 to .93) and
acceptable test–retest reliability over a mean re-test interval
of 34.14 days (r from .59 to .87), (Wells and Cartwright-
Hatton 2004). For further psychometric properties of the
MCQ-30, see Spada et al. (2008). In the present study, the
Cronbach’s alphas for the various subscales ranged from .71
(Need of control) to .86 (Positive beliefs about worry).
The Thought Control Questionnaire (TCQ; Wells and
Davies 1994) is a 30-item self-report inventory for assessing
the strategies used by individuals to control unpleasant and
unwanted thoughts. Each item is rated on a four point Likert-
type scale ranging from 1 (never) to 4 (almost always) with a
range from 30 to 120. This scale measures the use of the five
coping strategies: Distraction, Punishment, Worry, Social
Control, and Reappraisal. The TCQ proved to have accept-
able internal consistency (Cronbach’s alphas from .65 to .78)
and acceptable test–retest reliability over 6 weeks
(r between .67 and .83) (Reynolds and Wells 1999; Wells and
Davies 1994). The factor structure has widely been con-
firmed in clinical and healthy samples, and the subscales
have been proven to be independent (Fehm and Hoyer 2004;
Reynolds and Wells 1999). In the present study, the Cron-
bach’s alphas for the various subscales ranged from .68
(Worry) to .81 (Reappraisal).
The Ruminative Response Scale (RRS; Nolen-Hoeksema
and Morrow 1991) is a 22-item self-report inventory for
assessing individual differences in response to sadness or a
depressed mood (e.g., ‘‘I think about how alone I feel’’). Each
item is rated on a four-point Likert-type scale ranging from 1
(almost never) to 4 (almost always), with a possible range
from 22 to 88. Higher scores indicate higher levels of
rumination. In this study, the RRS total score was used. The
RRS showed highly satisfactory internal consistency
(Cronbach’s alphas from .88 to .92), and its high test–retest
stability over 5 months (r = .80) (Luminet 2004; Nolen-
Table 1 Demographic and clinical characteristics (N = 168)
Variable 1. Currently depressed
(n = 37) M (SD)
2. Previously depressed
(n = 81) M (SD)
3. Never depressed
(n = 50) M (SD)
Significant test, p value
and post hoc
Gender (female/male) 27/10 71/10 39/11 X2(2) = 4.23, p = .12
Age 37.49 (11.98) 37.42 (9.61) 38.06 (12.66) F(2,165) = 0.06, p = .95
Education, years 13.76 (3.84) 15.12 (2.64) 15.10 (3.63) F(2,165) = 2.53, p = .08
BDI-IIa 24.00 (9.06) 6.94 (7.21) 2.71 (3.04) F(2,162) = 114.74, p \ .001, 1 [ 2 [ 3
BAIb 17.41 (9.81) 6.42 (6.30) 2.35 (2.76) F(2,164) = 58.75, p \ .001, 1 [ 2 [ 3
Antidepressant 7 6 X2 (1) = 3.43, p = .06
Single/recurrent episodes 10/27 26/55 X2 (1) = 0.31, p = .58
BAI Beck Anxiety Inventory; BDI-II Beck Depression Inventorya Data missing from two previously depressed and one never-depressed control participantb Data missing for one never-depressed control participant
Cogn Ther Res
123
Hoeksema et al. 1994). For further psychometric properties
of the RRS, see Lam et al. (2003) and Luminet (2004). In the
present study, the Cronbach’s alpha for the total score was
.95.
Procedure
Participants were assessed individually over 2 days at the
University outpatient clinic at the UiT The Arctic Uni-
versity of Norway, Tromsø, Norway. The diagnostic
interview took place on the first day, and the self-report
measures were completed on the following day. The pro-
cedure was administered in the same order for all
participants.
