G Model

EJTD-112; No. of Pages 7

European Journal of Trauma & Dissociation xxx (2018) xxx–xxx

Available online at

ScienceDirect
www.sciencedirect.com

Research Paper

Childhood adversities and psychopathology in participants with

high and low severity of cognitive-attentional syndrome symptoms
Małgorzata Dragan *, Joachim Kowalski
Faculty of Psychology, University of Warsaw, ul. Stawki 5/7, 00-183 Warsaw, Poland

A R T I C L E I N F O A B S T R A C T

Article history: Objective. – The study aimed to examine the relationship between difficulties in emotion regulation,
Received 20 February 2019 different types of psychopathology and negative life experiences in a sample of young women. A
Received in revised form 22 May 2019 question was asked about the co-occurrence of different types of adversities and about the
Accepted 24 May 2019
psychopathology profile depending on the type of adversities.
Available online xxx
Method. – Five hundred and two women aged 18–25 years were examined with use of questionnaires
measuring difficulties in emotion regulation, symptoms of psychopathology (including problem
Keywords:
drinking) and different types of adverse experiences (including interpersonal childhood adversities).
Traumatic events
Emotion deregulation
Results. – Interpersonal childhood adversities, but not traumatic events that took place also after
Problem drinking 15 years of age, turned out to be a risk factor for difficulties in emotion regulation. Life-time traumatic
Childhood adversities events independently predicted symptoms of general psychopathology and posttraumatic symptoms.
Psychopathology Emotion regulation deficits turned out to be the main mediator between childhood adversities and
various symptoms of psychopathology, including problem drinking. Results of cluster analysis along
with discriminant function analysis revealed that childhood sexual trauma was the most differentiating
adversity in terms of severity of posttraumatic symptoms and problem drinking.
Conclusion. – The results of this study indicate that symptom profiles depend on the type of adversities
experienced in childhood. Of the various adversities examined, sexual abuse is associated with the most
severe symptomatology. However, regardless of the type of childhood adversities, the risk of
psychopathology, including problem drinking, is mainly increased by difficulties in emotion regulation.
These problems are the main, transdiagnostic risk factor underlying psychopathology reported by young
women.
C 2019 Elsevier Masson SAS. All rights reserved.

Metacognitive therapy (MCT) is increasingly used in the also associated with focusing one’s attention on threats, both
treatment of mental disorders. Meta-analytic reviews suggest internal and external, and maladaptive strategies for coping with
that MCT is particularly effective in treating emotional disorders, both recursive thinking and attention bias, e.g. thought suppres-
i.e. the disorders of depression, anxiety or trauma and stress- sion or avoidance.
related disorders (Normann, van Emmerik, & Morina, 2014; The relationship between single symptoms of CAS (i.e.
Sadeghi, Mokhber, Mahmoudi, Asgharipour, & Seyfi, 2015, rumination or biased attention or selected coping strategies)
Normann & Morina, 2018). Cognitive-attentional syndrome and psychopathology has been confirmed in clinical and popula-
(CAS) is the main target of interventions in MCT and the key tion-based studies involving the use of self-report questionnaires
factor in the development and persistence of symptoms in the (e.g. Borkovec, Alcaine, & Behar, 2004; Nolen-Hoeksema, 2000;
transdiagnostic metacognitive model of psychopathology (Wells, Birrer & Michael, 2011; Sun, Zhu, and So, 2017). Among them are
2002, 2009). This construct includes symptoms reported in also the research on single symptoms of CAS and trauma-related
research as key and common features of various disorders (Wells disorders (e.g. Bryant & Harvey, 1995; Briere, Hodges, & Godbout,
and Matthews, 1994). Its main element is a pattern of inflexible 2010; Kim, Jin, Jung, Hahn, &, Lee, 2017). However, according to the
and recurrent negative thinking, i.e. rumination or worry, but is metacognitive model, the common core of disorders is the whole
set of symptoms – the CAS. It is assumed that this syndrome results
from maladaptive metacognitive beliefs (dysfunctional metacog-
* Corresponding author. nition) that can be both positive, e.g. believing that persistent
E-mail address: [email protected] (M. Dragan). ruminations about some issue or predicament can be useful, and

https://doi.org/10.1016/j.ejtd.2019.05.005
2468-7499/ C 2019 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Dragan, M., & Kowalski, J. Childhood adversities and psychopathology in participants with high and
low severity of cognitive-attentional syndrome symptoms. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/
j.ejtd.2019.05.005
G Model
EJTD-112; No. of Pages 7

