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Review of Literature
Metacognition:
Metacognition is cognition applied to cognition. It monitor, control, and appraise the process of awareness. It consists of cognitive attentional syndrome (CAS) which contains various self-regulatory strategies or coping behaviors. Metacognition decides what we pay attention to along with the factors that enter consciousness. It also shapes appraisals and influences the types of strategies that we use to regulate thoughts and feelings. 25
Review of literature has shown that in 1997 an examine explored the connection among metacognition, responsibility and perfectionism in obsessive–compulsive disease. Sample consisted of 108 OCD patients, who completed an intensive (3 weeks) multimodal treatment such as behavioral, cognitive and metacognitive elements. Results indicated that obsessive–compulsive symptoms, cognitive and metacognitive beliefs were significantly decreased in the treatment phase and the responders of the same had larger reductions in these beliefs than non-responders. 26
In year 2000 a sample of 1132 participants was considered for a study evaluating function of rumination in depressive disorder and combined anxiety/depression signs and symptoms and this concluded rumination as a common cognitive pattern in depression. Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), Structured Clinical Interview for DSM (SCID), Beck Anxiety Inventory (BAI), ruminative responses scale all being the actively used tools. Hence it ruled out that the chronicity of depressive disorder was called out by rumination before taking into account the effects of baseline depressive signs and symptoms rather than predicting it afterwards. Further adding, anxiety signs and symptoms were watched for by rumination especially in specific attribution of human beings alliance with anxiety depressive signs and symptoms.27
Autonomic arousal, fear, worry and avoidance are the involved factors of fundamental reaction to anxiety and thus is labeled as cognitive model of anxiety disorders. A study carried out in 2011 recruited individuals in five groups particularly non-patients having no history of psychological and patients with primary GAD, social phobia, panic disorder and major depression; and every group consisted of 24 individuals. The tools involved here were anxious thoughts inventory (ATI) and meta-cognitions questionnaire (MCQ). And it put light that population with GAD record excessive poor metacognition ratings, thus alienating them from the alternative anxious, depressed and non clinical groups. And while the depressive population put forth a level of negative metacognition that falls among the other patients and patients with GAD.28
For this reason it is able to be said that early intervention might be beneficial and psychotherapeutic intervention is probably added in without or with medicine and within the beginning before the onset of acute psychopathology mindfulness or metacognitive therapies can also bring the identical effect as RCTs claiming the efficacy of CBT in mild to moderate depression. In spite of the fact that restricted literature is available from India, it is drastically studied in diverse psychiatric situation using those interventions. In 2016 the effective application of Mindfulness Integrated Cognitive Behavior Therapy (MICBT) in curing patients having obsessions without prominent overt compulsions, was being authenticated by a study whose fundamental objective was to take a look a look at the efficacy of mindfulness integrated cognitive behavior therapy in patients with predominant obsessions. The sample consisted of twenty-seven patients of OCD and recruited from the tertiary care psychiatric hospital over 14 months and on an outpatient basis all patients acquired 12–16 sessions of MICBT. The sample of patients considered here had been free of medication for at least 2 months prior to baseline assessment and they had rather a few or no overt compulsions. And the measures used here at baseline, mid and post treatment and 3 month follow up were Yale–brown obsessive-compulsive scale (YBOCS) and the clinical global impression scale. Results suggest that 18 (67%) carried out remission (55% discount within the YBOCS severity score) at three month follow-up as a result of MICBT.29
Beyond this, the study also signifies that in identifying male adolescents in particular, at danger for the onset of major depressive disorder in emerging adulthood, metacognition act as an essential element. Distinguishing meta-cognition is probably beneficial in early intervention however it also heightens the need to identify and the contrast in metacognition of clinical and non-clinical population. This implies that clinical population had greater positive beliefs about metacognition than non-clinical. A study investigated the relationships among rumination, depression and metacognition in adults with clinical depression (study1, n=200) and in adults without depression (study 2, n= 200). To suit this reason measures of metacognition, Positive Beliefs Rumination Scale (PBRS) become administered and it was observed that effective metacognitive beliefs have been a predictor of rumination in both depressed participants (? =0.31,p< .05) and in participants without depression (? = 0.58, p< .05). Depressed women and men with and without records of assault have been looked at while additionally pronounced the likewise findings. It is quite visible that these cross-sectional research all yoke together metacognitive beliefs about the beneficial use of rumination with self-reported rumination.30
