Depressive Symptoms are Associated with More Negative Global Metacognitive Biases in Combat Veterans, and Biases Covary with Symptom Changes over Time

Abstract

Metacognitive awareness, insight into one’s abilities, is thought to be disrupted in depression and posttraumatic stress disorder (PTSD), with more negative metacognitive biases and reduced awareness, respectively. However, studies have rarely examined global aspects of metacognitive awareness in depression and PTSD, instead using task-specific measures. In 467 trauma-exposed post-9/11 veterans, we administered assessments of PTSD and depression, self-report and objective measures of cognitive functioning (neuropsychological battery of memory, attention, and executive function measures), and self-report and objective measures of general health (index of five cardiometabolic factors). We used self-report/objective correlations to measure metacognitive sensitivity and 'self-report minus objective' scores to measure bias. We also examined associations between changes in metacognitive awareness and changes in PTSD and depression over time. Metacognitive sensitivity was comparable between individuals with and without PTSD and depression. However, metacognitive bias was significantly more negative in those with greater depressive symptoms (i.e., underconfidence) across cognition and health, independent of PTSD symptoms. Notably, metacognitive bias changes covaried with depressive and PTSD symptom changes two years later. This shows that, in trauma-exposed veterans, negative metacognitive biases are specifically related to depressive symptoms and these biases may be relatively domain general. Further, our longitudinal results suggest that, rather than being a stable trait, metacognitive biases change with PTSD/depressive symptoms over time.

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.…”

Importance of validity testing in psychiatric assessment: evidence from a sample of multimorbid post-9/11 veterans

“…They further found that veterans with PTS and depression (which was prevalent in our sample) may have difficulty dealing with strong and negative emotions leading to symptom exaggeration. Furthermore, depression may further contribute to symptom exaggeration as negative cognitive biases may exacerbate symptom report (Agnoli et al, 2023; Armistead-Jehle, 2010; McCormick et al, 2013). Our findings highlight the need for clinical assessments, including the CAPS-4/5 and SCID-4/5, to also include separate validity measures as overreporting can bias findings.…”