Thinking about thinking: an exploration of metacognitive factors in the development and maintenance of positive psychotic symptoms

The literature review discusses the role of metacognition, defined as the cognitive processes involved in ‘thinking about thinking’, in the development and maintenance of persecutory delusions and auditory hallucinations. Much of the literature points to a strong role for metacognitive beliefs in the experience of both clinical and non-clinical levels of these symptoms and evidence is emerging too for the importance of metacognitive strategies, for example thought control, in the maintenance of persecutory delusions. Research to date however, has relied predominantly on non-causal correlational methodology to investigate the relationship between metacognition and psychosis. In addition, there is some difficulty in discerning the contribution of metacognition to persecutory delusions and auditory hallucinations specifically, owing to combined analysis or inclusion of delusions that are not persecutory or hallucinations that are not auditory. Overall, the findings of this review support the application of the Self- Regulatory Executive Model (S-REF) to the positive symptoms of psychosis and research strongly demonstrates the key role of affective processes in the development and maintenance of clinical and non-clinical persecutory delusions and auditory hallucinations. The study aimed to explore the role of metacognitive strategies and metacognitive awareness in the maintenance of distress in non-clinical paranoia. A 2x2 between-subject experimental design (paranoia x condition) was employed. Seventy-three non-clinical staff and students participated in the study and were randomised to an experimental condition including an anxiety-inducing task or control condition. All participants completed measures of paranoia, anxiety, self- focus, metacognitive strategies and metacognitive awareness. Results demonstrated that participants with non-clinical paranoia experienced more paranoid cognitions, state and trait anxiety and used significantly more metacognitive strategies, including thought suppression. In addition, there was some evidence for lower metacognitive awareness in participants with high paranoia. These findings were not associated with condition. Future research and clinical implications in relation to the results are discussed.