2 M. Dragan, J. Kowalski / European Journal of Trauma & Dissociation xxx (2018) xxx–xxx

negative, e.g. assuming that negative thoughts and worries are 1.1. Stage 1 of the study
uncontrollable or dangerous (Wells, 2009; Wells & Carter, 1999).
Thus, CAS plays a central role in the metacognitive self-regulatory The purpose of first stage was to select participants to clinical
executive function model (S-REF; Wells and Matthews, 1994, interview. It was conducted through an internet survey panel by an
Wells & Matthews, 1996; Wells, 2002), according to which self- external company specializing in surveys. The panel members
regulatory executive function becomes activated when there is a collect points for participating in different survey studies, which
discrepancy between self-relevant goals and the perceived can then be exchanged for financial and/or material rewards. A
situation. In most people, periods of such activation, manifested final group of 1225 participants completed this stage of study.
as symptoms of CAS, are usually brief or even non-existent. Participants were required to live in Warsaw or the surrounding
However, some people experience prolonged CAS activation, area to ensure their ability to participate in further stage of the
which is understood in the S-REF model as a core, common study. The drop-out rate was 36%. Participants were selected to
component of and, at the same time, the cause of emotional meet quotas mirroring the population of Warsaw (Central
disorders. This process is prolonged by dysfunctional metacogni- Statistical and Office, 2017) in terms of gender, age, and education.
tion, which leads to the further persistence of CAS symptoms, and All first-stage participants completed three self-report question-
which in turn strengthen maladaptive metacognitions and naires described below. The questionnaires were used as a time
derivative meta-strategies for behaviors and cognitive processing. and cost-effective form of measurement of CAS symptoms, and
An example of this ‘‘vicious circle’’ process is the influence of a also because the findings of a pilot study suggested that a
belief that ‘‘I will be better prepared thanks to detailed analysis of combination of tools measuring aspects of CAS were more accurate
my past experiences’’. A person holding this belief is not only in predicting psychopathology symptoms (Kowalski & Dragan,
motivated to prolong rumination, but also due to focusing their 2019).
attention on this process, can fail to make active efforts to change
their emotional state (so possible adaptive emotional self- 1.1.1. The Cognitive-Attentional Syndrome Questionnaire (CAS-1)
regulation is inhibited). The CAS-1 questionnaire (Wells, 2009) consists of 16 items.
Although CAS and underlying dysfunctional metacognition are The first questions concern the frequency of rumination and worry
considered a transdiagnostic factor underlying emotional dis- as well as concentration on threats. The next items concern
orders and there is a significant evidence supporting their maladaptive behaviors used to cope with negative emotions
relationship with psychopathology, still little is known about and/or thoughts, e.g. thought and situation avoidance, drinking or
the role of environmental factors influencing their development. substance abuse, and attempts at controlling thoughts or
Meanwhile, it is well established in many studies that childhood emotions. The last items concern positive and negative metaco-
adversities increase the risk of emotional disorders not only in gnitive beliefs core to cognitive-attentional syndrome. The results
childhood, but also in later life (e.g. Kalmakis and Chandler, 2015; of the questionnaire were calculated as in the paper by Fergus et al.
Dragan, 2018). Similarly, many studies indicate the importance of (2012) – the last eight items were re-scaled to range from 0 to 8, to
early experiences for the development of adaptive self-regulation enable summing up results from all items together. With this
in general (Cicchetti, 2016). Therefore, it can be assumed that method of calculation, total results can range from 0 to 128, where
childhood adversity will be important also for the development of a higher result indicates a greater level of cognitive-attentional
dysfunctional metacognition and disturbances of cognitive-emo- syndrome. The Polish version was the first to be validated
tional self-regulation that are described in the metacognitive psychometrically, and in general had good psychometric proper-
model (CAS). So far, only one study by Myers and Wells (2015) ties. In the current study, CAS-1 had good internal consistency with
showed that early negative experiences (in particular, emotional Cronbach’s a = 0.85.
abuse) are an important factor in the formation of dysfunctional
metacognitions. Due to this gap in the research, the main purpose 1.1.2. Ruminative Response Scale (RRS)
of our study was first of all to find out if people with more severe The 22-item Ruminative Responses Scale focuses on responses
symptoms of the syndrome report more often adverse experiences to depressive mood, concentrating on the self, symptoms, and the
compared to people without such symptoms (Hypothesis 1). causes and consequences of such mood. The newer approach
However, as the CAS is seen as a basic and transdiagnostic factor of (Treynor, Gonzalez, & Nolen-Hoeksema, 2003) excludes from the
psychological disturbances in the metacognitive model, there is a scale items too highly correlated with depression measures and
need to conduct a variety of studies testing this assumption. Thus, distinguishes two subscales: a reflection subscale and a brooding
another purpose of our study was to verify the hypothesis stating subscale. Both brooding and reflection subscales consist of 5 items,
that people with high levels of CAS symptoms will be more likely, with results ranging from 4 to 20, where higher results indicate
compared to those with low or no symptoms of CAS, to obtain a higher levels of a particular response to depressed mood. The
diagnosis of emotional disorders based on structured clinical Polish version of the RRS (revised) has generally good psychomet-
interview (Hypothesis 2). For these reasons, we decided to recruit ric qualities (Kornacka, Buczny, &, Layton, 2016). In the current
people showing high and low-CAS symptoms and then to examine study, RRS had an excellent internal consistency of a = 0.94 and its
them for selected characteristics: childhood adversities and subscales had acceptable internal consistency: Brooding a = 0.83
symptoms of psychiatric disorders. and Reflection a = 0.76.

1. Material and methods 1.1.3. Metacognitions Questionnaire short version (MCQ-30)

The short version of the Metacognitions Questionnaire devel-
The study had two stages: in the first stage it was carried out on oped by Wells and Cartwright-Hatton (2004) concerns metaco-
a large group, from which the participants were selected to the gnitive beliefs: monitoring techniques, judgments, and beliefs
second stage. Informed consent was obtained from all individual about one’s thoughts and cognitive abilities considered essential
participants included in the study. The study was approved by the by the metacognitive model of psychopathology. Cognitive
Research Ethics Committee at the Faculty of Psychology, University Confidence, the second subscale, concerns one’s beliefs about
of Warsaw, Poland and performed in accordance with ethical insufficient cognitive abilities, the Positive Beliefs subscale consists
standards laid down in the 1964 Declaration of Helsinki and its of items about the advantageous qualities of worry, and the
later amendments. Cognitive Self-consciousness subscale concerns one’s tendency to

Please cite this article in press as: Dragan, M., & Kowalski, J. Childhood adversities and psychopathology in participants with high and
low severity of cognitive-attentional syndrome symptoms. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/
j.ejtd.2019.05.005
G Model
EJTD-112; No. of Pages 7

