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Commonly, individuals prone to hallucinations and delusions hold dysfunctional metacognitive beliefs and report higher levels of negative affect, yet, these associations have not been clearly investigated in non-clinical samples due to the failure to control for high intercorrelations between variables. The aim of the current study was to investigate how hallucination and delusion proneness are associated with dysfunctional metacognitions and negative affect. A cross-sectional sample of 715 students free from psychiatric diagnoses (Mage = 28.1 years, SD = 10.9, range 18–65) completed the Launay-Slade Hallucination Scale (LSHS-R); Peters et al. Delusion Inventory (PDI-21); Depression, Anxiety, and Stress Scale (DASS-21); and the Metacognition Questionnaire (MCQ-30). Findings that participants who were prone to both hallucinations and delusions reported elevated levels of negative affect support the need for targeted mental health treatment for individuals who experience psychological distress related to their hallucinatory and delusional experiences. While metacognition beliefs of need to control thoughts and cognitive self-consciousness, along with the anxiety and stress DASS-21 subscales appeared as significant cross-sectional predictors of proneness to hallucinations and delusions, only metacognitions demonstrated any notable predictive value for delusion proneness. This finding questions the role of metacognitions in determining hallucination and delusion proneness in non-clinical samples.
It has been suggested that psychotic symptoms, such as hallucinations and delusions, exist on a continuum that ranges from normality to clinical psychosis (David, 2010; van Os, Linscott, Myin-Germeys, Delespaul, & Krabbendam, 2009). This continuum model is supported by findings that hallucinations, simply described as false perceptions and delusions, commonly described as false beliefs, are prevalent in individuals without clinical psychosis (Choong, Hunter, & Woodruff, 2007; Freeman, 2006). Epidemiological studies, investigating a variety of psychotic symptoms, have found prevalence rates ranging from 4% (Tien, 1991) to 39% (Ohayon, 2000) in the general population. It has been hypothesised that hallucinations and delusions may result from dysfunction in the regulation of cognition (Morrison, 2001). In line with this, a number of researchers have proposed metacognition, a term used to describe the process of ‘thinking about thinking’ (Varese, Barkus, & Bentall, 2011), as an important factor in the development and maintenance of psychotic symptoms (García-Montes, Cangas, Pérez-Álvarez, Fidalgo, & Gutiérrez, 2006; Morrison, Wells, & Nothard, 2000).
The Self-Regulatory Executive Function model (S-REF; Wells & Matthews, 1994) states that a cognitive-attentional syndrome, described as a state of heightened self-focused attention, activation of dysfunctional beliefs, attentional bias, and ruminative processes, creates a vulnerability to psychological dysfunction. The S-REF model has been proposed as a framework for understanding a range of psychological dysfunctions, including rumination, obsessive compulsive disorder, depression, general anxiety disorder, and psychosis (Matthews & Wells, 2004; Morrison & Wells, 2003; Wells & Carter, 2001; Wells & Matthews, 1994). In accordance with the S-REF model (Wells & Matthews, 1994), it has been suggested that dysfunctional metacognitive beliefs regarding worry and intrusive thoughts, are implicated in the development and maintenance of hallucinations and delusions in both clinical and non-clinical samples (Barkus et al., 2010; García-Montes et al., 2006; Larøi & Van der Linden, 2005).
Other cognitive theories also suggest that hallucinations and delusions may results from disturbances in the regulation of cognition (e.g., David, 2004; Morrison, 2001; Varese & Bentall, 2011). High co-occurrence between hallucinations and delusions in both clinical and non-clinical samples further indicate that such experiences may share similarities in their cognitive underpinning (Larøi & Woodward, 2007; Lincoln, 2007). A common thread within cognitive theories is the idea that psychotic symptomatology results from misinterpretations of cognitive intrusions and that hallucinatory and delusional experiences may be due to misattributed intrusive thoughts, images, and impulses (Morrison, 2001). The meaning given to such experience may in turn influence the individual's behavioural, affective, and cognitive responses (Morrison, 2001). It should also be noted that Morrison et al. 's model does infer causality in that dysfunctional metacognitive beliefs lead to misattribution of intrusive thoughts to external sources, thus generating hallucinatory experiences. However, according to recent review (Varese & Bentall, 2011), the role of metacognitions in the genesis and maintenance of hallucinations is not consistently supported by empirical results, therefore requiring further research.
Symptoms of psychosis have been associated also with emotional disturbances (Freeman & Garety, 2003). Researchers have linked the onset, development, maintenance, and appraisal of hallucinations and delusions with negative emotional states in both clinical and non-clinical populations (Cella, Cooper, Dymond, & Reed, 2008; Freeman & Garety, 2003; Paulik, Badcock, & Maybery, 2006). In particular, a number of studies have found associations between increased negative affect, such as anxiety, depression, and stress, with the expression of hallucinatory and delusional symptoms in samples of otherwise healthy individuals (Allen et al., 2005; Paulik et al., 2006). However, contrary findings of Cangas, Errasti, Garcia-Montes, Alvarez, and Ruiz (2006), along with those by Morrison et al. (2000), demonstrate how inconsistent previous research has been in reliably demonstrating such relationships, especially for hallucination.
