It appears, however, that problems with intentional inhibition are not the only metacognitive deficit associated with deficits in the sense of agency. In this section I suggest that those suffering from verbal hallucinations and those at risk of developing them have unusual metacognitive beliefs. Although these beliefs are less central to the model I present here than the intentional inhibition deficit discussed above, an understanding of these beliefs is needed to complete this model.
Metacognitive beliefs are often quantified using the metacognitive questionnaire (MCQ) (Cartwright-Hatton & Wells 1997). The MCQ has five subscales designed to quantify the extent to which subjects (1) believe that worrying is good for them (e.g. ‘worrying helps me get things sorted out in my mind’) (2) believe that they can’t control their own thoughts and that a lack of control is dangerous (‘when I start to worry I can’t stop’) (3) are confident in their own cognitive abilities (‘I have little confidence in my memory for names and faces’) (4) are superstitious about their thoughts or believe they deserve to be punished for bad thoughts (‘if I didn’t worry about something and then it happened it would be my fault’) and (5) attend to their own thoughts (‘I pay close attention to the way my mind works’) (Cangas et al. 2006 pg 489, Lobban et al. 2002 pg 1355-1356).
Recently some studies have attempted to assess metacognitive deficits in schizophrenia (see, for example, Lysaker et al. 2005, Lysaker et al. 2007, Baker & Morrison 1998, Cangas et al. 2006, García-Montes et al. 2006a, Garcia-Montes et al. 2006b, Lobban et al. 2002, Morrison & Petersen 2003, Morrison & Wells 2003). For my purposes many of these studies are limited in their usefulness because metacognition is not clearly differentiated from theory of mind, performance of schizophrenic patients is not compared to that of healthy controls and there are no symptom group comparisons.
What we need is a comparison of specific symptom groups to psychiatric and healthy controls on tasks of metacognition. One study has done so for the sense of agency over one’s thoughts. If some forms of verbal hallucinations arise from a failure to metacognitively represent the occurrence of processes of generating inner speech, then patients experiencing hallucinations should report less of a feeling of control over their inner speech than controls. Baker and Morrison (1998) have found that this is the case. In one study they asked subjects to perform a word association task. The experimenter read a list of words and subjects had to think and state a word they associated with the word that was read aloud. After each word they thought subjects were asked (amongst other things) to rate the extent to which they felt they controlled the occurrence of the response word and the extent to which they wanted to think that (as opposed to another) word. The ratings of those with verbal hallucinations were compared to those of schizophrenic patients without verbal hallucinations and to healthy controls. Significantly lower ratings were given by patients with hallucinations on both questions compared to controls (Baker & Morrison 1998 pg 1204). This suggests that those with verbal hallucinations have difficulty in representing the control they have over their inner speech, in turn suggesting that a metacognitive model is promising.
However, there are problems with interpreting this study. Lobban and colleagues (2002) found that these differences were not significant when current levels of anxiety and depression were controlled for. This suggests that the deficit is not specific to verbal hallucinations. Furthermore, Langdon and colleagues report that those suffering from verbal hallucinations describe their inner speech in a way indistinguishable from healthy controls (Langdon et al. 2009). There are further problems with Baker and Morrison’s study. The non-hallucinating control group did contain patients with delusions (Baker & Morrison 1998 pg 1204) and it is not clear if any of these patients were suffering any of the delusions, such as thought insertion, which also involve an abnormal sense of agency over thoughts. This makes interpretation of these results tricky. Each symptom group will need to be tested on such metacognitive tasks (but tested for experiences relating to thoughts, emotions or intentions instead of just inner speech).
Further studies suggest that those with verbal hallucinations score significantly differently to controls on various subscales on the MCQ. However, many of these studies fail to control for current levels of anxiety (such as Garcia-Montes et al. 2006b, Morrison & Wells 2003, and Stirling et al. 2007). This makes their results hard to interpret as it is not clear whether the different beliefs relate to verbal hallucinations or to anxiety. As such I have left these studies out of this discussion, however, I emphasize that their results would be important were anxiety to be controlled for.
Lobban and colleagues (2002) is one of a few studies to test the metacognitive beliefs of those experiencing verbal hallucinations and control for the effects of anxiety. They used a modified version of the MCQ in which they took the five biggest contributors to each of 5 factors listed above and added some new questions of their own. Their analysis of this new questionnaire suggested that three additional subscales had been added relating to the extent to which subjects believed that (6) their thoughts should be consistent with one another (‘I should not have thoughts that contradict each other’) (7) people generally have intrusive thoughts (‘most people have thoughts that seem to come out of the blue’) and (8) they themselves had intrusive thoughts (‘I often have thoughts that I do not want to have’) (Lobban et al. 2002 pg 1353 and 1356). The answers to the questionnaire were compared across four groups. The first group all had a diagnosis of schizophrenia and reported current verbal hallucinations where the voice seemed to come from outside of their head. The second group had a diagnosis of schizophrenia but reported never hearing voices. Those who had delusions of thought insertion or other symptoms that may be the result of deficits in the sense of agency or otherwise related to verbal hallucinations were excluded from these groups to avoid problems with interpretation. In the third group were those diagnosed with an anxiety disorder (other than post traumatic stress disorder, generalized anxiety disorder or obsessive compulsive disorder and no co-morbid schizophrenia). In the final group were healthy controls (Lobban et al. 2002 pg 1353-1354).
Once current levels of anxiety were controlled for the only significantly different responses between those currently hallucinating and those who had never hallucinated were on the cognitive confidence sub scale. That is, those who were currently hallucinating were more likely than others with schizophrenia to lack confidence in their own cognitive abilities. However, this feature was shared by those with anxiety disorder, suggesting that it is not specific to verbal hallucinations per se. All the pathological groups were less confident in their cognitive abilities than healthy controls (Lobban et al. 2002 pg 1359).