Three hypotheses were put under test based on this research, forecasting first in the hierarchy is, metacognition is toweringly associated with anxiety and obsessive – compulsive (O-C) signs and symptoms, second presenting metacognition as a medium among obsessive – compulsive (O-C) signs and anxiety and third stating metacognitive predictors of anxiety varied from the ones of obsessive – compulsive (O-C) signs and symptoms. The sample comprised of 850 college students thus finding out high connections among metacognition, obsessive – compulsive (O-C) signs and anxiety. Likewise it also confirmed the relationship between obsessive – compulsive (O-C) symptoms and patients with anxiety as mediated by meta-cognition.31
The cross sectional association among rumination, experiential avoidance and depression is nicely proved wherein an interaction impact changed into observed between avoidance and rumination; and avoidance on the time of excessive rumination became determined to be related to depression symptoms. However in the longitudinal study there had been no such interaction discovered.32
Additionally which resulted in negative emotions as an effect of overdoing on rumination rating higher on metacognitive scales. This turned into supported by using a research on metacognitive beliefs and negative emotions where greater negative emotions have been proven via the ones having higher rankings on metacognition scale in evaluation to people with decrease rankings on metacognition. It also offers guide for role of metacognitive beliefs as a maintaining factor for negative emotions.33
Using wait-list controlled clinical trial, the influence of metacognitive therapy (MCT) on symptoms of body dysmorphic disorder (BDD) and thought fusion, were 20 patients from varied departments of a hospital, thus randomly assigning the patients into experimental or wait-list groups. Yale- brown obsessive compulsive scale changed for body dysmorphic disorder (BDD-YBOCS) and the thought fusion instrument (TFI) being the tools involved The experimental group went through eight weekly sessions whereas the control group remained inside the waiting-list till the cease of the follow-up. Measures have been taken at pre-test, post-test (after 2 months) and follow-up (after 6-months). The conclusions highlighted that the signs and symptoms of body dysmorphic disorder and thought fusion were being comprehensively reduced by metacognitive therapy as compared to the wait-list.34
In order to explore the relation between experiential avoidance and anxiety disorders in addition to the usefulness of avoidance and fusion questionnaire, a research was conducted in 2012, consisting a cross- section of 111 inpatients avoidance and fusion questionnaire (AFQ-Y), child behavior checklist(CBCL), youth self report(YSR), computerized diagnostic interview schedule for children( C-DISC), Wechsler intelligence scale for children- IV (WISC-IV), Wechsler adult intelligence scale (WAIS-III) being the tools used comprehensively. A revelatory relation between anxiety disorder and experiential avoidance, independent of depression, emerged as a result. 35
A research reported that MCT contributed through video- conferencing may also be very efficient. For this motive three participants were recruited through the Curtin university Psychology clinic. This novelty is to have a look at whether MCT can be a precious treatment for OCD whilst introduced through videoconferencing. The research used videoconferencing device, Structured Clinical Interview for DSM-IV (SCID), Yale-Brown obsessive compulsive scale (Y-BOCS), depression, anxiety and stress scales — brief shape (DASS-21), metacognitive questionnaire—short form (MCQ-30), working alliance inventory —short form-client (WAI-S-C). Clinically significant reductions in OCD signs and symptoms, depression, anxiety and stress are what the individuals experienced, as the result pointed out. Hence it turned out to be a cost effective step in many developing countries especially where patient- health practitioner ratio is extremely disproportionate, as a result of tripping in therapy via virtual mediums. 36

Cognitive Fusion & Thought control:
Cognitive fusion is a process that involves attaching thought to an experience. As per Harris people get tangled with their thoughts. They focus their attention on the contents of their mind rather than taking the information through their five senses and hence make decisions based on their internal experiences only. It is clinically important that the phenomena of cognitive fusion in clinical as well as non-clinical population in both must be apprehended. An attempt is to understand and the way fusion originates from one’s belief inside the content of the idea whereby brought on emotion is the end result of believability and meaning attached to the notion. There are three domains of thought fusion:
1.)Thought event fusion
2.)Thought object fusion
3.)Thought action fusion37
Thought control in OCD is an attempt to escape from unwanted, distressing thoughts. People with this disorder find thought control as the only way to improve the quality of their lives. As per the literature control of obsessive thoughts in the disorder consists of avoidance and removal of the same.38 Among many instruments used for measuring thought control, the one used in current study is thought control questionnaire in which there are statements tapping following thought control strategies:
1.)Distraction
2.)Self-control
3.)Worry
4.)Punishment
5.)Reappraisal39
Research has indicated that an examine evaluated cognitive fusion in nonclinical and highly anxious community sample conducted in 2012 on a sample which include 432 healthy undergraduates and 503 highly anxious community samples. The tools used had been computerized battery of questionnaires like BAFT questionnaire, anxiety sensitivity index (ASI), acceptance and action questionnaire-16 (AAQ-16), white bear suppression inventory (WBSI), spielberger trait anxiety inventory (STAI-T), penn state worry questionnaire (PSWQ), mindful attention awareness scale (MAAS), self-compassion scale (SCS) and quality of life inventory (QOLI). Thus evaluating the effectiveness of a famous self-assist workbook for anxious struggling and acceptance workbook for anxiety: a guide to breaking free from anxiety, phobias and worry the use of acceptance and commitment- the anxious group became receiving randomized clinical trials. Taking 503 members (394 females) into consideration, it was noticed that all the members completed the same evaluation battery aside from the management of Beck Anxiety Inventory. Consequences cautioned a hierarchical factor structure of the BAFT with three decrease order factors and one hierarchical factor and amazing internal consistency for the full BAFT score and for its elements.40
A study became conducted in 2013 metacognitive therapy in recurrent depression: A case replication series in Denmark. Patients who had been taken for the study were the first 4 consecutively assessed people referred to clinic with the aid of their general physician with a diagnosis of depression. The outcomes showed that this treatment is sufficient and had been related to symptom improvement when added away from its point of foundation and in a Danish help-seeking sample.41
Distinctions were quite visible in clinical and non-clinical population as subjected to metacognition, on other hand when compared it highlighted a drastic distinction in healthy controls amongst thought fusion, ritual beliefs and stop signals in patients with obsessive compulsive disorder and generalized anxiety disorder.42
Hence it can be implicitly stated that conditions like depression and anxiety are contemplated by using metacognition and fusion processes. Thus this brings forth our information of fusion and also that metacognition is known to be determining factor in addition to negative. Taking the earlier reference that cognitive appraisal of the process defines it being positive/ negative. An examine conducted to evaluate people’s belief about their thoughts on “effective metacognitive factors in students' depression” comprising a pattern of 70 undergraduate college students and amongst them, 35 depressed and 35 ordinary students had been selected. Wells Metacognition test become used that includes 65 items which is composed of five subscales. Positive worrying beliefs, uncontrollability and feeling of danger, beliefs about cognitive ability, general negative beliefs and cognitive self-awareness all being the subsequent subscales of this test. Results illuminated that all these subscales are significantly widespread in distinction between depressed and normal students.43
Similar findings had been suggested in a sample of anxiety disorders wherein a sample of 224 college students of University of Social Welfare and Rehabilitation Sciences had been administered questionnaires assessing anxiety and metacognition. Further Beck states that depression and anxiety effectively predicts metacognitive ideals though substantially. Adding to it he also states that general negative beliefs might also predict depression in contrast with other element.44
To assess the usability of metacognitive therapy on reduction of PTSD symptoms on accident survivors, another probe was administered in Shahr-e-Kord city, consisting a cross-section of 36 males who had been accident survivors and gone through the PTSD scenario. The subjects were randomly assigned into experimental group (N=18), control group (N=18). The experimental group received eight 90 min weekly sessions of metacognitive therapy. Scientific interview based totally on DSM-IV-TR, 2-Mississipi Post Traumatic Stress Disorder Scale (PTSD) scale, being the comprehensive tools. Reduction in PTSD symptoms through metacognitive therapy in experimental group during the post test and in the 2 month follow up session come into notice as the consequences and finally the impact of metacognitive therapy leading to a decrement in PTSD signs and symptoms got surfaced, as statistical interpretation were found to be eloquent between pre-test and post-test results in experimental group.45