Statistical Analyses
Analyses were conducted using the statistical package
SPSS for Windows, version 21 (IBM Corp., Armonk, NY,
USA, 2012). As the variables were approximately normally
distributed, with failures of normality being caused by
skewness rather than outliers, parametric tests were used
(Tabachnick and Fidell 2007). Differences in the demo-
graphic and clinical characteristics among the three groups
were compared by means of analysis of variance
(ANOVA) for continuous variables. Between-group com-
parisons of categorical variables were made by means of
the Chi square test (two-tailed).
A Discriminant Function Analysis was conducted to
explore which combinations of metacognitive and thought
control factors were the best indicators of discrimination
between the groups (i.e., currently depressed, previously
depressed or never clinically depressed) and to provide a plot
of the relative positions of the groups in discriminant space.
Results
Discriminant Function Analysis (DFA)
DFA allows for the identification of variables that could
correctly classify different groups. The results can be used
to visually represent the position of groups relative to each
other in a discriminant space. In this study, a DFA was
conducted using the MCQ, TCQ and RRS variables as
predictors of membership for the currently depressed,
previously depressed, and never-depressed groups. Table 2
shows the means and standard deviations of the predictor
variables as a function of group membership. Two dis-
criminant functions were calculated with a combined
v2(22) = 125.19, p \ .001, indicating a relationship
between the three groups and metacognitive and thought
control predictors that is highly unlikely to occur due to
chance alone. After removing the first function, there was
still an association between the groups and predictors,
v2(10) = 29.90, p = .001, indicating that this second
function also contributed significantly to distinguishing
between the three groups. These functions accounted for
79.9 and 20.1 %, respectively, of the variance between the
groups. The structure matrix (i.e., the loading matrix)
shows the correlations or loadings between the group
predictors (i.e., RRS-total, MCQ and TCQ variables) and
the discriminant functions (Table 3). The meaning of the
function can then be inferred from the pattern of loadings.
As observed in Table 3, the loading matrix shows that the
best predictors for distinguishing between group member-
ship (function 1) were, in descending order, rumination
(RRS-total score), MCQ ‘Negative beliefs about worry
concerning uncontrollability and danger’ (e.g., ‘‘My wor-
rying is dangerous for me’’), TCQ Worry (e.g., ‘‘I dwell on
other worries’’), TCQ Punishment (e.g., ‘‘I tell myself not
to be so stupid’’) and TCQ Distraction (e.g., ‘‘I think about
something else’’). The loading matrix further shows that
the second function, which maximally distinguished among
the groups, was correlated most highly, in descending
order, with MCQ Need of controlling thoughts (e.g., ‘‘I
should be in control of my thoughts all of the time’’), MCQ
Cognitive confidence (e.g., ‘‘I do not trust my memory’’),
TCQ Reappraisal (e.g., ‘‘I challenge the thoughts valid-
ity’’), and MCQ Positive beliefs about worry (e.g., ‘‘Wor-
rying helps me to avoid problems in the future’’). The
loadings indicate that Function 1 appears to indicate a
dimension of negative metacognitive belief as well as
suggests the use of the thought control strategies of rumi-
nation, worry and punishment at the positive end of the
continuum and the use of the thought control strategy of
distraction at the negative end of the continuum. Function 2
appears to be a dimension with high levels of beliefs about
the need for control and low cognitive confidence and high
positive beliefs about the need to worry at the positive end
of the continuum and high levels of the thought control
strategy of reappraisal at the negative end (see Fig. 1 for
further details).
Discriminant functions yield axes, and the centroids of
each group can be plotted along these axes. If there is a
large difference between the centroid of one group and the
centroid of another along a discriminant function axis, the
discriminant function separates the two groups (Tabach-
nick and Fidell 2007). Figure 1 shows a visual represen-
tation of group differences with respect to the two
discriminant functions.
The unstandardized discriminant scores for each func-
tion were used to determine which pairs of groups were
different with respect to the discriminant scores on the
discriminant functions. ANOVAs showed that there was a
significant overall main effect for Function 1,
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123
F (2,163) = 67.46, p \ .001, g2 = .45, and Function 2,
F (2,163) = 16.98, p \ .001, g2 = .17. Scheffe post hoc
comparisons showed that on Function 1, the currently
depressed participants had significantly higher scores than
the never-depressed participants, with the previously
depressed participants scoring in the middle (p \ .001).