M. Dragan, J. Kowalski / European Journal of Trauma & Dissociation xxx (2018) xxx–xxx 3

monitor cognition. The fourth subscale, Uncontrollability and exclusion criterion (so the modules included were A, B/C, and D to
Danger, explores negative aspects of worry, and the final subscale J). Information on the childhood adverse experiences was obtained
is about Need to Control Thoughts. The Polish version of this during the interview about post-traumatic stress disorder (module
questionnaire exhibits good psychometric qualities and is consid- F in SCID-I DSM-IV-TR), which includes a question about traumatic
ered equivalent to the English version (Dragan & Dragan, 2011). In events throughout life and allows to ask additional questions,
this study, the MCQ-30 had excellent internal consistency of including about whether person was ever a victim of violence.
a = 0.91 and its subscales had acceptable internal consistency, Thanks to this possibility, the interview was extended with the
with a values ranging from 0.76 to 0.88. same questions for the period of childhood, and the respondents
were also asked to evaluate relationship with parents and to
1.2. Stage 2 of the study indicate if they had any person with whom they had a close,
supportive relationship (adult close relative or someone from
From the sample of 1225 participants, two extreme groups of outside the family in a role of foster parent, or sibling).
150 participants each were selected to participate in the second-
stage study. Selection was made on the basis of results obtained in
the three questionnaires, thus a combination of the measurements 2. Results
was used in forming the two final groups of participants. These
criteria were adopted due to the lack of one recommended We present in this text detailed results from the clinical
measure of syndrome symptoms and as the results of previous interview (SCID-I) and questionnaire measurements specified
study suggested that combining tools predicts a greater amount of above. This part of study took from 45 minutes to (maximum)
variance in psychopathology symptoms (Kowalski & Dragan, 2 hours, as some participants did not report any clinical or
2019). The criterion for inclusion to one of the two groups was subclinical symptoms. The study was designed as a comparative
obtaining scores above the 66th percentile (high-CAS group) or one: examining differences between samples of participants with
below the 33rd percentile (low-CAS group) in each of the following low and high severity of CAS symptoms. Group differences were
scales: compared using the x2 test for dichotomous variables and
the Mann-Whitney U test. Cramér’s V and Cohen’s d served as
 the CAS-1 questionnaire; measures of effect size, i.e. differences between groups. Statistics
 the Brooding subscale from the RRS as well as; were calculated with IBM SPSS version 24 unless stated otherwise.
 the Need to Control Thoughts and; The two groups – HCAS and LCAS – generally did not differ in
 Uncontrollability and Danger subscales from the MCQ-30. socio-demographic measures (reported in the SCID-I preliminary
interview), except gender. There were more women in the HCAS
In addition to the CAS-1, the other subscales were chosen for group than in the LCAS group (33 vs. 22, x2 = 7.81, P = 0.005;
theoretical reasons. The brooding subscale from the RRS was Cramér’s V test = 0.29). However, there were no statistically
chosen as this aspect of ruminations is most prominently significant differences in age between groups (M = 31.40 in the
connected to emotional disorders (Olatunji, Naragon-Gainey, & HCAS group vs. M = 33.63 in the LCAS group; Student’s t-test non-
Wolitzky-Taylor, 2013), and the two subscales from MCQ-30 were significant at P = 0.16), structure of education (63% in the HCAS
chosen as these aspects of metacognitive beliefs are most group and 46% in the LCAS group had higher education; however
prominently connected to levels of anxiety and depression (Wells the x2 test was non-significant at P = 0.23), or in work and
& Cartwright-Hatton, 2004; Dragan & Dragan, 2011; Spada, relationship status. In comparison to the LCAS group, in the HCAS
Mohiyeddini, &Wells, 2008; Sarisoy et al., 2014). group fewer participants had stable work (57% vs. 72%), more were
To increase the reliability of diagnoses, affiliation to groups was single (41% vs. 33%) and fewer had children (30% vs. 46%), however
blinded and participants were invited in random order, which was x2 was non-significant in all of these cases. Moreover, in the HCAS
organized by the external company that conducted the panel group more participants were not currently in a romantic
research. Ultimately, 98 participants took part in the second-stage relationship (52% compared to 32% from the LCAS group;
study: 44 from the high-CAS group (HCAS) and 54 from the low- x2 = 4.34, P = 0.037, Cramér’s V test = 0.21).
CAS group (LCAS). Participants were first asked to fill-in self-report With reference to Hypothesis 1, an examination of prevalence
questionnaires, including the Symptom Checklist-27-plus (SCL- of childhood adversities in both groups was conducted. Fifty-eight
27-plus), which is a checklist-type questionnaire measuring participants from the entire sample (59%) reported adverse
depressive, vegetative, agoraphobic, and pain symptoms, as well experiences in the time of their childhood. Table 1 shows the
as social phobia (Kuncewicz, Dragan, & Hardt, 2014). In this prevalence of specific types of adversities, categorized on the basis
questionnaire, higher results indicate higher levels of the of qualitative analysis of participants’ answers to additional
associated type of psychopathology symptoms. SCL-27-plus had questions in SCID-I module F (finally, 18 types of childhood
acceptable internal consistency of a = 0.93 in this study and its adversities were distinguished). When it comes to group compa-
subscales had acceptable internal consistency with a values risons, more participants reported childhood adversities in the
ranging from 0.67 to 0.92. Participants also filled-in the three HCAS group (71% compared to 50% from the LCAS group; x2 = 4.19,
questionnaires used in the first stage of the study, as the time P = 0.040, Cramér’s V test = 0.21).
between the first and the second stages was more than two weeks. With reference to Hypothesis 2, several analyses were
This time-gap served as an opportunity to check the stability of all conducted. The HCAS group reported more psychological symp-
examined constructs. After this, participants from both groups toms in the preliminary interview (61.4% vs. 11.1% in the LCAS
were interviewed with the Structured Clinical Interview for DSM- group, x2 = 27.41, P < 0.001; Cramér’s V test = 0.53), as well as
IV-TR, research version (SCID-I/NP; First, Spitzer, Gibbon, & more current stressors (84.1% vs. 33.3%, x2 = 25.37, P < 0.001;
Williams, 2002; Polish version: Popiel, Pragłowska, and Zawadzki, Cramér’s V test = 0.51) and more subclinical symptoms (79.5% vs.
2014). This is a tool for the assessment of past and current 55.6%, x2 = 6.25, P = 0.012; Cramér’s V test = 0.25); only the
psychiatric diagnoses limited to Axis I psychological disorders and difference between the two groups in terms of somatic complaints
mental illnesses, based on DSM-IV-TR criteria (APA, 2000). This was not statistically significant (61.4% vs. 48.1%). Among the
interview was administered by a trained clinical psychologist with psychological symptoms reported in the preliminary interview
the use of the B/C module, as psychotic symptoms were an were lowered or bad mood, worrying, fatigue, and a state of stress