Giving attention to the thought control symptoms in OCD it is found that the task involves two processes both avoidance and removal of undesirable thoughts. A study was conducted with the aim of investigating thought control in relation to OCD symptoms. Sample consisted of non selected university students and university students who scored both high and low on self-report measure of OC symptoms were given to complete a computerized thought replacement task. Results indicated that in former group on replacing personal intrusive thoughts it took more time than replacing neutral thoughts and it further demonstrated that intrusive thoughts were rated more difficult to change and also were related to all three i.e. greater thought reoccurrence, larger emotional reaction and more discomfort.38
A study was carried out with the aim to examine the moderation effect of the thought control strategies on relationship between obsessive compulsive symptoms and meta cognitive beliefs and it comprised of 180 females and 95 males their ages. Tools used were demographic information questionnaire, thought control questionnaire, metacognition questionnaire, padua inventory- washington state university revision. Results indicated that thought control strategies such as distraction, worry , self-punishment all have positive effects on severity of obsessive compulsive symptoms.46
Metacognitive therapy seemed to be an effective tool in manipulating their psychological problems and beneficial treatment for anxiety disorders, as advised by a methodical reappraisal and meta- analysis on regulated treatment trials of metacognitive therapy for anxiety problems, as carried out in 2015. The studies involved controlled methodology and people above 18 years with anxiety disorders , thus excluding case studies having less than 4 instances and single case designed studies. 15 ordeals were being appreciated for methodical review by a comprehensive literature search. It put under light that as compared to control groups, each one protected research showed better treatment results statistically in generalized anxiety disorder, obsessive compulsive disorder and post traumatic stress disorder.47
In a varying clinical footings like alcohol dependence where a study conducted in 2014 wherein each alcohol and varying materials were used for emotional and cognitive regulation and hence became replicated and cognitive regulation and hence became replicated in 2017. Metacognitive patterns and distress intolerance in patients with alcohol and other substance dependence emerged as a contrast of the rationale of the prevailing study. Overall 45 patients with alcohol dependence (AD), 44 patients with substance dependence (SD) and 43 volunteers without AD or SD (control institution) were enrolled. Distress tolerance scale (DTS) and metacognitive questionnaire- 30 (MCQ-30) had been the main operative measures to follow the need of socio-demographic data. Final formulation put as a change that sufferers with AD had extensively lower scores on tolerance subscale and total distress tolerance scale. Patients with SD had drastically better scores in “appraisal” subscale on DTS than control group. Patients of both groups got higher scores in “positive beliefs” subscale of mcq-30 than control group. And among AD & SD groups on any MCQ-30 subscale and the entire scores , no significant distinction changes were located. As a conclusion it put under light that in SD group metacognitive law schemas provide much accountable prognosis than emotional regulation schemas as compared to AD group. The need of alcohol as a way of each cognitive and emotional regulation strategy is being much visible in people with alcohol dependence.48
After being given metacognitive therapy or cognitive behavior therapy for depression, neuropsychological changes were stated in a study in which forty-eight patients referred for outpatient treatment were taken as samples for this study and were being randomized to 12 weeks of MCT (n=23). At pre-treatment level assessment of mood severity and neuropsychological functioning was being done, the interval being of 4 weeks and at terminating (12 weeks) and surprisingly , more development in performance was recorded at a drastic level by MCT organization on an undertaking requiring spatial working and attention than the CBT group as the outcomes of this study. Thus as a result it put under light the role of MCT having a n upper hand over CBT in enhancing areas of executive functioning including attention. Not only this but it also showcased a non-rigid emphasis of MCT’s on attentional training and control of thinking, thus adding to an useful effect on neuropsychological functioning, which is stable with supposed mechanism of action. 49