A key limitation of previous research investigating cognitive and affective associations with hallucination and delusion proneness, potentially explaining inconsistent findings, has been the failure to control for high intercorrelations between variables (Varese & Bentall, 2011). Consequently, the aim of the current study was to investigate whether the combination of hallucinatory and delusional proneness is associated with higher levels of negative affect in a non-clinical sample. Specifically, the first aim was to compare levels of negative affect in non-clinical participants who are prone to both hallucinations and delusions, against those who are less prone to such experiences. The second aim was to clarify the cognitive-affective cross-sectional predictors of hallucination and delusion proneness in a non-clinical sample, while controlling for covariation between the assessed variables. It was predicted that in accordance with the S-REF model that those participants grouped as prone to both hallucinations and delusions would have higher levels of negative affect than those participants grouped as less prone. Furthermore, it was predicted that delusion proneness, dysfunctional metacognitive beliefs, and depression, stress, and anxiety would be significant predictors of hallucination proneness. Similarly, it was also predicted that hallucination proneness, dysfunctional metacognitive beliefs, and depression, anxiety, and stress would be significant predictors of delusion proneness.
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With regard to the first research aim, participants prone to both hallucinations and delusions reported significantly higher levels of negative affect than participants not prone to either hallucinations and delusions. While positive associations between hallucination proneness, delusion proneness, and negative affect have been found previously (e.g., Cella et al., 2008; Paulik et al., 2006), to the best of the researchers' knowledge, this is the first investigation to show that participants prone to both hallucinatory and delusional experiences report comparatively higher levels of negative affect.
In accordance with the S-REF and Morrison's (2001) model, delusions may result as secondary symptoms from misinterpretations of cognitive intrusions and abnormal perceptual experiences (Krabbendam et al., 2004; Larøi & Woodward, 2007). As according to Garety, Kuipers, Fowler, Freeman, and Bebbington (2001), experiencing negative emotions may further increase the chance of interpreting such symptoms as threatening, and if negative affect is a consequence of hallucinatory and delusional experiences, such symptoms could reinforce each other.
In relation to the second research aim, it was predicted that delusion proneness, dysfunctional metacognitive beliefs, and depression, stress, and anxiety would be significant predictors of hallucination proneness. The results provided some support for this hypothesis, showing that a substantial proportion (32%) of hallucination scores could be accounted for by the predictors. Delusion proneness was found to be by far the strongest predictor, with uncontrollability and danger and cognitive self-consciousness making small additional contributions towards hallucination scores. Furthermore, while initial correlations indicated small to medium positive associations between hallucination proneness and all measures of negative affect (stress, depression, and anxiety), these variables failed to make a significant contribution towards hallucination scores in the regression.
In accordance with the S-REF model of vulnerability to psychological dysfunction (Wells & Matthews, 1994), it has been suggested that a combination of positive and negative metacognitive beliefs are implicated in hallucination proneness (Baker & Morrison, 1998; Larøi & Van der Linden, 2005). Although the current investigation found that negative beliefs about the uncontrollability and danger of thoughts predicted hallucination proneness, these metacognition only explained very small percentages of hallucination proneness variance. These findings, which importantly controlled for intercorrelations between variables, suggest that metacognitions and negative effect are not central constructs in mediating or moderating hallucination proneness.
It was also predicted that hallucination proneness, dysfunctional metacognitive beliefs, and depression, anxiety, and stress would be significant predictors of delusion proneness. Results indicated that 47% of variance in delusion proneness scores could be explained by the predictors, however, hallucination proneness emerged as the strongest predictor of delusion scores. While metacognition beliefs such as need to control thoughts and cognitive self-consciousness, along with the anxiety and stress DASS-21 subscales appeared as significant cross-sectional predictors, only the metacognitions demonstrated any notable predictive value for delusion proneness. Interpretation of the combined positive findings for the role of metacognition in delusion proneness alongside the negative findings for hallucination, is that these results do not fit with the original S-REF influenced account of Morrison of negative metacognitive beliefs leading to intrusive thoughts generating cognitive dissonance which in turn motivates their externalisation (metacognition leading to the formation of psychotic symptoms). Rather it could be speculated that need to control thoughts and cognitive self-consciousness may, more simply, have a role in increasing attention towards unusual thought content and/or increasing distress, which may be a maintaining factor for these unusual thoughts.
The findings of the current investigation highlight the close association between hallucination proneness and delusion proneness in non-clinical samples. It was demonstrated that participants who are prone to both hallucinations and delusions report comparatively higher levels of negative affect. This finding is new in the literature, and may have important implications for mental health service provision. By controlling for covariations between hallucinations, delusions, dysfunctional metacognitions, and negative affect, the current study addressed an important methodological limitation seen in previous research. From these analyses, the cognitive-affective mechanism underlying the expression of hallucinatory and delusional experiences in non-clinical samples was further clarified. These data support the contention that metacognitions have only a limited association with hallucinatory but a larger involvement in the genesis of delusional experiences in non-clinical samples. While this is in opposition to theoretical standpoints such as by Morrison, Haddock, and Tarrier (1995) who propose hallucinatory and delusional experiences may be due to misattributed intrusive thoughts, images, and impulses, as well as Wells & Matthews' S-REF model (1994), these data do further support recent claims by Varese and Bentall (2011): ‘Although the results from the analogue studies included in this review support the existence of robust relationships between hallucination proneness and metacognitive beliefs, these studies suffered from methodological limitations which might have led to inflated estimations of these associations’ (p. 861).
These findings have implication for the management of hallucinations and delusions symptoms in non-clinical populations. The finding that participants prone to both hallucinations and delusions are at risk of elevated levels of negative affect supports the need for targeted mental health treatment for individuals who experience distress associated with such cognitions. Most importantly from this research, the suggestion that dysfunctional metacognitions do not play any meaningful association with the expression of hallucination symptoms in non-clinical samples, questions the evidence base of metacognitive-focussed techniques for the treatment of hallucination conditions in such populations.