Please cite this article in press as: Dragan, M., & Kowalski, J. Childhood adversities and psychopathology in participants with high and
low severity of cognitive-attentional syndrome symptoms. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/
j.ejtd.2019.05.005
G Model
EJTD-112; No. of Pages 7

4 M. Dragan, J. Kowalski / European Journal of Trauma & Dissociation xxx (2018) xxx–xxx

Table 1 P < 0.001; Cramér’s V = 0.43). There was a similar result for
Types of childhood adversity in groups of participants with high and low level of
lifetime diagnoses according to SCID-I: a lot more participants
symptoms of cognitive-attentional syndrome.
from the HCAS group had a lifetime diagnosis (70.5% vs. 11.1%,
Type of adversity HCAS LCAS Total x2 = 36.33, P < 0.001; Cramér’s V = 0.61). The occurrence of a
(n=44) (n=54) (n=98)
diagnosis depending on the reported childhood adverse experien-
Alcohol abuse (father) 1 2 3 ces was also included in the analysis. Table 3 shows the number of
Alcohol abuse (father) and physical abuse 6 3 9 participants who obtained a diagnosis (lifetime) on the basis of
Alcohol abuse (father) and neglect – 2 2
SCID-I in both groups – HCAS and LCAS – and within subgroups
Alcohol abuse (both parents) and physical abuse 1 1 2
Alcohol abuse (both parents) and neglect – 2 2 separated on the basis of reporting childhood adversities or their
Alcohol abuse (mother) and neglect 1 1 lack.
Neglect 3 4 7 As can be seen from the comparison of Tables 1 and 3, all HCAS
Parental divorce and neglect 3 3 6
participants who reported childhood adversities met the criteria
Serious arguments between parents and neglect 5 3 8
Physical abuse 1 2 3
for the disorder in SCID-I. However, in the case of the LCAS group,
Physical abuse and neglect – 1 1 the disorder was diagnosed only in 6 out of 27 people reporting
Physical and sexual abuse 1 – 1 adverse experiences in childhood, which means that in 21 people
Death of a loved one 3 – 3 with such experiences no disorders were diagnosed. This
Parental overprotection and control 2 – 2
observation suggested that childhood adversities were a possible
Mental disorder of a parent 2 – 2
Care for a sick family member (parentification) – 1 1 moderator of relationship between CAS and SCID-I diagnoses.
Excessive requirements of parents 1 – 1 Thus, a three-way x2 model was used to assess relationships of two
Bullying 1 3 4 bimodal variables (level of CAS and lifetime diagnosis) when
Total 31 27 58
controlling for another bimodal variable – presence of childhood
HCAS: high cognitive-attentional syndrome group; LCAS: low cognitive-attentional adversities. Results of this analysis are presented in Table 4.
syndrome group. Fisher’s exact test was used as 3 of 8 cells had frequencies of
observations below 5. There was a significant relationship of CAS
or nervousness. Among the frequently reported subclinical level and lifetime diagnosis when controlling for childhood
symptoms were lowered mood, single panic attacks, social anxiety, adversities. For no childhood adversities, x2 = 5.88, P = 0.031
problem drinking, as well as fear of insects, altitude, or blood (Fisher’s exact test), Cramér’s V = 0.38. For presence of childhood
sampling. When it comes to current stressors, the participants adversities, x2 = 27.44, P < 0.001 (Fisher’s exact test), Cramér’s
pointed mainly to relationship or family problems, stressful or V = 0.61.
boring work, lack of free time, too much to study, and financial Moreover, participants from HCAS group reported much less
problems. Among the most frequently reported somatic often during an interview having a close, good relationship in the
complaints were back and chest pains, headaches, migraines, childhood with at least one adult person or siblings (36% compared
being overweight, and gastric problems. The difference between to 81% from the LCAS group; x2 = 20.79, P = 0.001, Cramér’s V
HCAS and LCAS groups in symptoms reported in the SCID-I test = 0.46). Similarly to the case of diagnoses, a three-way x2
screening module was also significant (U = 252.5, P < 0.001; model was used to assess associations of two bimodal variables
Cohen’s d = 1.83). The mean results of questionnaires with group (level of CAS and lifetime diagnosis) when controlling for another
comparisons and effect sizes are presented in Table 2. bimodal variable – presence of good relationship in childhood.
The percentage of participants from the HCAS group who Results of this analysis are presented in Table 4. Fisher’s exact test
received a current diagnosis according to SCID-I was significantly was used as 3 of 8 cells had frequencies of observations below 5.
higher than that in the LCAS group (40.9% vs. 5.6%, x2 = 17.99, There was a significant association of CAS level and lifetime

Table 2
Mean results of questionnaires and LCAS versus HCAS group comparisons.

Questionnaire Low CAS M High CAS M U test Cohen’s d d CI 90%

(SD) (SD)