This implies that depressive and anxiety issues have negative metacognition as a precursor or vice versa, as a result these may additionally effect metacognition and fusion . A study was carried out considering teenagers who had depression, the Oregon Adolescent depression project (OADP) made a chain of questions concerning the associations among metacognition and adolescent depression. Participants consisted of 1,709 community adolescents who had been diagnostically assessed on four occasions among the ages of 16 and 30. Confirmatory factor analysis was used based on 4 tools that assessed self-consciousness, self-reinforcement and mastery. Along with determining higher ranges of higher ranges of dysfunctional metacognition in adolescence as a predictor of a primary incidence of major depressive disorder in rising maturity for male but not for female adolescents, it is also visible that metacognition is being deeply complimented with concurrent depression symptoms, with weighty extra associations for female as opposed to male adolescents. Thus putting under light that treatment options addressing metacognitive ideals may be in particular powerful in treating depression, mainly for female adolescents. Further, this study indicates that metacognition may act as an essential element for identifying adolescents at danger for the onset of major depressive disorder in emerging adulthood, especially amongst male adolescents.50
Cognitive fusion while mediating the relationship of illness appraisals and anxiety, cognitive appraisal of events or situations relies upon one’s cognitive strategies such as fusion and attributions thus influencing one’s quality of life. Further cognitive fusion is being determined to predict depression. A study conducted in 2015 brings to light that together illness cognitions, avoidance and self-compassion in conjunction with cognitive fusion all are predictors of distress and quality of life in sample of cancer suffering adults. The sample consisted of 105 adults and tools were used to assess most cancers related mind, coping style, self-compassion, cognitive fusion, distress and quality of life. The results recommended that cognitive fusion was the more potent predictor of anxiety symptoms.51
Shame memories and depression symptoms are determined by a significant role of experiential avoidance and both the role of cognitive fusion and experiential avoidance is well supported in a study of 2015 carried out with a sample of 181 which include 66 males and 115 females. The tools used in the study had been shame experiences scale (SES), impact of event scale-revised (IES-R), acceptance and action questionnaire-II (AAQ-II), cognitive fusion questionnaire (CFQ) and depression, anxiety and stress scale (DASS-42). The results appear to signify that cognitive fusion affects symptoms of depression; partially via experiential avoidance.52
Overuse of maladaptive thought control strategies like worry and self-punishment by people with OCD is being initiated by erroneous beliefs about the importance and need to control thoughts. A study was conducted considering thought control strategies such as mediators of the relationship between obsessive beliefs and OCD symptom dimensions wherein a sample of 102 adults with OCD was examined. In line with the hypotheses of this study the relationship between dysfunctional beliefs about the control of thoughts and unacceptable obsessions is being mediated by the use of punishment as a thought control strategy. 53
The genre of literature dealing with this very symptom clearly proposes the view that the people with high cognitive fusion and excessive experiential avoidance may be are more prone to psychological distress. This become studied in 2016 on a sample consisted of 955 where in 301 had been adult males and 654 were females who finished online questionnaires. The questionnaires used had been cognitive fusion questionnaire (CFQ), acceptance and action questionnaire-II (AAQ-II), depression, anxiety and stress scale-21 item version (DASS – 21) and PTSD check list-5-civilian version (PCL-5). The aim was to see the interactive effect of cognitive fusion and experiential avoidance on anxiety, depression, stress and posttraumatic stress signs and symptoms and the study discovered that yes there is a visible association among cognitive fusion and symptom measures being most powerful at higher ranges of experiential avoidance.54
The applicability of brief metacognitive therapy as against cognitive behavioral therapy had been compared by an intervention examine in a global outpatient setting. The sample comprised of these 30 patients who had been mentioned to a psychiatric university hospital for outpatient services and they had been further referred for CBT. Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), anxiety and thoughts inventory had been the used assessment instrument in this study and it found that the sample suffering from anxiety and fear suggested apprehensible extra improvement when given metacognitive remedy as opposed to those receiving remedy as usual. It turned into concluded that it may be properly and correctly delivered as a short treatment in a heterogeneous clinical practice setting.55
