An observational treatment study of metacognition in anxious-depression

Abstract

Objective: Prior studies have found metacognitive impairments are linked to a transdiagnostic dimension of anxious-depression, manifesting as reduced confidence in performance (‘metacognitive bias’). However, previous work has been cross-sectional and so it is unclear if under-confidence is a trait-like marker of anxious-depression vulnerability, or if it resolves when anxious-depression improves.Methods: Data were collected as part of the ‘Precision in Psychiatry’ study, a large-scale transdiagnostic, four-week observational study of individuals initiating internet-based cognitive behavioural therapy (iCBT) or antidepressant medication. Self-reported clinical questionnaires and perceptual task performance were gathered to assess anxious-depression and metacognitive bias at baseline and four-week follow-up. Primary analyses were conducted for individuals who received iCBT (n=649), with comparisons between smaller samples that received antidepressant medication (n=88) and a control group receiving no intervention (n=82).Results: Prior to receiving treatment, anxious-depression severity was associated with under-confidence in performance in the iCBT arm, replicating previous work. From baseline to follow-up, levels of anxious-depression were significantly reduced, and this was accompanied by a significant increase in metacognitive confidence (B=0.17, SE=0.02, p<0.001). These changes were correlated (r(647)=-0.12, p=0.002); those with the greatest reductions in anxious-depression levels had the largest increase in confidence. In the antidepressant arm, anxious-depression reduced (B=-0.61, SE=0.09, p<0.001) and confidence increased (B=0.31, SE=0.08, p<0.001). Among controls, confidence remained stable from baseline to follow-up (B=0.11, SE=0.07, p=0.103). Conclusions: Metacognitive biases in anxious-depression are state-dependent; when symptoms improve with treatment, so does confidence in performance. Our results suggest this is not specific to the type of intervention.

Information search under uncertainty across transdiagnostic psychopathology and healthy ageing

“…In line with previous research, an anxious-depression (AD) dimension was associated with low confidence in task performance, even in the absence of objective deficits (Benwell et al, 2022;Fox et al, 2023;Hoven et al, 2023;Katyal et al, 2023;Rouault et al, 2018). However, when high AD participants had the chance to increase confidence through seeking additional information, they did not take it more often than those scoring low for AD.…”

“…In line with previous studies (Benwell et al, 2022;Fox et al, 2023;Hoven et al, 2023;Moses-Payne et al, 2019), no relationships surviving multiple comparison correction were found between metacognitive efficiency (meta-d'/d') and any of the symptom dimensions, age, or sex for either the first or final decisions (see Supplementary Figure S3).…”

“…A number of studies have shown that both clinical (David et al, 2012;Fox et al, 2023;Hoven et al, 2019;Seow et al, 2021) and sub-clinical (Benwell et al, 2022;Hoven et al, 2019Hoven et al, , 2023Rouault et al, 2018) psychopathology are associated with selective alterations in metacognition and subjective confidence. For example, Rouault et al (2018) found that a transdiagnostic symptom dimension characterised by 'anxious-depression' (AD) was associated with systematically low confidence during performance of a perceptual decision making task with confidence ratings, despite no detriment in 1 st -order performance.…”

Two distinct stimulus-locked EEG signatures reliably encode domain-general confidence during decision formation

“…This is in line with previous studies that found strong between-task correlations of metacognitive bias (Ais et al, 2016;Benwell et al, 2022b;Mazancieux et al, 2020), suggesting overall confidence level is a domain-general, trait-like characteristic that is less influenced by task-specific representations and evidence type. This highlights that maladaptive confidence calibration may have a more pervasive influence on everyday life, in line with its association with symptoms of psychopathology (Benwell et al, 2022b;Rouault, Seow, et al, 2018) and longitudinal evidence of confidence bias improvement with mental health treatment (Fox et al, 2023). Hence, identifying reliable, domain-general EEG predictors of confidence may represent a first step towards understanding neural mechanisms relevant for mental health.…”

How underconfidence is maintained in the face of reality

“…These relationships are observed in both "local" confidence judgments on individual trials [2][3][4] and "global" confidence as measured through long-run self-performance estimates 5 (which we refer to as global SPEs [6][7][8] ). Conversely, remission from depression symptoms, through either therapy or antidepressants, is found to ameliorate underconfidence 9,10 . However, previous studies examining the link between metacognition and symptoms have been descriptive, and a mechanistic understanding of why confidence distortions in anxious-depression persist despite otherwise intact performance remains elusive.…”