CAS-1 27.77 (14.96) 69.07 (15.63) 73.5*** 2.7 2.22–3.18

RRS
***
Brooding 7.63 (2.29) 14.22 (3.23) 117 2.35 1.91–2.80
Reflection 6.54 (1.82) 11.23 (2.95) 185*** 1.91 1.50–2.33
Total 14.17 (3.16) 25.48 (5.57) 83*** 2.50 2.04–2.96
MCQ-30
Cognitive confidence 11.41 (4.41) 14.38 (5.12) 736** 0.62 0.27–0.97
Positive beliefs 7.35 (2.38) 10.89 (5.07) 629.5*** 0.89 0.54–1.25
Cognitive selfconsciousness 9.76 (2.99) 15.04 (3.58) 293*** 1.60 1.21–1.99
Uncontrollability and danger 9.53 (3.35) 18.02 (3.68) 105.5*** 2.41 1.97–2.86
Need to control thoughts 8.90 (2.99) 15.71 (3.20) 161*** 2.20 1.77–2.63
Total score 46.94 (10.88) 74.04 (11.12) 96.5*** 2.46 2.01–2.91
SCL-27plus
Depressive symptoms 1.38 (2.01) 7.70 (5.05) 230*** 1.64 1.25–2.04
Vegetative symptoms 4.33 (2.84) 7.69 (3.24) 481.5*** 1.10 0.74–1.47
Agoraphobic symptoms 0.82 (1.81) 3.71 (2.91) 417*** 1.19 0.82–1.56
Social phobia symptoms 3.12 (2.40) 9.84 (3.75) 159*** 2.14 1.71–2.56
Pain 6.42 (2.70) 9.24 (2.85) 520.5*** 1.02 0.65–1.38
General symptom index 15.61 (7.86) 38.20 (12.66) 148*** 2.14 1.72–2.57

HCAS: high cognitive-attentional syndrome group; LCAS: low cognitive-attentional syndrome group; CAS-1: Cognitive-Attentional Syndrome Questionnaire; RRS:
Ruminative Response Scale; MCQ-30: Metacognitions Questionnaire short version; SCL-27-plus: Symptom Checklist-27-plus.
**
P < 0.01.
***
P < 0.001.

Please cite this article in press as: Dragan, M., & Kowalski, J. Childhood adversities and psychopathology in participants with high and
low severity of cognitive-attentional syndrome symptoms. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/
j.ejtd.2019.05.005
G Model
EJTD-112; No. of Pages 7

M. Dragan, J. Kowalski / European Journal of Trauma & Dissociation xxx (2018) xxx–xxx 5

Table 3
Numbers of participants with current and lifetime diagnoses in HCAS and LCAS groups.

Categories of disorders HCAS LCAS

(SCID-I DSM-IV-TR) (n=44) (n=54)

No adversity Adversity No adversit Adversit

(n=13) (n=31) y (n=27) y (n=27)

Current Lifetime Current Lifetime Current Lifetime Current Lifetime

Agoraphobia – – 1 1 – – – –
Depression (MDD) – – 2 2 – – – –
MDD + specific phobia – – – 1 – – – –
MDD + social phobia – 1 – 1 – – – –
MDD + anxiety disorderNOS – – – – – – – 1
Depressive disorder NOS – – 1 1 – – – –
Depressive disorder minor – – – – – 1 – –
Dysthymic disorder – – 1 1 – – – –
Dysthymic disorder + MDD – – – 1 – – – –
Cyclothymic disorder + bulimia – – 1 1 – – – –
GAD – – 4 1 – – – –
GAD + social phobia – – 2 1 – – – –
GAD + MDD – – – 3 – – – –
GAD + MDD + pain disorder – – – 1 – – – –
PTSD – – 1 – – – 1 2
PTSD + MDD – – 1 1 – – – –
PTSD + MDD + S – – – 1 – – – –
PTSD + social phobia – – 1 – – – – –
PTSD + social phobia + MDD – – – 1 – – – –
PTSD + binge eating – – 1 – – – – –
PTSD + binge eating + MDD – – – 1 – – – –
PTSD + panic disorder – – – 1 – – – –
PTSD + alcohol abuse – 1 – – – – – –
Social phobia – 1 – – – – – –
Anxiety disorder NOS – – 2 4 – – 1 1
Alcohol abuse – – – – – – 1 1
Substance abuse – – – 1 – – – –
Binge eating – – – 1 – – – –
Adjustment disorder (mixed) – 1 – 1 – – – –
Total – 4 18 27 – 1 3 5

HCAS: high cognitive-attentional syndrome group; LCAS: low cognitive-attentional syndrome group; MDD: major depressive disorder; GAD: generalized anxiety disorder; S:
suicide attempt with hospitalization; PTSD: posttraumatic stress disorder; NOS: not otherwise specified.

Table 4 group, 1 – high-CAS group), examining sensitivity and specificity.

Contingency table of levels of CAS and lifetime diagnosis when controlling for
When comparing diagnoses formulated on the basis of SCID-I to
childhood adversities and the presence of at least one close, good relationship with
adult or sibling in childhood. group classification, we observed that sensitivity is 71%, while for
test specificity the figure is 89%. The positive and negative
Level of CAS Lifetime Percent (%)
predictive values are 84% and 79%, respectively, and accuracy is 81%.
diagnosis

No Yes Yes

Childhood adversities 3. Discussion

No High 9 4 30.8
Low 26 1 3.7
The study aimed at testing hypothesis that participants with
Yes High 4 27 87.1
Low 22 5 18.5 severe symptoms of the CAS more often report adverse experiences
Total High 13 31 70.5 in childhood compared to participants without such symptoms.
Low 48 6 11.1 Results of this study show that indeed, participants with high
Good relationship levels of CAS symptoms (HCAS group), classified on the basis of a
No High 4 24 85.7
combined score from the results of three questionnaires, are
Low 6 4 40
Yes High 9 7 43.8 significantly more likely to report childhood adversities than those
Low 42 2 4.5 with low symptoms of CAS (LCAS group). However, the most
Total High 13 31 70.5 interesting result is that people from the HCAS group who
Low 48 6 11.1
simultaneously report adverse experiences meet the diagnostic
criteria of the disorder more often than participants reporting
either CAS symptoms or adverse experiences alone. Actually, the
diagnosis when controlling for presence of good relationship in vast majority of the cases of disorder are in the subgroup of HCAS
childhood. For no good relationship in childhood x2 = 7.94, P = 0.01 group with childhood adversities and these experiences turned out
(Fisher’s exact test), Cramér’s V = 0.46. For presence of good to be a moderator of relationship between CAS and (lifetime) SCID-
relationship x2 = 14.14, P = 0.001 (Fisher’s exact test), Cramér’s I diagnoses. It is good to remind that CAS symptoms are extended
V = 0.49. thinking (rumination, worry), attentional bias towards threats and
Finally, we also measured the general performance of diagnoses, non-adaptive strategies to deal with negative thoughts and
comparing the occurrence of diagnoses formulated on the basis of emotions such as avoidance. These characteristics are long
SCID-I (treated as binary variable: 0 – no diagnosis, 1 – at least one recognized in the literature – in studies examining only separate
diagnosis) to the classification of CAS groups on the basis of three symptoms, never set of them – as correlates and consequences of
questionnaires (treated as general indicators of CAS, 0 – low-CAS traumatic experiences (e.g., attentional bias – Bryant & Harvey,