After current levels of anxiety were controlled for the only significantly different responses between those currently hallucinating and those with anxiety disorder was on the subscale measuring the extent to which subjects believed their thoughts should be consistent with one another. That is those who were currently hallucinating were more likely than those with anxiety disorder to believe that their thoughts should be consistent with one another. Interestingly, those with a diagnosis of schizophrenia but who had never hallucinated tended to fall between those who were hallucinating and those with anxiety disorder on this scale. There was no significant difference between the non-hallucinating group and either of the other pathological groups. A larger sample size may show an effect here. However, as it stands this is enough to show a profile of altered metacognitive beliefs in cases of verbal hallucination. All of the patient groups tended to think their thoughts should be more consistent with each other than the healthy controls (Lobban et al. 2002 pg 1360).
This study suggests that those with verbal hallucinations have an unusual set of metacognitive beliefs. The pattern of metacognitive beliefs displayed by those with verbal hallucinations is characterized by a tendency to lack confidence in one’s cognitive abilities and to believe that one’s thoughts should be consistent with each other. After current levels of anxiety are controlled for, it is only the union of both sets of beliefs that differentiates those with verbal hallucinations from other schizophrenic patients and those with anxiety disorders.
Garcia-Montes and colleagues (2006a) attempted to extend this research to see if scores on the MCQ were associated with hallucination predisposition in healthy people. They used the revised hallucination predisposition scale (RHS) to quantify subject’s hallucination predisposition. The RHS has been shown to measure predisposition to both visual and auditory hallucination. Subjects were also given the MCQ and had their current level of anxiety measured.
After controlling for current levels of anxiety significant correlations between a predisposition to both auditory and visual hallucinations and a tendency to lack confidence in one’s own cognitive abilities were discovered (García-Montes et al. 2006a pg 314). This suggests that a lack of confidence in one’s own cognitive abilities is not specific to verbal hallucinations. However, this does not threaten the above finding that it is the tendency to lack confidence in one’s cognitive abilities and believe that thoughts should be consistent with each other that is specific to verbal hallucinations. Unfortunately Garcia-Montes and colleagues used the original version of the MCQ, not the modified version used by Lobban and colleagues. As such they had no measure of beliefs about the consistency of thoughts. This version of the MCQ does not have the resources to challenge the findings of Lobban and colleagues.
Verbal hallucinations are not the only clinical symptoms associated with unusual metacognitive beliefs. Patients suffering from generalized anxiety disorder or obsessive compulsive disorder and those showing mild forms of the symptoms of these disorders also have unusual metacognitive beliefs. In order to confirm the specificity of unusual beliefs discussed above to verbal hallucinations it is worth pausing to examine what is unusual about the metacognitive beliefs of those suffering obsessive compulsive or other anxiety symptoms.
Patients suffering from obsessive compulsive or generalized anxiety disorder differ from healthy controls in their scores on the original MCQ. Both those suffering from obsessive compulsive disorder and those suffering generalized anxiety disorder score higher on subscales 2 and 4 than controls. This indicates that both disorders are associated with a tendency to believe that one cannot control one’s thoughts, that this lack of control is dangerous and that one deserves to be punished for bad thoughts or other superstitions about one’s ‘bad’ thoughts. Those with obsessive compulsive disorder also differ from controls and those with generalized anxiety disorder on subscale 5, indicating that they pay an unusually high amount of attention to their own thinking. Those with generalized anxiety disorder do not differ from healthy controls on this subscale (Cartwright-Hatton & Wells 1997). Similarly subjects taken from a healthy sample who nevertheless score highly on self report measures of anxiety and obsessive compulsive like symptoms score higher subscale 2 of the MCQ than controls. Indicating that they tend to believe that they lack control over their thoughts and that this lack of control is dangerous (Irak & Tosun 2008 pg 1320). Subjects reporting obsessive compulsive like symptoms also scored higher on subscales 1, 3 and 5 (Irak & Tosun 2008 pg 1320-1323).
From these studies it is apparent that those suffering from obsessive compulsive or other anxiety symptoms also have unusual metacognitive beliefs. However, the unusual beliefs they hold are different from those held by people who suffer from verbal hallucinations. Those suffering from verbal hallucinations tend to believe that their thoughts should be highly consistent with one another and to lack confidence in their mental abilities. In contrast, those suffering from obsessive compulsive disorder tend to believe that they cannot control their thoughts, that this lack of control is dangerous, they deserve to be punished for bad thoughts or other superstitions about one’s bad thoughts and they pay an unusually high amount of attention to their own thinking. Patients suffering from generalized anxiety differ from those with obsessive compulsive disorder only in that they pay no more attention to their thinking than healthy controls. It is worth noting that the studies which examine the metacognitive beliefs of those suffering from obsessive compulsive or generalized anxiety disorder use the original version of the MCQ and not the modified version from Lobban and colleagues (2002), so they do not assess whether or not these patients lack confidence in their mental skills ala those suffering from verbal hallucinations. Furthermore in the Lobban and colleagues study those with verbal hallucinations did not differ from those with anxiety disorders on the subscale measuring patients’ confidence. However, this is consistent with the above claim that both the belief that one’s thoughts should be highly consistent with one another and the lack of confidence in one’s mental abilities characterize the unusual metacognitive beliefs of the patient suffering from verbal hallucinations.
These studies are all correlational. That is they found correlations between symptoms (or vulnerability to the symptoms) and scores on the MCQ subscales. As such we aren’t entitled to make any inference about what causes this relationship on the basis of these results alone. All we know is that those with verbal hallucinations or who are vulnerable to them do have some unusual metacognitive beliefs.
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