With respect to Function 2, the previously depressed par-
ticipants had significantly lower scores compared to both
the currently depressed and the never-depressed partici-
pants (p \ .001). The currently depressed participants did
not differ significantly from the never-depressed partici-
pants on Function 2. In total, this analysis suggests that the
currently depressed participants score higher than the pre-
viously depressed participants, who, in turn, score higher
than the never-depressed participants on negative meta-
cognitive beliefs about uncontrollability/danger and the use
of the thought control strategies rumination, worry and
punishment (i.e., CAS). In addition, the previously
depressed participants report a higher use of the thought
control strategy reappraisal, along with lower dysfunctional
metacognitions concerning the need to control their
thoughts, higher confidence in their cognitive function and
lower levels of a need to worry (positive metacognition)
compared to currently depressed and never-depressed
participants.
Discussion
This study aimed to expand our knowledge on metacog-
nitions and coping strategies in MDD and to explore how
worry-related metacognitions and a broad range of thought
control strategies might differentiate participants with
current depression, those who are recovered, and those who
have never been depressed.
The results of the DFA showed that two significant
discriminant functions could distinguish among the three
groups. The subscale loadings on the functions suggested
that Function 1 was a dimension comprised of extended
self-referent thinking (rumination, worry, punishment) and
beliefs about the uncontrollability and dangerousness of
worry. The negative end of this construct was comprised of
the use of distraction as a mental regulation strategy. This
function is consistent with the cognitive-attentional syn-
drome (CAS) that is linked to psychological disorders in
Table 2 Means and standard deviations of predictor variables as a function of group membership (N = 168)
Predictor variable Currently depressed
(n = 37) M (SD)
Previously depressed
(n = 81) M (SD)
Never depressed
(n = 50) M (SD)
RRS-total 56.57 (11.65) 43.38 (12.31) 32.04 (7.09)
MCQ-30
Positive beliefs 9.54 (3.60) 8.14 (2.85) 8.44 (2.36)
Negative beliefs 14.54 (4.29) 10.70 (4.16) 8.34 (1.67)
Cognitive confidence 13.84 (4.98) 9.74 (3.53) 9.54 (2.74)
Need of control 11.97 (3.50) 8.80 (2.77) 8.74 (2.33)
Cognitive self-consciousness 13.19 (3.55) 12.41 (3.76) 11.84 (3.69)
TCQ
Distraction 13.83 (3.28) 14.91 (2.99) 15.94 (2.52)
Punishment 10.97 (3.90) 9.61 (2.72) 8.28 (1.62)
Reappraisal 14.19 (3.96) 15.20 (3.58) 13.18 (4.15)
Worry 12.03 (2.56) 10.14 (2.45) 9.32 (2.18)
Social control 13.25 (1.80) 12.89 (2.24) 12.60 (2.21)
MCQ Metacognitive Questionnaire, RRS Ruminative Response Scale, TCQ Thought Control Questionnaire
Table 3 Structure matrix: pooled within-groups correlations between
discriminating variables and standardized canonical discriminant
functions
Variable Function 1 Function 2
RRS-total .91* -.04
MCQ-Negative beliefs .68* .12
TCQ-Worry .44* .17
TCQ-Punishment .39* -.04
TCQ-Distraction -.29* -.05
MCQ-Cognitive self-consciousness .15* .01
TCQ-Social control .12* .03
MCQ-Need of control .45 .56*
MCQ-Cognitive confidence .47 .56*
TCQ-Reappraisal .11 -.45*
MCQ-Positive beliefs .15 .30*
MCQ Metacognitive Questionnaire; RRS Response Style Question-
naire; TCQ Thought Control Questionnaire
* Largest absolute correlation between each variable and any dis-
criminant function
Cogn Ther Res
123
the metacognitive model (Wells 2009; Wells and Matthews
1994). Interestingly, the negative loading of distraction on
this function suggests that diverting attention away from
negative thoughts (e.g., ‘‘I keep myself busy’’) is incon-
sistent with strong beliefs about the uncontrollability and
danger of worry and the presence of an intense CAS.