Please cite this article in press as: Dragan, M., & Kowalski, J. Childhood adversities and psychopathology in participants with high and
low severity of cognitive-attentional syndrome symptoms. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/
j.ejtd.2019.05.005
G Model
EJTD-112; No. of Pages 7

6 M. Dragan, J. Kowalski / European Journal of Trauma & Dissociation xxx (2018) xxx–xxx

1995; avoidance – Briere et al., 2010; rumination – Kim, Jin, Jung, can be treated as confirmation of the general assumptions of the
Hahn, &, Lee, 2017). However, the metacognitive model proposes metacognitive model about the existence of a syndrome common
that they constitute a whole set of symptoms, being a common to various mental disorders. The diagnoses obtained are varied, but
core of various emotional disorders. Results of our study confirm the vast majority of cases belong to the group of so-called
that this set of symptoms, the CAS, is a significant factor in emotional disorders (depressive, anxiety, stress, and trauma
predicting diagnoses of emotional disorders, but this association disorders). The frequent co-occurrence of disorders in the CAS
depends on the occurrence of adverse experiences in childhood. group is also noteworthy. Perhaps this is related to the fact that the
This interaction suggests that early adverse experiences, such as study targeted people with the highest severity of CAS symptoms,
abuse or neglect, are a significant risk factor for the development of which correlate positively with the severity of psychopathology
the CAS, including the formation of dysfunctional metacognition, symptoms. This means that high severity of CAS symptoms is
which is a key element responsible for the presence of syndrome associated with a greater risk of psychopathology intensification
symptoms. and the co-occurrence of disorders.
Alternatively, participants with severe CAS can be more likely to Thirteen participants from the HCAS group did not receive any
report negative experiences from childhood due to the well-known lifetime diagnosis established on the basis of SCID-I. According to
in psychology mood-dependent memory effect. The same effect the metacognitive model, although these participants might be
may be responsible for another result of our study – an interaction currently able to control the symptoms of the syndrome, they are
between CAS and having a good, supporting relationship childhood still at risk of a future disorder. Moreover, among them, only four
in predicting lifetime diagnoses formulated on the basis of SCID-I. belongs to the subgroup of participants not reporting childhood
However, this result may also be seen as in line with attachment adversities – thus, the vast majority in the HCAS group being
theory and confirming research results showing the protective role diagnosed with psychiatric disorder reported simultaneously
of high-quality parent-child relationships and their profound effect adverse experiences in childhood. This finding confirms the
on resilience (e.g. Collishaw et al., 2007). Unfortunately, there is still significant role of such experiences in shaping the risk of psychiatric
little research on the relationship between patterns of attachment disorders in adulthood. In addition, the results indicate that current
and metacognition. However, Myers and Wells in their study stress is much more often reported by people from the HCAS group,
published in 2015 have shown that anxious attachment was which is in line with the metacognitive model, according to which
positively associated with maladaptive metacognition, and this stressors are triggers to CAS. These observations are compatible
relationship remained significant after controlling for early abuse with the results of research on the role of current stress in the
and current negative affect. Yavuz et al. (2019) have recently found course of psychiatric disorders (Riboni & Belzung, 2017).
in research on a large sample of adolescents that metacognition is On the other hand, six participants in the LCAS group received a
an important mediator of the relationship between quality of lifetime diagnosis according to SCID-I. Five of them reported
attachment and symptoms of somatization. Results of these studies adverse experiences in the childhood, and among them – one
are in line with existing studies confirming the assumption of person received a diagnosis of PTSD. The absence of CAS symptoms
attachment theory that insecure attachment is a risk factor for in these participants can be understood by indicating two probable
general disturbances in adaptation and psychopathology. problems: imperfect diagnosis of the syndrome (e.g. due to the use
The second hypothesis tested in this two-stage study, was that of self-report questionnaires) or the importance of other processes
people with high levels of CAS symptoms, compared to those with that this syndrome does not include or does not adequately identify.
low levels of CAS symptoms, more often meet the criteria for For example, the problem here may be the increased avoidance or
mental disorders. In general, the hypothesis has been confirmed: lack of awareness regarding own cognitive-emotional processing
the study showed that participants from HCAS group significantly and related behaviors (inability to insight – to adopt a meta-
differ in symptoms of psychopathology from those from the LCAS perspective), or on the other hand, the presence of processes specific
group. Participants from the HCAS group obtained a diagnosis from for disorders not included in SCID-I, such as personality disorders.
SCID-I, either current or lifetime, significantly more often than did Moreover, in the case of alcohol abuse (one case), it is believed that
those from the LCAS group. Moreover, the obtained level of this disorder might be related to a slightly different set of
sensitivity (the ability to correctly identify those with a diagnosis) metacognitions (Spada & Wells, 2006), mostly concerning the role
may be considered as moderately high, while the specificity is even of alcohol/substances in emotional regulation. Observations re-
higher; the positive and negative predictive values of SCID garding participants from the LCAS group might be seen as
diagnoses reach relatively high levels as well. Although it is the confirming the notion that CAS cannot be seen as the universal
case that assignment to the LCAS group on the basis of combined underlying factor of all cases and all mental disorders as well,
score slightly better predicts a lack of SCID-I diagnosis (11% false especially in the context of results from studies on different emotion
positives), affiliation to the HCAS group predicts the presence of a regulation strategies and exploring the neural and biological
SCID-I diagnosis at a moderate level (29% false negatives). mechanisms of illnesses (e.g. del Rio-Casanova, Gonzalez, Paramo,
However, the relatively high specificity and moderate sensitivity, van Dijke, &, Brenlla, 2016). This issue undoubtedly requires further
together with the significant correlations between symptoms of research. However, to date, the role of CAS in emotional disorders is
psychopathology (measured with SCL-27-plus) and the remaining backed by the strongest evidence; indeed, the general metaco-
three questionnaires (CAS-1, RRS, MCQ-30), suggests that these gnitive model was first developed for this type of disorders.
tools for measuring CAS symptoms have potential for research. The basic limitation of the study is a relatively small sample of
They allow the calculation of the combined score of CAS symptoms, participants, which means that it is difficult to generalize the
as low scores on the questionnaires (the low combined score) results, and thus they can be only treated as preliminary.
indicate a low probability of having an Axis I disorder, and a high Moreover, the number of men in the HCAS group was relatively
combined score, on the other hand, indicates a relatively high small, and much smaller than the number of women (12 vs. 32),
probability of such a diagnosis. Taking these various results into which makes it impossible to make gender comparisons in terms of
account, we can therefore assume that the presence of CAS is a diagnosis within HCAS/LCAS groups. This is one of the most
good predictor of current and lifetime Axis I disorders. Thus, it can important limitations of this study. This problem is due to the fact
be assumed that it is highly probable that people with high that it was difficult to obtain consent from men qualified for the
symptoms of this syndrome will present symptoms of psychiatric HCAS group to participate in the study and the difficulty in
disorders at some point in their life. Therefore, the obtained results controlling assignment the gender makeup of the groups resulting