Another examine conducted in 2016 to affirm the variations of gender within the expression of anxiety symptoms, depressive, obsessive and compulsive and of ways these are encouraged with the aid of metacognitive competences, in both sexes, in healthy subjects. Whereas in order to evaluate the place of metacognition on the premise of gender and its relation to other psychological makeovers, no studies have been carried out. Having primary targets, in this examine the primary target turned into to assess metacognition by using gender and to explore the constructs of meta cognition, anxiety, depression, pathological worry and obsessive- compulsive symptoms in two groups, defined the second aim. The two groups being 64 participants(32 men+ 32 women) who participated in this examine, all were evaluated with the Meta Cognition Questionnaire(MCQ-30), State Trait Anxiety Inventory(STAI), Beck Depression Inventory(BDI), Penn State Worry Questionnaire(PSWQ). But no gender differences were being monitored by the T-test for two independent samples for MCQ-30. Meaningful interaction between dysfunctional meta cognitive beliefs and distinctive constructs taking gender as base were being discovered as effects of co-relational analysis. The final outcomes of this examine point out that gender differences might play a path breaking role in the clinical efficacy of treatments.56
A study performed in 2016 comprising of 2 year follow-up study of group metacognitive therapy for depression in Norway highlighted the efficiency of MCT over CBT , in which 11 patients were cross-sectioned who in turn had been suggested by putting into action general practitioners to a psychiatrist. The findings of an open trial of the effects and chance acknowledged to group metacognitive therapy for depression, exhibited that group MCT in the treatment of depression that had survived efficacy after one and two years, beyond what has been same usually suggested for cognitive behavioral therapy (CBT).57
Ruminative pattern or anticipation may give rise to triggered anxiety and this in turn is associated in associated in fusion with anxiety reaction and the cognitive procedure where the thoughts of an individual are entangled. Further cognitive fusion is impaired by rumination path which defines this entanglement. . A study investigated, if getting entangled with one’s thoughts dysregulate the era, experience and regulation of feelings. A revelation was made out of a sample of 55 adults having depressive and panic symptoms that cognitive fusion while mediating in emotion differentiation leads to co-activation of multiple negative emotions like fear, anxiety, avoidance and many others. The outcomes of cognitive fusion on depression and panic signs are being mediated by this multiple emotion co-activation (MECA). Connections among cognitive fusion, impaired emotion differentiation and mentally ill-health are being novel, preliminary empirical insight into by these effects.58
Depression is a most sustained ailments overtime engaging almost 15 % of the population thus drawing great attention of clinicians. It could lead to 1% disability in clinical population. In India on its own the prevalence and disability resulting from depression has been pronounced to be 18% of the arena population.59
A waiting list randomized controlled trial with six months follow-up- resulted in another same trial that was performed applying metacognitive therapy for depression in adults. The trial being performed in 2017 comprising 39 patients having depression who were confronted by instantaneous MCT (10 sessions) or a 10-week wait list period (WL) received 10 sessions of MCT after the waiting period. And thus the finding came out with the indication that MCT is a hopeful therapy for depression.60
Advancing further in 2017 according to a study the function of metacognition and obsessive- compulsive symptoms in psychosis turned into examination and big imbrication of symptoms turned into observed signs and symptoms of psychosis, OCD symptoms and metacognition (30.2-37.3%) and metacognition extensively sured strong favourable supplementations with all the symptom measures , consisting of 194 community controls as sample to complement the basic net survey measuring tiers of fearful imagination, inclination to delusions, symptoms of OCD, depression, nervosity and metacognitions. As a result a strong beneficial correlation with symptoms of psychosis and the interlinks have been nevertheless existing after controlling for symptoms of anxiety and depression, all had been indicated by the study. Metacognition and OCD-signs and symptoms were observed to be present in 53.8% variance in paranoid ideation and 43.8% was the part of hallucinations.61
Review of literature shows that metacognitive beliefs hold importance for obsessive compulsive disorder. It tells about the various thought control strategies used by patients with OCD from which we come to know that patients with OCD use maladaptive thought control strategies. Limited studies have addressed the fusion pattern of patients with OCD . This was not adressed by the earlier therapies, in which faulty cognitions are addressed to improve patient’s functioning . Similarly identifying cognitive fusion and thought control will also result into better outcome. Understanding of these will help in increasing the effectiveness of metacognitive therapy and acceptance and commitment therapy which are the current trends and address the element of fusion . Hence improving the patient’s functioning level.

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