Indeed, the use of distraction as a thought control strategy
may represent a greater ability to flexibly control attention,
which is considered a protective factor in Wells’ model. A
recent study confirmed that attention control moderated the
relationship between the CAS and symptoms of psycho-
pathology (Fergus et al. 2012). Function 1 discriminated
among each of the groups, suggesting that there is a con-
tinuum of strength in CAS and negative metacognition that
increases across the never-depressed, recovered and cur-
rently depressed groups. The finding that the recovered
group remained significantly elevated in this function
compared with the never-depressed group may be impor-
tant, as it suggests that the function does not entirely revert
to normative levels following a depressive episode. This
result may indicate that the CAS and negative metacog-
nitions have stable trait-like properties that distinguish
depression-prone individuals from those who are not vul-
nerable. It may also or alternatively represent a scar effect;
once depression has been experienced, the changes intro-
duced in thinking styles and metacognition do not readily
revert to normal. If the scar explanation is correct, we do
not know whether the occurrence of depression itself or the
way that depression is treated that contributes to such an
effect. It is likely, however, that the recovered group still
experiences residual depressive symptoms; if this is the
case, the CAS and metacognitions could not have fully
reverted back to ‘never-depressed’ levels.
In summary, the results relating to Function 1 may be
interpreted as the never-depressed participants using more
distraction to address negative thoughts, whereas the cur-
rently depressed participants use rumination, worry and
punishment as self-regulatory strategies and hold strong
beliefs about the uncontrollability and danger of thinking.
The second discriminant function represents strong meta-
cognitive beliefs about the need to control thoughts (e.g., ‘‘If I
could not control my thoughts, I would not be able to func-
tion’’) coupled with low cognitive confidence (e.g., ‘‘I do not
trust my memory’’) and positive beliefs about worry (e.g.,
‘‘Worrying helps me to get things sorted out in my mind’’). At
the negative end of this function sits the use of reappraisal
(e.g., ‘‘I try to reinterpret the thought’’) as a thought control
strategy. This function presents an intriguing pattern because
never-depressed and currently depressed participants did not
differ on this dimension, suggesting it is not specific to current
depression. Instead, this factor appears uniquely related with
having experienced recovery from a depressive episode. More
specifically, recovery appears to be associated with higher
levels of the use of reappraisal as a thought control strategy,
along with lower dysfunctional metacognitions concerning
the need to control thoughts, lower memory confidence
problems and lower levels of positive beliefs about the need to
worry. This function could be understood as a consequence of
Never depressed
Previously depressed
Currently depressed
-2
-1
0
1
2
-2 -1 0 1 2
Group centroid
CAS:MCQ-Negative beliefsRRS-RuminationTCQ-WorryTCQ-Punishment
MCQ-Need of controlMCQ-Low cognitive confidenceMCQ-Positive beliefs
TCQ-Distraction
TCQ-Reappraisal
Fig. 1 Perceptual map of
groups in discriminant space.
CAS Cognitive Attentional
Syndrome, MCQ Metacognitive
Questionnaire, RRS Response
Style Questionnaire, TCQ
Thought Control Questionnaire
Cogn Ther Res
123
having undergone some type of psychological treatment (e.g.,
cognitive therapy with a focus on the use of reappraisal), or it
could reflect the effects of being treated with antidepressants.
Unfortunately, we had only sparse, unsystematic retrospective
information about participants’ treatment history; therefore,
we are unable to comment on this further. However, another
factor should still be considered. The never-depressed group
did not use reappraisal, presumably because they had no need
to, whereas the currently depressed also did not use reap-
praisal, even though this strategy might help them. The
recovered group was different from the never-depressed and
the currently depressed groups, suggesting that they might be
in a chronic state of reappraising their thoughts; this very
process could contribute to maintaining their recovery status.