Please cite this article in press as: Dragan, M., & Kowalski, J. Childhood adversities and psychopathology in participants with high and
low severity of cognitive-attentional syndrome symptoms. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/
j.ejtd.2019.05.005
G Model
EJTD-112; No. of Pages 7

M. Dragan, J. Kowalski / European Journal of Trauma & Dissociation xxx (2018) xxx–xxx 7

from the fact that assignment to groups was blinded. Therefore, it Central Statistical Office (2017). Demographic atlas of Poland. (Warsaw: Author. Avail-
able from: stat.gov.pl/en).
seems necessary to include a larger number of men with CAS Cicchetti, D. (2016). Developmental psychopathology (3). New York: Wiley.
symptoms in future studies, to make detailed analyses of gender Collishaw, S., Pickles, A., Messer, J., Rutter, M., Shearer, C., & Maughan, B. (2007).
differences possible. As well as the difficulties analyzing gender Resilience to adult psychopathology following childhood maltreatment: Evidence
from a community sample. Child Abuse and Neglect, 31, 211–229.
differences, it is worth highlighting one more possible limitation of Del Rı́o-Casanova, L., González, A., Páramo, M., Van Dijke, A., & Brenlla, J. (2016). Emotion
this study. In a situation where all researchers are familiar with the regulation strategies in trauma-related disorders: Pathways linking neurobiology
purpose of the study, one may wonder about reliability of and clinical manifestations. Reviews in the Neurosciences, 27, 385–395.
Dragan, M. (2018). Adverse experiences, emotional regulation difficulties and psycho-
diagnoses. To ensure such reliability, affiliation to HCAS/LCAS pathology in a sample of young women: Model of associations and results of
groups was blinded for the purposes of this study; the clinical cluster and discriminant function analysis. European Journal of Trauma & Dissocia-
psychologist conducting interviews did not know to which group tion. http://dx.doi.org/10.1016/j.ejtd.2018.12.001
Dragan, M., & Dragan, W. Ł. (2011). Psychometric properties of the Polish version of The
each participant belonged. Participation in the study was orga-
Metacognitions Questionnaire-30. Psychiatria Polska, 45, 545–553.
nized by an external company, and participants were brought to Fergus, T. A., Bardeen, J. R., & Orcutt, H. K. (2012). Attentional control moderates the
the study in random order. Even though the mean length of relationship between activation of the cognitive attentional syndrome and symp-
interviews was different for the two groups (the duration for the toms of psychopathology. Personality and Individual Differences, 53, 213–217.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002). Structured clinical
LCAS group was much shorter than for the HCAS group), interview for DSM-IV-TR axis I disorders. New York: Biometrics Research, NY State
information on the subjects’ affiliation and, hence, the possibility Psychiatric Institute (Research Version, Patient Edition [SCID-I/P]).
of identifying this regularity, was available only after the end of the Kalmakis, K. A., & Chandler, G. E. (2015). Health consequences of adverse childhood
experiences: A systematic review. Journal of the American Association of Nurse
study. The results of the diagnosis are also confirmed somewhat by Practitioners, 27, 457–465.
the results of intergroup comparison in terms of psychopathology Kim, J. S., Jin, M. J., Jung, W., Hahn, S. W., & Lee, S. H. (2017). Rumination as a mediator
measured by the SCL-27-plus. between childhood trauma and adulthood depression/anxiety in non-clinical
participants. Frontiers in Psychology, 8, 1597.
To conclude, findings of this preliminary study confirm the Kornacka, M., Buczny, J., & Layton, R. L. (2016). Assessing repetitive negative thinking
assumptions of the metacognitive approach to psychopathology – using categorical and transdiagnostic approaches: A comparison and validation of
high scores on scales measuring rumination and other symptoms three Polish language adaptations of self-report questionnaires. Frontiers in Psy-
chology, 322, 1–13.
of cognitive-attentional syndrome as well as dysfunctional Kowalski, J., & Dragan, M. (2019). Cognitive-attentional syndrome – The psychometric
metacognitive beliefs were found to be associated with a high properties of the CAS-1 and multi-measure CAS-based clinical diagnosis. Compre-
probability of Axis I disorder according to SCID-I. Moreover, the hensive Psychiatry, 91, 13–21.
Kuncewicz, D., Dragan, M., & Hardt, J. (2014). Validation of the Polish version of Scl-27-
high comorbidity and other symptomatology was observed in the
plus. Psychiatria Polska, 48, 345–358.
participants with the highest scores on these scales. On the other Myers, S. G., & Wells, A. (2015). Early trauma, negative affect, and anxious attachment:
hand, low scores were associated with lower probability of The role of metacognition. Anxiety, Stress, & Coping, 28(6), 634–649.
suffering from such a disorder. This means that CAS symptoms Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed
anxiety/depressive symptoms. Journal of Abnormal Psychology, 109, 504–511.
are a good predictor of current and lifetime psychopathology, and Normann, N., van Emmerik, A. A. P., & Morina, N. (2014). The efficacy of metacognitive
for this reason it is worth recommending screening for CAS. therapy for anxiety and depression: A meta-analytic review. Depression and
However, our study also showed that symptoms of the syndrome Anxiety, 31, 402–411.
Normann, N., & Morina, N. (2018). The efficacy of metacognitive therapy: A systematic
interacts with childhood adversities. This suggest that early review and meta-analysis. Frontiers in Psychology, 9, 2211.
adverse experiences are significant factor in the etiology of the Olatunji, B. O., Naragon-Gainey, K., & Wolitzky-Taylor, K. B. (2013). Specificity of
CAS and related psychopathology. However, taking into account a rumination in anxiety and depression: A multimodal meta-analysis. Clinical Psy-
chology Science and Practice, 20, 225–257.
preliminary nature of the study, which limits the generalization of Popiel, A., Pragłowska, E., & Zawadzki, B. (2014). Ustrukturalizowany wywiad kliniczny
results, it is recommended to conduct further research on this topic do badania zaburzeń z osi I DSM-IV-TR. Warsaw: Pracownia Testów PTP (SCID-I-TR,
in the future. Polish version).
Riboni, F. V., & Belzung, C. (2017). Stress and psychiatric disorders: From categorical to
dimensional approaches. Current Opinions in Behavioural Science, 14, 72–77.
Disclosure of interest Sadeghi, R., Mokhber, N., Mahmoudi, L. Z., Asgharipour, N., & Seyfi, H. (2015). A
systematic review and meta-analysis of controlled treatment trials of metacogni-
tive therapy for anxiety disorders. Journal of Research in Medical Sciences, 20, 901–
The authors declare that they have no competing interest. 909.
Sarisoy, G., Pazvantoğlu, O., Özturan, D. D., Ay, N. D., Yilman, T., Mor, S., Korkmaz, I. Z.,
Kaçar, Ö. F., & Gümüş, K. (2014). Metacognitive beliefs in unipolar and bipolar
Funding source
depression: A comparative study. Nordic Journal of Psychiatry, 68, 275–281.
Spada, M. M., & Wells, A. (2006). Metacognitions about alcohol use in problem drinkers.
Primary funder is National Science Centre, OPUS grant no. Clinical Psychology and Psychotherapy, 13, 138–143.
Spada, M. M., Mohiyeddini, C., & Wells, A. (2008). Measuring metacognitions associated
UMO-2015/17/B/HS6/04157.
with emotional distress: Factor structure and predictive validity of the metaco-
gnitions questionnaire 30. Personality and Individual Differences, 45, 238–242.
Acknowledgements Sun, X., Zhu, C., & So, S. H. W. (2017). Dysfunctional metacognition across psychopa-
thologies: A meta-analytic review. European Psychiatry, 45, 139–153.
Treynor, W., Gonzalez, R., & Nolen-Hoeksema, S. (2003). Rumination reconsidered: A
This work was supported by the National Science Center (NCN) psychometric analysis. Cognitive Therapy and Research, 27, 247–259.
[OPUS grant number UMO-2015/17/B/HS6/04157]. Wells, A. (2002). Emotional disorders and metacognition: Innovative cognitive therapy.
Chichester: Wiley.
Wells, A. (2009). Metacognitive therapy for anxiety and depression. New York: Guilford
References Press.
Wells, A., & Cartwright-Hatton, S. (2004). A short form of the metacognitions ques-
Birrer, E., & Michael, T. (2011). Rumination in PTSD as well as in traumatized and non- tionnaire: Properties of the MCQ-30. Behavioural Research and Therapy, 42, 385–
traumatized depressed patients: A cross-sectional clinical study. Behavioural and 396.
Cognitive Psychotherapy, 39, 381–397. Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical perspective. Hillside,
Borkovec, T. D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and Hove: Erlbaum.
generalized anxiety disorder. In R. H. Heimberg, C. L. Turk, & D. S. Mennin Wells, A., & Matthews, G. (1996). Modelling cognition in emotional disorder: The S-REF
(Eds.), Generalized anxiety disorder. Advances in research and practice (pp. 77– model. Behaviour Research and Therapy, 34, 881–888.
108). New York: Guilford Press. Wells, A., & Carter, K. (1999). Preliminary tests of a cognitive model of generalized
Briere, J., Hodges, M., & Godbout, N. (2010). Traumatic stress, affect dysregulation, and anxiety disorder. Behaviour Research and Therapy, 37, 585–594.
dysfunctional avoidance: A structural equation model. Journal of Traumatic Stress, Yavuz, M., Aluç, N., Tasa, H., Hamamcıoğlu, İ., & Bolat, N. (2019). The relationships
23, 767–774. between attachment quality, metacognition, and somatization in adolescents: The
Bryant, R. A., & Harvey, A. G. (1995). Processing threatening information in posttrau- mediator role of metacognition. Journal of Child and Adolescent Psychiatric Nursing,
matic stress disorder. Journal of Abnormal Psychology, 104, 537–541. 32, 33–39.

Please cite this article in press as: Dragan, M., & Kowalski, J. Childhood adversities and psychopathology in participants with high and
low severity of cognitive-attentional syndrome symptoms. European Journal of Trauma & Dissociation (2019), https://doi.org/10.1016/
j.ejtd.2019.05.005