Objective
The aim of the study was to compare a clinical sample with eating disorders to different control samples on self-report measures of metacognition and eating disorder symptoms, in order to investigate the role of metacognition in eating disorders.
Method
The clinical group consisted of 53 female patients with eating disorders who completed the Metacognitions Questionnaire-30 and the Eating Disorder Examination Questionnaire 6.0. One-hundred and fifty women who served as a control group completed the questionnaires as an Internet survey. This control group was divided into three groups based on self-reported history of eating and psychiatric problems (N = 47), other psychiatric problems (N = 37), or no such problems (healthy controls: N = 66).
Results
The clinical group scored significantly higher on dysfunctional metacognition than healthy controls, especially on “negative beliefs about uncontrollability and danger”, “need to control thoughts”, and total MCQ-30 score. Eating disorder symptomatology was positively correlated with metacognition. Metacognition explained 51% of the variance in eating disorder symptoms after controlling for age and BMI, with “need to control thoughts” as the most important factor.
Conclusion
Metacognitive beliefs may be central in understanding eating disorders, and metacognitive treatment strategies could be a promising approach in developing new psychological treatments for eating disorders.
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V, APA, 2013) defines the criteria for different eating disorders such as Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). All these eating disorders share an intense fear of weight gain and a distorted body image that often serve as a basis for negative self-evaluation. Eating disorders are associated with severe physical and psychosocial consequences, and are considered difficult to treat (Fairburn & Harrison, 2003). Cognitive behavioral therapy is considered the treatment of choice for BN (National Institute for Health and Care Excellence [NICE], 2004), but there is insufficient evidence to conclude on a treatment of choice for AN (Bulik, Brownley, Shapiro, & Berkman, 2012). Prognostic indicators suggest that severity of psychiatric comorbidity relates to outcome for BN, while severity and duration of AN relates to outcome for treating AN (Keel & Brown, 2010).
These findings may indicate that there is a need for a new understanding of eating disorders which again may pave the way for more efficient treatments. The metacognitive model has identified transdiagnostic psychological processes that are involved in several disorders (Wells, 2009). It represents a new perspective and as such it may be of interest to explore if it contributes to the understanding of eating disorder symptoms. Metacognitive theory states that psychological disorder results from an inflexible and maladaptive response pattern to cognitive events, which is labeled the Cognitive Attentional Syndrome (CAS). The CAS consists of persistent worry and rumination, threat monitoring and ineffective coping strategies that contribute to the maintenance of the problem (Wells, 2013). The CAS is controlled by erroneous beliefs about trhinking. These beliefs are called metacognitions, which refer to internal cognitive factors that control, monitor and appraise thinking. They are both positive- and negative metacognitive beliefs. Positive metacognitions are concerned with the benefits of worry, rumination, threat-monitoring, and counter-productive coping strategies. Example of a positive metacognition related to eating disorders could be “I must worry about my weight and eating in order to control my weight”. Negative metacognitions are concerned with the uncontrollability and danger of thoughts and cognitive experiences. Example of a negative metacognition in eating disorders could be “Worrying about my body and weight could make me go mad”. For more detailed descriptions of positive and negative metacognition in Anorexia Nervosa see Woolrich, Cooper, and Turner (2008). These negative and positive metacognitive beliefs are the driving force of the CAS. Metacognitive treatment aims to eliminate the CAS to enable new learning to take place (Wells & Matthews, 1996).
There are several reasons why the metacognitive model could be beneficial for understanding and treating eating disorders. First, eating disorders seem to have many similarities with other types of psychiatric disorders related to worry where metacognitions are central, like generalized anxiety disorder (Konstantellou, Campbell, Eisler, Simic, & Treasure, 2011), and obsessive–compulsive symptoms (Halmi et al., 2005). Second, rumination (e.g. “I think about all my shortcomings, failings, faults, and mistakes”), which is an important aspect in the metacognitive treatment of depression, seems to also be of relevance in patients with bulimic symptoms (Nolen-Hoeksema, Stice, Wade, & Bohon, 2007). Third, eating disorders have a high rate of comorbidity (Hudson, Hiripi, Pope, & Kessler, 2007), and because the metacognitive model focus on common psychological processes that transcend diagnostic borders, this approach could be considered especially relevant in treating eating disorders.