However, the data appear to suggest that this is not a ‘normal’
state, as this group remains different from never-depressed
individuals. Accordingly, previously depressed individuals
may still have ‘‘extended processing’’, that is, CAS, but their
content has changed. From the perspective of the S-REF
model (Wells and Matthews 1994, 1996), this shift might
suggest that fundamental processes involving the regulation of
thinking processes may not have changed following recovery
from depression and may represent a relapse marker.
The findings from the present study are consistent with the
metacognitive model and further highlight a role for meta-
cognitive beliefs and rumination in the presentation of
depression. The present results support the continued
exploration of the role of worry-related metacognitions and
thought control strategies, in addition to rumination. This
role is in accordance with the metacognitive model, which
proposes metacognition and extended thinking, such as
worry, as trans-diagnostic features of emotional disorders
(Wells 2009). Further research is required to examine the
possibility of identifying individuals at risk of developing or
re-experiencing future depressive episodes on the basis of
their metacognitive profiles. In particular, further studies
should examine if the use of reappraisal as a strategy can
generate counterproductive effects later on by keeping the
CAS (i.e., extended thinking) activated.
There are limitations within the present study. First, the
sample consisted of mainly females and mildly depressed
participants. Second, we did not assess the presence of
comorbid Axis-I disorders among the participants. How-
ever, the present study’s low mean scores on the BAI for
the previously depressed group indicate that few of the
previously depressed participants had clinical levels of
anxiety symptoms at the time of assessment. Third, the
study only contained information regarding the partici-
pants’ current antidepressant medication use. Future stud-
ies should assess exposure to other treatments. Further
research among clinical samples is needed to test the
generalizability of our findings to more severely depressed
and male groups of patients. Additionally, prospective
studies are necessary to examine the possible causal effects
of metacognitive beliefs on thinking styles in MDD.
In conclusion, negative metacognitive beliefs concern-
ing uncontrollability/danger and the use of thought control
strategies in the form of rumination, worry and punishment
can be contrasted with a self-regulated style of distraction
to effectively discriminate among groups of depressed,
recovered and never-depressed individuals. In addition, the
tendency to use reappraisal appears to be unique among
those who have recovered from depression, but this is not a
cognitive style that occurs in never-depressed individuals.
This finding raises the question of whether reappraisal is
adaptive or a risk marker that occurs as a consequence of
having been formerly depressed.
Acknowledgments This study was supported by ‘‘The National
Program for Integrated Clinical Specialist and PhD-training for Psy-
chologists’’ in Norway. This program is a joint cooperation between
the Universities of Bergen, Oslo, Tromsø, the Norwegian University
of Science and Technology (Trondheim), the Regional Health
Authorities, and the Norwegian Psychological Association. The pro-
gram is funded jointly by The Ministry of Education and Research
and The Ministry of Health and Care Services. The study was also
supported in part by the Psychiatric Research Centre of Northern
Norway. The authors would like to thank the participants and the
research assistants who contributed to the data collection. We would
also like to thank Professor Adrian Wells for commenting on an early
draft of the manuscript. Last but not least, we would like to thank the
anonymous reviewers for helpful suggestions, which contributed to
the improvement of this paper.
Conflict of Interest Marianne Halvorsen, Roger Hagen, Odin
Hjemdal, Marianne S. Eriksen, Ase J. Sørli, Knut Waterloo, Martin
Eisemann and Catharina E. A. Wang do not have any commercial
association that might pose a conflict of interest in connection with
the manuscript.
Informed Consent All of the procedures followed were in accor-
dance with the ethical standards of the responsible committee on
human experimentation (institutional and national) and with the
Helsinki Declaration of 1975, as revised in 2000. Informed consent
was obtained from all patients before entering the study.
Animal Rights No animal studies were carried out by the authors
for this article.
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